2019

CBAHI
Questions & Answers

Prepared By
QUALITY AND
PATIENT SAFETY
DEPARTMENT
 QUESTIONS
 What is the Hospital vision,
Mission, Values?
 What are Hospital rules that
you are following?
 What are Hospital rules that
you are following?
CBAHI Q & A
ANSWERS
 Vision : Being a pioneer in providing a unique quality medical
services to the community of Al- Taif
 Mission: A private institution providing quality health care services.
Known as a hospital of choice for professionals and consumers.
 Values : To value those we serve, guided by our commitment to
excellence, leadership and Islamic religion
We are Following Hospital code of conduct that identify :
 Full compliance with all applicable laws and regulations and with
the highest standards of ethical business conduct.
 All persons, including patients, visitors and staff are treated with
respect.
 Respect the religious beliefs and practices of the citizens of the
Kingdom, and particularly the beliefs and practices of their Hospital
colleagues and Hospital patients. Avoid actions, comments or
mannerisms which could be considered as insulting or
objectionable.
 Provide excellence in patient care and observe the following
guidelines regarding patient relationships:
 Receive patients with courtesy and offer assistance whenever it is
required.
 Avoid eating, drinking, smoking, chewing gum, boisterous behavior,
undue familiarity or other similar actions in the presence of
patients.
 Ensure that all working hours are devoted to assigned
responsibilities and duties.
 Perform assigned duties in a careful and honest manner giving the
best effort for the Hospital.
 All personnel are required to display on their upper dress their
employee ID badge at all times.
 All employees, male and female, should at all times practice the
principle of modesty and respectable interaction during activities,
gatherings, or when dealing with each other.
 Employees shall not engage in any activity that might create a
conflict of interest for the hospital or for themselves individually.
 All employees shall not take advantage of their position to seek
personal gain through the inappropriate use of information or
abuse of their position.
 All employees shall follow all restrictions on use and disclosure of
information. This includes following all requirements for protecting
information except as authorized by the owner of the information
or as otherwise permitted by law.
 All employees are responsible for safeguarding the confidentiality
of information related to the privacy of patients, hospital
information, and information owned by others.
 No staff member shall accept any gift, favors, services or other
things of value under the circumstances from which it might be
inferred that these were offered for the purpose of influencing
them in avoiding hospital rules, policies, procedures, or generally
accepted business or medical practices.
 Every employee has to believe in “Customer Satisfaction” concepts
and that the satisfied customer is essential to our success.
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 How to Report Violations of
the Code of Conduct?
 Are you familiar with policy
of ………?
 Or can you show me this
policy ?
 What is your role in Quality
& patient safety program?
 What is your role in Risk
management program?
 Who is your department
Head?
 Can you show me your
Department Organization
chart?
 Did you receive Job
description?
 Where your roles and
responsibilities are
identified?
 Did you attend orientation
program in the beginning of
your work?
 (General Orientation )
CBAHI Q & A
 All employees shall comply with all laws and regulations governing
the handling and disposal of hazardous materials, other pollutants
and infectious wastes.
 No employee shall use, possess, distribute or be under the
influence of alcohol, narcotics or other dangerous illegal drugs in
or out of the hospital at any time.
 Instances of violations should be reported to one or more of
the following individuals depending on the circumstances:
 Staff member’s immediate supervisor;
 Nursing Director or Medical Director
 Human Resources Manager
 Yes ,it is available on the share folder or hardcopy
 You should know how to access policies and procedures
 Complying with hospital policies and procedures
 Complying with guidelines
 Participation in improvement project (N.B. You should be familiar
with the improvement project that was done in your department?
 Collecting the data required for measuring The Key performance
indicator (KPIs)
 Reporting any incidents or near misses by using OVR form
 You should be familiar with your department risk assessment?
 You should know how to access to your Department ORG. Chart (in
your depart manual )
 Yes I received and signed it during the
appointment process in the hospital
 My responsibilities are identified in it
 Yes ,and it was giving information about
 Mission and vision and organization chart
 Fire safety disasters-and hazardous materials
 General information on the paging and telephone system.
 information on infection control
 General information on staff evaluation process
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 Did you receive orientation
about your department
before starting your job?
 After appointment who gave
you departmental
orientation?
 What are the topics that
were discussed in the
departmental orientation?
 Who evaluate your
performance and when?
 Do you know the
recommendations of your
department head to improve
your performance?
CBAHI Q & A
 Definition of adverse and sentinel events along with the
process of reporting
 Hospital policy on abuse and neglect of children and adults.
 General information about staff health program
 General information about important local cultural and social
themes
 General information about the hospital-wide quality, patient
safety, and risk management plans.
 Ethical conduct and expected professional communication with
patients and colleagues.
 Patient rights.
 Yes ,I received departmental orientation from my immediate
supervisor / department head
 The orientation topics were about
 Departmental policies and procedures
 Specific job responsibilities
 Safe operation of equipment and medical devices
including troubleshooting and malfunctions reporting.
 Clarification on all topics provided in the general
orientation as needed
 My immediate supervisor/department head is responsible
for my performance evaluation
 Evaluation is done after 3 months from appointment in
hospital (probationary period) ,then every year (annually)
 The outcome of the performance evaluation is used to set
objectives for performance improvement and professional
development
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 QUESTIONS
 Do you know what is the tool
that that hospital adopt in
process improvement?
 Did you or your department
participate in any
improvement activities?
 How can you report any
incident occurred?
 Can you tell me what is the
difference between near
misses / adverse
event/Sentinel event?
CBAHI Q & A
ANSWERS
 FOCUS PDCA
Find Opportunity for Improvement
Organize team
Clarify the process
Understand the causes of the problem
Select solutions
Plan for the solution (action plan )
Do the action plan
Check the effect on small scale or short time
Act implement solution for long time
You should be aware of any improvement project done in your
department
By using OVR form
I will write the OVR form and send it to quality department within 24
hrs.
Near misses: An event or situation that could have resulted in an
adverse event but DID NOT HAPPENED either by chance or through
timely intervention.
Adverse event: any event that is not consistent with the routine
operation which happens at the hospital and cause harm to staff
/patient or any hospital property
Sentinel event : unexpected occurrence involving death, serious
physical or psychological injury and include the following
 Unexpected death.
 Unexpected loss of limb or function.
 Wrong patient, wrong procedure, or wrong site.
 Retained instrument or sponge.
 Serious medication error leading to death or major morbidity.
 Suicide of a patient in an inpatient unit.
 Infant abduction or discharge to a wrong family.
 Maternal death.
 Hemolytic blood transfusion reaction.
 Air Embolism.
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 What you will do during System  I will inform IT department first
down time?
  Then I will use the manual forms (in each department you will
 What if the system or module find folder called downtime forms )
that you are using on HMS is
down?  After the system return back ,I will enter the data again

