KNH

Joint Commission
Readiness Guidebook
Version 2.0

Guidebook
 KNH Joint Commission
Readiness Guidebook

Table of Contents
Mission, Vision and Values ............................................................................................. 3
International Patient Safety Goals................................................................................... 4

Access to Care and Continuity of Care ........................................................................... 9

Patient Rights, Confidentiality and Privacy .................................................................... 10

Assessment of Patients /Care of Patients ..................................................................... 12

Anesthesia and Surgical Care/Patient & Family Education ............................................ 14

Governance, Leadership, and Direction ........................................................................ 15
Management of Information .......................................................................................... 17

Staff Qualification and Education .................................................................................. 19

Quality Management System ........................................................................................ 21

Infection Prevention and Control................................................................................... 23

Medication Management and Use ................................................................................ 25

Facility and Safety Management……………………………...……………………………….28

Page 2 of 32
 Mission, Vision and Values
Mission Statement
We are committed to provide highest
quality healthcare services and
education to our customers and their
families by continuous improvement
guided by national and international
standards to preserve and enhance
healthy life
Vision Statement
To establish unique healthcare model,
leading region by exceeding customer
expectations
Core Values
1. ISLAMIC VALUES:
We are guided by our Islamic values in our
relationship towards our patients, customers
& society.
2. Teamwork:
We have the interest to achieve the same
goals.
3. Care and Safety:
We are strictly committed to provide safety,
security & privacy for our patients,
customers, and society.
4. Continuous education and
improvement:
We continuously establish high level of
knowledge and skills for continuous hospital
and society improvement.
Page 3 of 32
 International Patient Safety Goals
INTRODUCTION AND PURPOSE
A. CORRECT PATIENT
IDENTIFICATION
1. When the patient Identification Process
shall be started?
• At the registration process in OPD or
ER and in Admission Office
2. What are your Patient identifiers/What
methods can be used?
• In outpatient settings (OPD, ER,
Radiology, Laboratory, OPD
pharmacy):
✓ Using patient Full name
(consist of 3 names)
✓ Birth of Date
• When Patient is Admitted (NICU,
PICU, IMCU, ICU, LDU, OR, WARD):
✓ Using patient Full name
(consist of 3 names)
✓ Patient MR Number
3. How to identify the unconscious
Patients?
• By his/her companions/Identification
papers, If unavailable
• Using Unknown Male 01, Unknown
female 02 and next MRN
4. When do you actively verify the identity
of your patients?
• Before performing diagnostic or
therapeutic procedures on the patient
units
• Before performing surgical operations in
the Operating Room / Invasive
procedures outside operating room
• Administration of medication
• Administration of blood or blood
products
• Collecting blood and other specimens
for clinical testing or diagnostic
radiology procedure
Survey Tips
•Patient with Similar names or same
names – Shall be highlighted - Patient
ID Alert sign
• Two practitioners must check the
blood /blood products
• Sending the patient for other services
within the hospital
• Serving patients with special Diet
• Mothers and newborns are accurately
identified at each interaction and before
final custody is passed to a parent upon
discharge
• Identifying the dietary trays, labeling
mother’s milk that is expressed and
stored for hospitalized infants,
• other treatments prepared specifically for
the patient.
5. What is the process of infant
identification?
• Each mother and newborn infant will be
accurately identified immediately after
birth while the mother and infant are still
in the birth room.
• Dual ID band is the responsibility of the
NICU nurse attending the delivery. The
designated nurse is responsible for
having the identification verified by a
second attendee. An attending
physician, obstetric technician, or
another nurse may verify identification.
• Record information on the New Born
Chart.
• One bracelet is placed on the wrist of
the mother. This should be the same
wrist that holds the mother’s inpatient
Page 4 of 32
 International Patient Safety Goals
INTRODUCTION AND PURPOSE
identification band.
• The other bracelet is placed on the
left ankle of the newborn with
following information: Name of the
mother, Mother’s medical record
number, Date and time of birth,
Gender, weight and name of
physician
• When the infant is admitted /
registered in the system, a new ID
band will be placed in the right wrist
with the following information: Baby
(gender) of (mother’s full name),
New born new medical record
number, Date and time of birth.
6. How can we handle a patient who
refusing to wear a Wristband?
• Nurse should do her best to
convince patient by the importance
of ID band then refer to Patient
educator then to the treating
physician.
• If all of the above methods are
failed, the ID band must be
attached to a visible part of the
patient’s body appropriate to the
patient’s condition and allergies.
• If patient is refusing the attached ID
band, other alternative methods for
identification shall be agreed upon
and written in the progress notes/
nurses notes.
7. What would you do if there is no
choice to attach patient's wristband
on any skin?
• The wristband shall be attached to
a visible part pf the patient’s clothes
with a safety pin.
B. VERBAL OR TELEPHONE ORDERS
AND TELEPHONE REPORTING OF
CRITICAL TEST RESULTS
1. How do you receive a verbal /
Telephone order?
• The order shall include: Name of the
prescriber - Date and time of the order-
Signature of person receiving the order
• The complete order shall be read back
by the receiver to the prescriber
• Receive the conformation from the