 What are patient and family Patient And Family Rights

rights and responsibilities
 Acquire the best health care available in safe environment.
 Have the physician of your choice and request another
consultant “if needed”; and to know the names/ roles of
those who are involved in your care.
 Know all the information about your case, diagnosis,
treatment and the estimated cost and to respect your
decision.
 Maintain strict confidentiality for any information related to
your illness, treatment and document in.
 Be treated pain free.
 Refuse signing the consent form for any test or treatment
that you did not have proper information about them.
 Refuse treatment after knowing & being informed of the
medical consequences. Special form should be signed for
that.
 Treated with respect to your traditions and believes
 Get a copy for any information or documents, such as medical
report, sick leave, bills as documents in your medical chart
(According to MOH policy).
 Request a review of the hospital bill and to receive an
explanation of an unclear item.
 Ask to be discharged from the Hospital, against the physician
/ medical advice and to sign for that (DAMA form) if the
condition is not life threatening.
 Choose the person who represents you in signing the hospital
documents including release of information.
 Have medicine prescription, follow-up appointments when
discharged from the hospital.
 Complain from any unsatisfied services and receive an
explanation and support according to hospital policies.
 Truthfully informed when your needs exceed hospital
capability for care and facilitate transfer you to another
health care setting as recommended.
 Be treated in privacy and respectful manner.

•What are patient and family Patient And Family Responsibilities

rights and responsibilities

CBAHI Q & A |Page5

  Know and follow the law of the Kingdom of Saudi Arabia and
the hospital’s rules and regulations as explained to you by the
hospital staff.
 Be cooperative and follow the care recommendations given
to you by your attending physician and nurses.
 Provide accurate and complete information concerning your
complaint and illness.
 Provide and sign all admission required documents.
 Do not disturb hospital’s staff, other patients and
maintenance hospital’s property.
 Pay all your hospital bills related to hospitalization, services,
telephone calls, etc.
 Fill and sign required consents regarding to all services.
 Follow-up the treatment plan established by your physician
including the instructions of nurses as they carry out the
physician’s orders.
 Restricted a SMOKE FREE facility.

CBAHI Q & A |Page6

 Questions Answers
Surveyor will ask medical director and Yes we received it and it is found in the electronic library and in the
head of departments about staff bylaws: desktop in all computers.
Was it distributed to all medical staff?

Also will ask some staff about medical

bylaws if they received on starting the
job?