prescriber who gave the order
• The Order shall be documented in
Physicians Order Sheet
• The individual who gave the order
shall sign the order within 24 hours
2. What shall you do if you received
critical results and you didn’t find the
Physician Who Ordered it?
• Report to on-call physician then to
head of Department then to medical
Director or ER Physician
3. Could all medications be ordered by
Phone?
• No. Narcotic and controlled
medication, Concentrated
electrolytes, pressor agents,
parenteral nutrition not to be ordered
by telephone.
C.IMPROVING THE
COMMUNICATION DURING THE
TRANSITION OF CARE
1. Do you have a process to handover
patients at the end of shift?
• Yes, SBAR Method (Situation,
Background, Assessment and
Recommendations)
2. What is the Process to transfer
patients to Radiology?
• Verbal handover using SBAR
technique
D. IMPROVING THE SAFETY OF
HIGH-ALERT MEDICATIONS
Page 5 of 32
 INTRODUCTION AND PURPOSE
Do you store concentrated
electrolytes in your unit?
• We do not have concentrated
electrolytes; it is stored in the
pharmacy.
Do you have LASA list & or High alert
medications list ?
• Yes we have and it is available in
the global share (Pharmacy ,forms,
lists)
Survey Tips
- Don’t Forget Critical results of Bed Site test
(Glucometer) , Respiratory function tests ,
Echo or ECG and specimens/samples
collections
- SBAR Board in ICU used by Physicians in
handover process
1. What are examples of measures
used to improve the safety of
HAMs?
• List of HAMs is Available
• Using High Alert Red Sticker
• Keep in the Locked cabinet
• All physicians must write daily
orders for concentrated electrolytes,
heparin, and insulin.
• Nurses must independently double
check all High-Alert medications
before administration;
• Secured medication room
3. Where are LASA placed / stored &
how do you ensure the safety of
LASA?
• List of LASA is available
• Using Tallman lettering on LASA
labeling.
• Using yellow stickers affixed on
cassettes or storage shelves of
LASA drugs as well as on the drug
Survey Tips
• TIME OUT IS OBSERVABLE
STANDARD
• DON’T FORGET Pre-Procedural
Verification in ER- DENTAL-
OB&GYNE, RADIOLOGY Invasive
procedure
itself.
• Placing LASA medications in locations
separate from each other or in
nonalphabetical order.
• Separate LASA medications from each
other by at least one medication in
between.
E. ENSURE SAFE SURGERY
1. How is site marking done?
• Prior to marking the site(s), the
physician performing the
procedure/surgery verifies the patient’s
identification, consent(s), full details of
the procedure, medical record data
including history and physical,
laboratory tests, radiographs and any
implant or prosthesis (as applicable) to
confirm accuracy.
• The physician performing the
procedure/surgery asks the patient to
state the procedure(s) and
site(s)/side(s) of surgery as well as
point of the site(s).
• The site mark is completed before the
patient enters the procedure/operating
room.
• The marking shall be clear and
unambiguous. It may be “ arrow
• Site marking may be waived in critical
Page 6 of 32
 INTRODUCTION AND PURPOSE
emergencies at the discretion of the
operating physician, but a “time out”
or pause should be conducted
unless there is more risk than benefit
to the patient.
• If patient refuses marking, provide
the patient with information to
understand the benefits of marking
and implication of refusal. Use
diagrams to do the marking (do not
cancel the procedure).
• All implants will be used for any
patient must be tracked and all
information of implant and patient
must be documented in (patient
information for implant tracking log
book)
2. Do you make a bedside procedure?
• Yes, we have list of invasive
procedures done outside the
operating room. Time out must still
occur with all parties involved.
3. Which surgery would be
exempted in site marking?
• Tonsillectomy
• Hemorrhoidectomy
• Single organ cases (C-section, cardiac
surgery)
• Teeth
• Premature infants
4. Could You Describe the Time-Out?
• A verbal “time out” or pause must be done in
the location where the procedure is to be
performed
• The patient does not have to be awake of the
“time out”
• Checklist coordinator will often be a
circulating nurse.
• Time Out will follow an active communication
with answering Positive and negative
5. What would be done before incision
Closure?!
• “Sign-Out”
• Nurse verbally confirms with the team: the
name of the procedure recorded
• That instrument, sponge and needle
counts are correct (or not applicable)
• How the specimen is labelled (including
patient name, MR number )
• Are there any equipment problems to be
addressed?
• Surgeon, anesthesia professional and
nurse review the key concerns for
recovery and management of this patient.
F. REDUCE THE RISK OF HEALTH
CARE–ASSOCIATED INFECTIONS
HAND HYGIENE
1. When will you perform hand hygiene?
• Before touching the patient
• Before clean / aseptic procedure.
• After body fluid exposure risk
• After touching a patient
• After touching patient surroundings.
CARE BUNDLE
• Implementing bundles of care will have
the greatest impact on patient outcomes
when the hospital identifies gaps in best
practice or continued poor outcomes in
a particular area.
• Examples of bundles include central
line–associated bloodstream
infection (CLABSI), ventilator-
associated pneumonia (VAP),
catheter-associated urinary tract
infection (CAUTI), surgical site
infection (SSI), and severe sepsis
bundle.
G. REDUCE THE RISK OF
Page 7 of 32
 International Patient Safety Goals
INTRODUCTION AND PURPOSE
PATIENT HARM RESULTING
FROM FALLS
1. How could you identify the
Patients with high risk of fall?
• In the inpatient, we use the Modified
Morse Fall Scale to identify adult
patients with High risk of fall
• For pediatric patients, Humpty
Dumpty scale would be used
• For Outpatient and ER, we are doing
fall risk screening
2. How Frequent do you do fall
reassessment to your
patients?
• Based on the following indications:
✓ Narcotic administration,
✓ Medication effects, such as those
anticipated with sedation or
diuretics.
✓ Post fall event.
✓ Change in level of consciousness
✓ Immediately post-operative
3. Give me examples of
interventions to decrease the risk
of fall?
• Post a “Falls prevention Program”
sign
• Call bell and belongings in easy
reach
• Patient/Family Education
• Lowest position of bed with brakes
locked
• Remove unnecessary equipment and
furniture