What are the medical bylaws? It is the agreement between the hospital top management and the
physicians
What it includes? It includes procedures of appointment, reappointment, credentialing,
granting privileges , peer review , ethical conduct and standards of
practice
What is peer review? Peer review is the evaluation of a practitioner’s professional
performance by peers and includes the identification of opportunities
to improve the quality and safety of the provided care.

And how does it happen in your In departmental meetings ,we identify morbidity and mortality cases
department? and if the head of department sees that the case need to be sent to
peer review committee, the case is discussed in peer review
committee(Chaired by the medical director)

How do we select cases for peer  Practice Performance evaluation findings

review?  Sentinel event.
 Ministry Of Health reportable cases
 Ministry of Health Patient complaint
 Aggregated OVRs that reveal threatening trend for a certain
practitioner.
 Recommendations from other committees/departmental meeting
How do we evaluate peer review We evaluate all cases by appropriateness, effectiveness and timeliness
cases? of care
eg.: Delay in diagnosis or management, using improper resources or
medical equipment, Ineffective medication outcome as adverse drug
reaction or medication error.
N.B: You can say case example but only if the case was discussed in
departmental meeting

What can be the results of the peer Results can be :

review committee?  Counseling
 Training
 Unplanned/focused performance evaluation
CBAHI Q & A |Page7
#Surveyor can ask head department
about how to deal with the result of peer
review?
Can you object the decisions of the
peer review committee or any other
committee?
How is your practice performance
being evaluated?
How do the clinical leaders and the
medical director in your hospital take
a decision or improve quality and
safety of care?
What are the hospital committees?
How do you make sure that you serve
the same standard of care to all
patients?
What are the adopted guidelines in
your hospital? and how they are
selected?
Where you can find these guidelines?
Do you have other guidelines as per
your specialty?
CBAHI Q & A
 Putting the physician of concern under supervision for a
temporary period
 Reviewing (or limitation) of granted privileges
 End of contract
Yes, I can by using the appeal rights Within ten (10) days of the receipt
of the decision if there was Insufficient evidence in the meeting record
to support the decision.
The head of department uses ongoing practice professional evaluation
form with predetermined criteria and I sign it
They are communicating via the hospital committees.
They discuss quality ,safety and risk management
issues
By using Clincal practice guidelines and Private hospitals' laws and
regulations.
Surveyor will ask about the content of practical guidelines(You should
read the guidelines)
The hospital leaders in the medical council decides to adopt 5 main
guidelines which are selected according to the top 5 diagnosis that the
hospital serves and they are:
1. Acute Bronchitis
2. Acute Sinusitis
3. Bronchial Asthma
4. Diabetic Polyneuropathy
5. Type 2 diabetes
In the electronic library in your computer's desktop
(Folder's name Circular and regulations)
Yes I have ,also in the electronic library.
And these guidelines are selected by the physicians in each department
and discussed in the monthly departmental meeting.
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How do you communicate with each
other in your department (or do you
have departmental meeting in your
department?)
Provision of Care Questions
What cases you will accept in your
hospital?
What cases you will accept in OPD
and when you will do screening?
Screening in OPD and ER
How it is done and who is
responsible?
CBAHI Q & A
Yes,we have monthly departmental meeting and we may discuss the
following:
1. Equipment Needed
2. Mortality & Morbidity Cases
3. Patient Complains
4. Incidents/ Near misses & corrective action
5. Improvement projects
6. New services
7. Adopting Guidelines
8. Selected cases for peer review
9. Staff complaints
10. Other issues referred from medical council or other committee.
According to the hospital mission and scope of services and availability
of resources (as bed availability, required specialty, medical equipment)
According to the hospital mission and scope of services
Screening is done for all patients before registration by the registration
staff to know if the patient's required specialty is within our services or
not
In the Emergency Department, screening for patients is done once the
patient arrives to ER, to determine:
 The need for measures of isolation (as patient with infectious
respiratory disease), using a special form of: Communicable
Diseases Screening Sheet
 ER Physician is responsible for determining out of scope services
by visual screening and physical examination for the patient.
 The patient’s immediate needs/urgency of care, based on the
Triage criteria and documented in the Triage form.
Screening for patients in OPD:
is done once the patient arrives to OPD clinics' reception, to determine
the Out of scope of services and special needs as physical disabilities
by visual screening and questioning the patient/family
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What are the services that are not
served by your hospital?
If you decide to admit one patient
and you don’t have bed available
what you will do?
Surveyor will ask staff about availability
of laboratory test and radiological
investigations?
CBAHI Q & A
We will manage the patient and will do life saving measures untill bed
is available(maximum 2 hours if the patient was in ER)
If no bed is available, we will stabilize the patient and we will arrange to
transfer the patient to another hospital by sending fax with report from
Most Responsible Physician of the patient
Yes, investigations are available according to our laboratory and
radiology scope of services and when there is unavailable investigations
in our lab for example ,we use a reference laboratory (Alborg)
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What will you do If you are faced by a patient and you can't understand his/her language?