Page 8 of 32
 Access to Care and Continuity of Care
INTRODUCTION AND PURPOSE
A. TRIAGE , REGISTRATION ,
ADMISSION :
1. Explain how to receive your patients
inside the Hospital?
• In ER, we are triaging patients using
Canadian Triage and Acuity Scale
• In the reception ER and OPD ,
communicable disease screening
criteria
• In OPD, we assess if the requesting
service is available in the hospital or
not.
2. Do you have admission and registration
policies?
• Yes, you can find it in Global Share -
-General Hospital manual
3. What are the needed information before
admission?
• His/her condition and the need for
admission, management plan, and
outcome and possible complications
and expected costs
• Informing the patient for any waiting
time or delay in care
• The location and the level of care
and if isolation is required
4. Describe the Admission Process for
Critical care patients?
• We have ICU, PICU and NICU
admission Criteria as Well as
Discharge Criteria
• Refer to ICU, PICU and NICU
Policies to State it
5. IF there is No available bed in the
Hospital or ER, what will you do?
• There is immediate communication
between Head nurses, Medical Director
and Admission and Discharge office to
highlight a case of bed Shortage
• Optimizing Discharge Process
• Hold patient in ER up to 6 hours
Survey Tips
• Indicators for patient Flow
available on Global Share
• Triage Criteria – Never to be
Missed lobal share
• All hospital KPIs,improvement
project available on Global
Share
• Temporarily Upgrade or Downgrade
Patients
• Admit to an alternative inpatient unit
• Reschedule any elective procedure
• Read: Managing Patient Flow Policy
B. PATIENT TRANSFER :
1. How the patient will be transferred to ICU
from ER?
• Based upon ICU admission Criteria,
Assess the staff and Equipment needed
• Decide with the intensivist the care
needed
• Proper handover of patient verbally and
written to ICU physician and Nurse
• Reviewing the Physician orders and Care
given in the ER
• Using Inter-departmental Transfer Form
• Physician shall accompany patient if
needed
2. How can you ensure the safety of patient
during the transfer to another hospital?
• Physician will communicate with receiving
hospital physician and determine the best
choice for patient
• Determine the resources needed
• Stabilize patient first
• Available staff with appropriate
resuscitative training
• Explain the process to patient/family
Page 9 of 32
 Access to Care and Continuity of Care
INTRODUCTION AND PURPOSE
• Complete the transfer checklist and
check the appropriateness of
ambulance and the availability of
needed supplies or equipment.
C.PATIENT DISCHARGE
How could you make your patient
discharge smooth?
• Discharge Planning is started upon
patient admission
• Educate the patient and family of
expected date of discharge
• Mode of Transportation needed and
follow up instructions
Do you have any process to manage
patient willing to discontinue his care
inside the hospital, Describe it?
• Yes, we have the DAMA process
• The cause of his decision shall be
acknowledged and to be discussed
with discussed with patient/family
• Patient shall be educated about
how risk will be if he chose to be
discharged
• Then to sign a refusal form
6. How could you deal with case of
Patient elopement?
• We shall inform the patient relation
office to contact the patient
• To discuss with him his causes and
advise him to resume his care and
what are the risks of his no treatment
• Inform Police as deemed necessary
and in case of Patient with
communicable diseases
Page 10 of 32
 Patient Rights, Confidentiality and Privacy
INTRODUCTION AND PURPOSE
1. How do we protect patients’ privacy and
confidentiality?
We guard the privacy and confidentiality of
patients by:
• Following MOH guidelines before releasing
patient information
• Making sure only authorized persons
review patients’ records
• Not talking about patients in elevators or
other public areas
• Logging off computer screens and
guarding folders that contain confidential
patient information
• Allowing computer access through a
password system
• Giving treatments and examining patients
in private
• Asking the patient’s permission before
discussing their care in front of visitors or
other patients
• Knocking on the patient’s door before
entering and pulling privacy curtains once
in the room
• Shutting doors when an exam or test is
being done
• Disposing of patients’ papers and reports in
designated containers or shredding them
2. How would you deal with patient with
different language or Mute or Deaf?
• We have list of translators and staff who
can communicate with mute or deaf
patients.
• We also have a handbook for sign
language.
3. How can your patient ask for Second
Opinion?
• He can ask his physician or Patient
affairs or Nurses then to contact his primary
physician to inform him about patient wish
then to document this in the file
Survey Tips
• Do NOT Resuscitate Policy
• We have a Directory for patient
values and beliefs for our patient
population
• Never to leave the Medical
records on the counter
• Additionally, patient can request
outside Second Opinion and then to be
granted a temporary privilege.
4. Can the Patient Submit a Complaint
and Do you have any form for
complaint?
• Yes, we have complaint forms available
in the units.
5. Show Me How you are obtaining the
Patient Consent for Invasive procedure?
• The physician / health care provider
performing the procedure shall assess
the Decision capacity of the Patient.
• Discuss to Patient about the proposed
treatment, Alternatives, Risks, Benefits,
risks of No treatment and likelihood of
success.
• When a person is not physically or
mentally capable of giving consent
,mentally deficient or unconscious,
consent must be obtained from the
patient’s first degree legal guardian.
• If the patient is required emergency
procedure and the family are available
informed consent shall be obtained.
• If the family is not available two
consultants must sign the consent for the
procedure.
• DO NOT FORGET DENTAL
PROCEDURE IN CLINIC
Page 10 of 32
 Patient Rights, Confidentiality and Privacy
INTRODUCTION AND PURPOSE
6. Do you have a recent case of Brain
death, if yes; tell me how to deal
with?
• Brain Death Diagnosis is done by two
consultants using National Brain Death
protocol
• Family Approach is very important
• Fill the related consent
7. Patient Values and Beliefs, how to
identify?
• Ask patient for his values affecting his
management plan + Culture Directory

Page 11 of 32
 Assessment of Patients /Care of Patients

Survey Tips
1. In Outpatient, how to identify patient
with nutritional /functional problems if • Management of Victims of Abuse or
appropriate? Neglect: Assessment in ER – Managing
• Physician uses specific the acute definition – Report to Local
Nutritional/functional Screening criteria Authority- Admission if there is Medical
placed in the Checklist in Outpatient Desktop condition requiring admission
2. How to identify patient’s victim with
abuse and how to report?
• We have abuse assessment form every hour or less than that if needed
• We have to report to Medical • Change the patient’s position and
Director/Duty Manager/Admin Director release and reposition the restraints every
hour
• Duty manager to report to police
7. How to detect patient with deteriorating
3. Do you have any POCT occurred in
medical status?
your department and how to manage?
• We are monitoring Early Warning
• Yes, we have POCT for Glucometer
Signs and it’s POSTED in each unit
and Bilirubin (NICU)
• We have rapid response team
• We have quality control, critical results
schedule who can be contacted.
identifications, maintenance and calibration
record
8. Do you have any timeframe for
4. Do you have lab/rad tests turnaround
Assessment and reassessment?
time?
• In OPD initial assessment is done in the
• Yes , we have turnaround time poster
1st visit
posted in all units.
5. How do you as a physician order a • In Inpatient medical assessment is
service for a patient? done within 24 hours
• Physician order is entered in the • Nursing assessment is initiated upon
electronic medical record (OPD/ER) and in admission and complete documentation
the Doctor Order Sheet (Inpatient Units) before the end of the shift (within 12 hours).
• Diagnostic imaging and clinical • For intensive care units (NICU, PICU,
laboratory test orders shall include a clinical ICU), nursing assessment is initiated upon
indication/rationale when required for admission and complete documentation
interpretation. within 4 hours of admission.
6. How to apply patient restraints? • Nursing reassessment is done every
• There must be a Physician order shift and as needed.
indicating the type of restraint
• The patient’s rights, dignity, and well-
being shall be maintained
• Communication with family
• Apply the appropriate size restrain
• Assess the skin and reassess patients
Page 12 of 32
 Assessment of Patients /Care of Patients
9. What is your role in case of blood
transfusion reaction?
• Stop Transfusion
• Hang Normal Saline with new tubing at
KVO
• Collect a post transfusion blood sample
and first voided urine
• Inform the physician and document
• Inform the laboratory and return the
following:
✓ Post-transfusion specimens.
✓ Blood or blood component pack.
✓ Infusion set with any retained
solutions.
✓ File the original copy of blood order
and administration form in the
patient’s medical record.
• Monitor vital signs and urinary output
STAFF INTERACTION
• What is the Number for Rapid
response team?
• ----------------------------------------
• What are adult and pediatric
Early Warning Signs?
• -------------------------------------------
-------------------------------------------
-------------------------------------------
• What is the time frame of
physician and nurse’s
assessment in ICU?
• -------------------------------------------
-------------------------------------------
• What is TAT for CBC in
emergency (Use TAT Poster)?
• -------------------------------------------
-------------------------------------------
-------------------------------------------
Page 13 of 32
 Anesthesia and Surgical Care/Patient & Family Education
• What is the validity of pre-
anesthesia assessment?
• Within 24 hours for minor surgeries
and ASA I patient and shall be
assessed before the day of surgery if
undergoing major surgery or if the
patient has a medical problem
1. Describe the Handover process
occur in between OR and PACU?
• Upon arrival to PACU, the same
anesthesia team will monitor the patient
until discharge from recovery room. No
handover required inside recovery
2. What are the implantable device
you are tracking in OR?
• Orthopedic implantable
• Surgical Mesh
• ENT implantable
• Intraocular lenses
3. Do you have any timeline for
documenting operative report?
• The Operative report shall be
documented before leaving the
Operation Room
4. Frequency of monitoring of patient
under sedation?
• 5 minutes during procedure
• Post procedure: Q5 minutes x3, Q15
minutes x4, Q30 minutes x2 and Q1 hr
x2
• Should be uninterrupted
5. What type of patient education
shall be given for patients after
anesthesia/sedation?
• Post-procedural pain management and
it is part from anesthesia and sedation
consent
6. Regarding Anesthesia or sedation
drugs, What are your consideration
when you calculate patient doses?
• We have to consider the age (pediatric
Survey Tips
• Never to let patient leaves OR without
completing the OR report
• Pathological Sample is Critical &
handling process of the sample
• Patient Educational Material Needed
to be available all the time
or geriatric )
• Additionally , patient co-morbidities
such as liver or kidney impairment ,
epilepsy , heart or Chest problems
• Check policy Care Of Patient
Undergoing Moderate and Deep
Sedation
7. Surveyor will ask family about the
education they received in
hospital?
• Family shall be educated about all
items of care if thy will take care of
patient
• Family shall be educated in
appropriate way , language and
methods
8. Have you offered any additional
skills training for staff with regard to
cultural competency?
• Yes , Staff is receiving frequently lecture
on cultural competency on regular basis
9. What are the methods used in
patient and family education?
• Verbally, printed material and
demonstration
Page 14 of 32
 Governance, Leadership, and Direction
1. What are the hospital Mission and
vision?
• We are committed to provide highest
quality healthcare services and
education to our customers and their
families by continuous improvement
guided by national and international
standards to preserve and enhance
healthy life
• To establish unique healthcare model,
leading region by exceeding customer
expectations
2. How can you define the hospital
leadership?
• Hospital organization chart is available
all over the departments and Global
Share
3. How could you know about the
hospital quality program?
• Indicators’ results are posted in the
Department boards and Global Share
• Quality Improvement project is
published in Global Share
• IPSGs Results are posted regularly
4. How the quality is managed in the
hospital?
• There is departmental indicators used
to measure the departmental
performance
• Quality and patient safety committee
oversees the quality program
• Every Improvement project is
developed with staff participation
5. What is the Culture of safety in the
hospital?
• KNH provides lectures to educate staff
about the Safety Culture
• Balance between no-blame culture and
accountability
• Professional behavior
• Team Work
• Learning organization
Survey Tips
• Reporting of any Ethical Issues through
Complaint or OVR to Ethics Committee
•
• Reporting Culture
6. Is it safe to report against any
issues could bring risk to patients?
• Yes , We can report manually/through
Mobile application
• KNH is implementing a culture that
support & prevent retribution
7. If you find any unethical issue or
facing ethical dilemma how to
solve it?
• We are going to report to the ethics
committee
• Ethics Committee solves this issue
effectively and timely
• Also, Code of Conduct/Ethics is
available through the share Folder
• We are trained on code of ethics
• Conflict of interest is available and we
ae trained on it
8. What are the Guidelines and
protocols used in KNH?
• Pneumonia
• Jaundice
• Sepsis
• DKA
• Stroke
• NEW Additions***Covid-19, DKA in
Pediatric, Severe Pre-eclampsia,
Multiple Trauma, Status Epilepticus
Page 15 of 32
 Governance, Leadership, and Direction

Critical Issues
• Do not Forget Product Recall Report in case of deficient item
or recalled product.
• Needs identified based on screening criteria in initial nursing
assessment e.g. nutrition or smoking cessation
• Initial assessments by consultants, social worker, Dieticians
• Plans of Care are based on the initial assessment findings
• Physicians orders documented and executed
• Progress Notes reflect the current plan of care,
interdisciplinary planning Fall risk assessment (Modified
Morse Fall Scale, Humpty Dumpty Scale on admission and
daily), Pain assessment and patient’s response to
medications and other interventions, Patient understanding of
education
• Handovers including shift-to-shift, unit-to-unit and unit-to-
diagnostic and procedural areas
• Universal protocol checklist completed for invasive
procedures (includes those done at bedside)
• Discharge planning
• Medical, Nursing care plan
• No unapproved abbreviations
• Date/time, legible signature and licensure present for all
documentation
• Specimens collected and labelled using appropriate
precautions
• Glucometers cleaned between patients with hospital-
approved disinfectant
• Glucometer control solutions initialed, dated when opened;
not expired (within 90 days of opening)
• Blood transfusions verified, and vital signs recorded
• Critical values read back and appropriate response initiated
Page 16 of 32
 Management of Information
1. Do you use any abbreviations?
Survey Tips
• Yes, we have an approved list of
abbreviation available in Share Folder and Standardized Definition,
every unit Abbreviation and Symbols policy and
• Also, there is a prohibited list of approved and prohibited
abbreviation
abbreviations lists
• We didn’t use abbreviations in
consent/discharge summary/patient
addendum/amendments
information or instructions.
8. How long is the
2. Where are the Policies of your
history/assessment valid?
department?
• History taking and Physician
• All departmental/Hospital Wide
assessment is valid for 30 Days then to be
policies and work instruction and others
repeated
are available in Global Share and there is
9. Do you share in Medical record
a hard copy
auditing?
3. Did you Trained on those Policies?
• Yes , we have an annual auditing
• Yes, there is an attendance sheet
schedule addendum/amendments
4. How to identify each patient entry?
• Every patient entry is dated , timed
and authorized by signature and stamp/ID
number
5. How to request lab/radiology
services in case of Oasis is down?
• We have a sample of all medical
record in hardcopy forms available in each
unit
6. Have you been trained before on
planned and unplanned downtime
of Oasis?
• Yes, The material of training is
available on Global Share
• The attendance sheet has to be
available
7. If there is an error in writing in
Medical Record, what will you do?
• A single line should be drawn through
the incorrect information and write ME or
ERROR on top of the wrong entry then
beside it must be dated, signed and
stamped
• Make a notation or refer to
Page 17 of 32
 Management of Information
> (greater than) Write “greater
< (less than) than” Write “less
Critical Issues than”
Abbreviations for Write drug names
• Be Cautious when you write drug names in full
an Abbreviation.
• Never to use Prohibited Apothecary units Use metric units
Abbreviation
@ Write “at”
• Records and information are
protected from loss, destruction, cc Write “mL”
tampering, and unauthorized or "ml" or
access or use
“milliliters” (“mL” is
preferred)
Prohibited Abbreviation
Do Not Use Use Instead µg Write "mcg" or
U (unit) Write "unit" “micrograms”

IU (International Write "International

Unit) STAFF INTERACTION
Unit"
Q.D., QD, q.d., qd Write "daily"
(daily) QOD, q.o.d, • How do you ensure Information
Q.O.D., Write "every other
qod privacy, confidentiality, and
day"
(every other day) security in your unit?
Trailing zero (X.0 Write X mg • -----------------------------------
mg)* Lack of
Write 0.X mg • -----------------------------------
leading zero (.X mg)
MS Write "morphine • What shall you do when you
sulfate" Write witness breaching to information
"magnesium sulfate" confidentiality?
MSO4 and MgSO4 • -----------------------------------
• -----------------------------------

Page 18 of 32
 Staff Qualification and Education
1. Do you have staff health program
in your hospital? If yes what do you Survey Tips
know about it?
• Yes, Staff Health and Safety Program
provide a responsive to urgent and All employees are exposed to
non-urgent staff needs to maintain staff communicable disease shall
physical and mental health. report to Staff Health Clinic
• We have Staff Health Clinic
2. What do you do if you need to (SHC).
know something or to ensure any You shall know your HB
point in your duties and immunity & varicella & MMR
responsibilities?
• I have read my current Job
Description available in Global Share
3. If a physician shows up on your • using specific checklist in the
unit to do a procedure, how do you probationary period and annually
know he or she is privilege? 9. What are the components of A
• Through the Privilege for physician on staff health and safety program?
hospital Global share • Initial employment health screening and
• (Important for OR/Admission) preventive immunizations
4. When you were hired? Who met • Control harmful occupational exposures,
you for hiring? such as exposure to blood and body fluid
• I was hired on ……. and harmful noise levels
• HR then, technical evaluation that is • Annual medical examinations
conducted by Head of Department. • Safe patient handling
Then HR Manager to verify KNH
• Managing workplace violence
requirements for employment
• second victims of adverse or sentinel
5. Who is responsible for performing
events
Credential and privilege in KNH?
• Treatment for common work-related
• Credential and Privilege Committee
conditions, such as back injuries, or
6. How long are privilege
generated? more urgent injuries, counseling and
follow up
• For Two Years
7. What are the level of orientation
that you have taken in KNH?
• General Orientation
• Specific departmental orientation
• on Job orientation
8. How can you as a supervisor
ensure that your staff are competent
in their duties?
• By doing Competence assessment
Page 19 of 32
 Staff Qualification and Education

Critical Issues STAFF INTERACTION

Page 20 of 32
 QUALITY
Quality MANAGEMENT SYSTEM
Management System
1. What is the culture of safety in
KNH?
• A culture of transparency that promotes
patient safety
2. How does KNH support a culture
of safety?
• Promoting transparency through
promoting the reporting of near misses
and adverse events
• Non punitive response to reporting
• Learning from our mistakes
• Disclosure of incidents & near misses
conducted every quarter for hospital staff
3. What is Near miss?
• Is an Incident or situation directly
associated with care or services provided
within the hospital that could have
resulted in an accident, injury, illness or
property damage, but did not, either by
chance or through timely intervention.
4. What is the Sentinel event?
• Is a patient safety event (not primarily
related to the natural course of the
patient’s illness or underlying condition)
that reaches a patient and results in any
of the following:
• Death
• Severe temporary harm or Permanent
harm
5. Sentinel Event Reporting
Process
• Immediate notification to:
• Your supervisor
• QM director
• Administrator on call
• OVR Report should be submitted to the
QM office.
6. What is done after a sentinel
event occurs?
• Root cause analysis is done (RCA) by
Root Cause Analysis Team. Action
Plan will be designed as appropriate and
Survey Tips
• Occurrence Variance Reporting
System policy- it is important to know
what the reportable incidents are.
• We have an electronic application to
report OVRs in addition to the
manual forms.
implemented immediately.
7. Who takes action according to the
results of root cause analysis?
• Hospital leadership
8. Give an example of a sentinel
event that occurred in KNH
• Medication error resulted in major
morbidity.
9. Who is responsible for
performance improvement
activities in your hospital?
• Hospital leadership
• Head of departments
• Front line staff
• Facilitator: Quality professionals
“Quality Is Everybody’s Job”
10. How do you involve staff
members in improvement projects?
• Frequently nominated to participate in
relevant improvement initiatives:
• Improvement methodologies used are:
• FOCUS PDCA
• Lean Management
11. Who is involved in the process of
designing and implementing your
improvement projects?
• Front liners (the most knowledgeable
about the current process)
• Representatives from other relevant
departments
• Quality professionals as facilitators
12. Who is responsible for
Page 21 of 32
 Quality Management System
recommending performance
improvement initiatives to
leaders? STAFF INTERACTION
• In the Quality and patient safety
committee, recommendations are What are your department
presented by the quality team in indicators?
collaboration with relevant HODs. • ----------------------------------------
• Ideas boards • ----------------------------------------
• Ideas e-mail
• Personal interview
• OVRs What are performance
13. How do you become aware of improvement projects that have
the need for a performance done in your department?
improvement initiative?
• Near misses and adverse events • ----------------------------------------
• Patient feedback
• ----------------------------------------
• Deteriorating KPIs
14. How do you keep track of data
analysis?
• Results are printed & posted on
relevant Departments Boards
• Hospital share folder

15. Who is responsible for selecting

hospital wide measures?
• Hospital leadership according to the
following:
• High volume
• high cost
• High risk
• Strategic goals
16. Mention the name of a proactive
risk management approach?
• FMEA (failure mode and effect
analysis)

17. What is FMEA applied to?

Critical, high risk processes.

Page 22 of 32
 InfectionPREVENTION
INFECTION Prevention and
ANDControl
1. What should you do to prevent
the spread of infection?
• The prevention of infection is each
person’s responsibility. Treat all blood
and bodily fluids as if potentially
infectious
• Hand hygiene is the single most
important procedure to stop the
spread of infection
• Tips for effective hand hygiene
include:
• Apply one or two pumps of antiseptic
hand gel and cover all of the hand
surfaces, including fingernails and in • Use soap and water if hands are visibly
between fingers as the WHO poster
for beside each alcohol dispenser.
Rubbing for 20-30 seconds until dry
OR
• Rub well-lathered hands together for
40-60 seconds using the same WHO
steps for alcohol followed by thorough
rinsing under running water. Use
paper towel to wipe your hands dry
and to turn off the faucet
2. When to cleanse hands:
- As per WHO5 moments
• Before contact the patient
• Before a septic technique
• After contact the patient
• After touching patient surroundings
• After contact with body fluids, mucous
membranes and wound dressings
- When I arrive the hospital
- After using the before putting on
gloves
- After bathroom
- After removing gloves
- Before meals
- When visibly soiled
- before I leave the hospital
CONTROL
Survey Tips
AA
JCI surveyor will observe the
hand hygiene practice during
their visits in hospital units
• The use of gloves does not eliminate
the need for good hand hygiene
soiled or when caring for a patient with
Clostridium difficile infection or
norovirus
3. What are important “contact-times”
when disinfecting equipment and
surfaces?
• Plastisept for surfaces 1 minute after
each patient
• Detrosept for all medical equipment
after each patient
• Also see Chemicals for Cleaning and
Disinfecting Environmental Surfaces
instruction on nursing board and
housekeeping policy
4. What is the action done if the no. of
patients with a +ve communicable
disease exceeds 2 within 3 hours?
Activate external disaster code
5. What is Monthly surveillance
statistics include?
It is available on nursing board
• Hand hygiene - VAP
• CLABSI - CAUTI
• SSI C- Section – Appendectomy
• MRSA bacteremia - BSI
6. When to apply standard
precautions?
• When dealing with blood, body fluids, non-
Page 23 of 32
 Infection Prevention and Control
intact skin, mucous membrane to all
patients.
7. How do you ensure early
recognition of global
communicable diseases?
• In ER and OPD and during reception
use visual screening checklist & nursing
assessment, ask the Following
questions:
1. In the past 2 weeks do you have
a fever? (If the patient suffered
from fever, ask him/her about
having rash in the past 2 weeks)
2. In the past 2 weeks, have you
traveled outside KSA?
(See if the area suffered from
certain outbreak)
3. In the past 2 weeks did you
suffer from cough, shortness of
breath or difficulty of
Breathing? Do any of the close
contacts have the same
symptoms?
8. What is the action taken if the
patient meets the criteria for + ve
communicable disease?
• Provide a surgical mask for the patient
to wear, place patient in -ve pressure
room,
• Inform head nurse, IC staff, and dept.
9. What do you do if you suffered a
sharp injury?
• Wash area with soap and water,
encourage free flow of blood, report to
Staff clinic, Infection Control
Department and complete an OVR
report
10. What is the exact expiry
date on any supply?
• The last day of expiry month
11. What do you do when an
expired supply is discovered
in your area?
• It should be returned to the
stores
12. How you use single use
device in KNH?
• Use it only as single use device
13. Who decides that the patient
needs isolation?
• The Treating Physician in
collaboration with the Infection
Control staff
14. How do you reduce the risk
of HAIs?
• By applying standard precautions
to all patients, isolation
precautions to
• Suspected/ confirmed infectious
cases,
• Complying to bundles for patients
on medical devices
15. Who are the patients
indicated for isolation?
• Patients who are suspected of
infectious diseases, as well as
confirmed cases by lab tests,
patient transferred from another
hospital
16. What are the types of
isolation?
• Contact
• Airborne
• Droplet
Page 24 of 32
 Medication Management and Use
1. What are the initiatives of KNH to 6. What is the practice for
minimize the unnecessary use Controlling Narcotics Stock?
of Broad-Spectrum • Narcotic stock check must be made
Antimicrobials? twice daily by the unit nurse at shift
• Implement antibiotic stewardship policy exchange on the narcotic audit form
2. What are the restricted • The pharmacist shall check on the
antibiotics? stock monthly (included in the
1. Vancomycin inspection list)
2. Imipenem 7. What should you do to ensure
3. Meropenem safe medication management
4. Cefepime and 4th generation for newly admitted patient?
cephalosporins • Medication reconciliation within 24
5. Piperacillin/Tazobactam hours from admission
6. Teicoplanin 8. What are the main factors
7. Rifampicin considered in the
8. Tigecycline appropriateness review?
9. Linezolid • Appropriateness of the drug, dose,
10. Colomycn frequency, and route of administration
11. Invanz (Ertapene • Therapeutic duplication
• Real or potential allergies or
3. Who can approve on introducing sensitivities
a new drug? • Real or potential interactions between
• Pharmacy and P&T Committee the medication and other medications
or food
4. What will be done if the • Variation from hospital criteria for use
physician prescribed non- • Patient’s weight and other
formulary drugs? physiological information
• Pharmacy approves and procures in co-
ordination with the supply Chain
Department for limited number of times Survey Tips
after which this medication shall be AA
added to the formulary In case of unclear medication order
The Pharmacy Department shall not
5. What are the precautions while dispense then:
dealing with concentrated • Contact prescriber for clarification
electrolytes? • If the prescriber is unavailable,
• Present only in the ICUs and central contact another physician on the
pharmacy, not allowed to be present in same service and team
the floors • If the above are unavailable, contact
• Labeled with red label as it is high alert the on-call physician
medication
• stored separately from another
medication

Page 25 of 32
 Medication Management and Use
9. How can you report any Adverse
Drug Events?
• Through Adverse Drug Reaction Form
10. What precautions should be
done during administration of
HIGH alert medications?
• Verification by 2 nurses
• Double check prior to administration
• Two nurses shall compare the label
with the product and the label of the
Pharmacy against the written order
and the medication administration
record.
• Double check of the infusion pump for
correct rate
11. Dose the organization use
PRN order? Describe how?
• Yes, All orders for PRN
• Medication must be specific for dose,
maximum daily dose, indication and
time interval.
12. What shall be done regarding
the medication brought by the
patient?
• Physician check medication If the
patient will continue this medication
then the physician, order them
• Medication shall be checked, labeled,
dispensed, and documented by the
Pharmacy
13. What are the types of
medication ordering?
• Stat dose orders
• As needed (PRN) orders Emergency
orders
• Weight-based orders
14. Do you allow range orders?
• No
15. Who adjust weight based doses?
• The physician then the doses is reviewed
by the pharmacist with consideration of
the history of the patient
16. What is the organization policy for
dispensing emergency
medication?
• If cardiopulmonary case: use crash carts
• If any other emergency case: dispensed
from the pharmacy as STAT order within
15 minutes
17. What is appropriate for reviewing
Total Parenteral Nutrition (TPN)
products?
• Pharmacists evaluate this
product upon procurement
adjusting doses and selection of
the appropriate product for the
patient is the role of the ICU
doctor
18. What is the organization policy
regarding expiry date of opened
vials?
• Upon exceeding the expiry date specified
by the pharmacy, vials discarded
according to infection control instructions
in the red bag
19. How can you store the
controlled substances?
• stored in safety cabinets
• double locked
• the two keys should be kept with
separate 2 staff
•
Page 26 of 32
 Facility Management and Safety
1. What should you In case of
fire ?
Follow the R-A-C-E protocol:
R = Rescue all persons from
the immediate area of the fire.
A = Activate the alarm and
dial ---444---to report the fire.
C = Contain the smoke or fire by
closing all doors.
E = Extinguish/Evacuate by using
the proper fire extinguisher
2. How do you use a fire
extinguisher?
P = Pull the pin located between
the two handles.
A = Aim the base of the fire.
S = Squeeze the handles together.
S = Sweep from side to side at
the base of the fire. AGAIN IF NE
3. Which extinguisher used for
extinguishing fires involving
burning cloth, paper, or
wood?
POWDER, or you can use WATER
4. Which extinguisher used for
electrical equipment motors,
switches, and flammable
liquids?
The fire extinguisher contains (CO2)
5. How often do you have fire drills?
Schedule / department and shifts.
6. Which fire extinguisher should not
be used on electrical equipment,
motors, and flammable liquids?
Fire extinguisher Type A that contains
water.
.
7. Who is authorized to shut off
the oxygen valves in the event of a
fire or another emergency?
Charge nurse on specific unit
8. What does your hospital consider
as a “disaster?”
Any situation, which affect the normal
operations in i.e, flood, snow. Earth
quick.
9. How do you test your emergency
preparedness program?
The Safety Committee conduct 6 mock
disaster drills per year and full drill / year
10. What information should one attempt
to obtain from someone calling in a
bomb threat?
• Exact Language used by the caller.
• Location of the bomb.
• When explosion is to occur.
• Type of speech of caller.
• Background noise noted.
• Gender of the caller.
• Words used repeatedly
11. Who should be contacted upon
receiving a bomb threat?
• Administrator
• Security
• Safety Officer
• Department Heads
Page 27 of 32
 Facility Management and Safety
12. What do you do if someone,
whether a patient, visitor, or
employee becomes extremely
agitated or violent?
• Remain calm, allow them to
verbalize, keep distance, and keep
exit open, call ---444---
13. In case of fire disaster who
should call Civil Defense?
The KNH call center operator,
near ER reception.
14. When new equipment is bought
or loaned to your unit you
should?
Call the work order line for a visual
and electrical inspection before use.
15. How do you report an
equipment malfunction?
• Put an out of order tag on it
and takes it out of service!
• Call in a work order or send directly to
Bio-med for service.
16. Who is authorized to shut off the
oxygen valves in the event of a
fire or another emergency?
Charge nurse on specific unit.
17. Where can the details about every
chemical used are found?
I Material Safety Data Sheet (MSDS)
Manual.
18. Other than the (MSDS), where
can the hazardous material name
and hazard warning for that
material be found?
On the container label
19. What first aid measures are
necessary when working with the
hazardous chemicals found in
your department?
• Check the MSDS for each specific
chemical in the MSDS Manual
located
20. For KNH medical waste and
other waste what color do we use?
• Yellow bags for Infectious waste
• Red bags for Pathological
waste
• Black bags for General/Normal
waste
21. Where do you dispense
needles and sharps?
In the sharps containers
22. Describe your hospital-wide
smoking policy
• Patients not allowed smoking our
hospital without a physician’s order
to do so.
• if the patient is unable to escort
outside, then arrangements made
through security department.
• All employees are required to smoke
in the designated employee smoke
area only which is located by the
employee parking lot.200 SR fine of
violation.
23. What type of incidents should
you report?
• Any patient, visitor, employee, or
physician incident or unusual
happening.
• Fill out an Incident Report obtained
from your supervisor.
Page 28 of 32
24. Facility Management and Safety
25. How do you report an employee
incident?
1. Fill out an Incident Report
immediately and notify your
supervisor immediately.
26. What would you do if you
suddenly involved in a
potentially dangerous situation?
• Protect yourself and call for help
as soon as possible.
• Remain calm.
27. How soon after witnessing
a security incident should an
Incident Report be completed?
As soon as the incident occurs.
28. What procedure do you follow
when theft has occurred in an
area?
• Whether hospital or personal
property, make sure the item has
not been misplaced.
• Alert your supervisor.
• Fill out a Security Incident Report.
• (The supervisor will contact
Security.)
29. What is the first response in
case of code pink alert?
Secure the access Entrance and Exits,
keep watching for suspicious actions and
luggage.
30. By which ways we are exposed
to chemicals? (4 ways)
• Inhalation : Breathing in dusts,
mists and vapors -
• Ingestion : Eating contaminated
food
• Absorption : Skin contact with a
chemical
• Injection: Forcing an agent into
• the through a needle or a high-
pressure device A NEEDLE ORGH-
PRESSURE
31. The main causes of fires are?
• Neglect and lack of follow-up.
• Lack of fire tools maintenance and
supervision.
• Lack of knowledge of the means of
public safety.
• Poor housekeeping around electric
equipment.
• Improper Storage and usage of
Flammable materials.
32. KNH Fire Fighting Systems
consist of what?
• Fire Extinguishers.
• Fire Hose Reels.
• Automatic Sprinkler Systems.
• Detection / Alarming Systems.
33. Fire is a chemical reaction
between three elements, what are
they?
Oxygen/air, fuel/material,
heat/source of ignition
34. Incident Command Center
(ICC): It is located at:
Hospital Executive Director Office
35. Who is responsible for
maintaining safe practices in the
hospital?
Everyone is responsible for safe
practice
Page 29 of 32
 Facility Management and Safety
STAFF INTERACTION
36. What is the meaning of
hazardous materials sign?
• Red: for fire.
• Yellow: for substance reactivity
and stability
• White: for special hazards and
precautions.
• Blue for health hazard
37. KNH Safety Management
Program consist of 7 elements,
what are they?
• Safety of the building.
• Security.
• HAZMAT (Hazardous Materials)
and Waste Management
• Disasters / Emergencies
• (Internal, External)
• Fire Safety.
• Medical Equipment.
38. WHAT IS KNH CODES
Fire Safety:
Locations of my department’s pull
stations:
• ----------------------------------------
Location of my department’s fire
extinguisher:
• ----------------------------------------
• ----------------------------------------
Location of my department’s fire exit:
• ----------------------------------------
• ----------------------------------------
Location of my department’s oxygen
shut-off valve:
• ----------------------------------------
• ----------------------------------------
Who has the authority to shut off the
oxygen shut-off valve during
emergencies?
• ----------------------------------------
• ----------------------------------------
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Ut

Page 31 of 32