I will use the Hospital list of translators(language bank) and list of foreign embassies:

CBAHI Q & A | P a g e 11
What will you do if are faced by a
disabled patient (Deaf, Blind, Has
Functional limitation)?
The most responsible physician must have
the privilege to admit patients and to be
a most responsible physician
Surveyor will ask physician about his
privilege to admit the patients?
What are your other functions as a MRP?
CBAHI Q & A
Our hospital has assistive devices like wheelchairs and we have
assisstants to assisst the patient in finalizing the registration and
admission procedures
We also have staff who are aware with the Sign language
We will call them to assisst us in communicating with the
patient(Ms.Dina Medical director admin.)
Yes, I am following my privilege In admitting the patient under my name
(MRP=Most Responsible Physicians)
 I am in charge of the over-all management of patients under my care
 Documentation of the patient’s plan of care.
 Collaborates and communicates with the other health care
practitioners.
 Supervises patient's rounds daily with his / her team and ensures
patient rounds are conducted during weekends and holidays.
 Reviews management of patient with the Specialists and residents for
in-patients
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When you complete the assessment your patient?
And does it differ if the patient is in the general ward or in Critical areas?

What is the content of the assessment and does initial assessment differs from reassessment?

CBAHI Q & A | P a g e 13
Discharge Planning and are you aware of
it?
What is Discharge planning ?
It is preparing the patients for discharge.(Continuity of Care)
When to start ?
Upon admission
A nurse only can do it ?
No,a Multidisciplinary team coordinated by the Most responsible
physician & the assigned nurse.
For All patients ?
Discharge planning needs assessment is done for all patients but
Discharge planning is done according to the Discharge planning criteria
that is found as regards to patient condition.
Who will Participate in this?
Patient/Family and all healthcare providers needed according to the
patient condtion ;eg.dietician,social worker,physiotherapsit.

Who needs specialized assessment from 1. Obstetrics & Women In Labor 2. Gynecology
your patients? 3. Neonatal (Newborn-NICU( 4. Pediatric-PICU
5. Physical Therapy 6. Anesthesia (Preoperative(
7. Emergency Patients 8. Critical patient (ICU)
9. Dialysis 10. ESWL(Lithotrepsy)
11. Frail elderly patients 12. Terminally ill patient
13. Alcohol/Drug abuse 14. Dental/Hearing/Speech
assessment defects

CBAHI Q & A | P a g e 14
 15. Venous Thrombo-embolism 16. Patients in severe or
chronic pain
17. Abuse and neglect 18. Patient at nutritional risk
19. Patient at Psycosocial risk

Do you know who vulnerable patients are Venerable patients are:

and how to deal with them?
 Immune-compromised
 Comatose
 Elderly and Frail(over the age of 75 and unable to perform at least three
"activities of daily living")
 Terminally ill
 Disabled
 Children
 Neonates and infants
 Emergency patients
 Patients with signs of abuse and neglect

I deal with them according to the vulnerable patients' policy as follows:

 Respect patient/family rights and dignity

 Protect them from insult or abuse from staff,vistors or other patients
 Refer to social worker for further assessment
 Ensure all equipment and assistive devices are available
 Safety and security measures are implemented (eg. Call bells, Cameras
and secured doors)
 Perform specialized assessment(as appropriate to the patient's condition)
 Develop multidisciplinary care plan (if required by patient's condition)
 Consider discharge planning as early as possible

CBAHI Q & A | P a g e 15
Pain management: Pain screening is done by nursing staff
What is your role in pain management? If there is pain ,comprehensive assessment is done by the physician as follows:

There are many tools for pain assessment (according to the patient's age):
 Neonatal Infant Pain Scale (NIPS)
 Face, Legs, Activity, Cry, Consolability (FLACC)
 Wong-Baker Face Pain Rating Scale / Face Scale (FS)
 Verbal Pain Rating Scale (VPRS)
 Non-Verbal Pain Scale (NVPS)

Pain management is according to WHO stepladder guideline and pain

medications' guidelines(you can find it attached to pain management policy
and in hospital formulary medication)

Pain medication:
Are attached to pain management policy
And they are part of our hospital's formulary drugs

Blood transfusion Process: we have policy and approved by blood utilization committee that includes the
ordering of blood and how to take sample for cross matching
How do you request , handle, administer
blood and What you will do if any Blood transfusion request:
complications happened during blood
transfusion?

CBAHI Q & A | P a g e 16

Restrained patients:
How you order restraint and how you
monitor the restrained patient
For how long will last the restraint
order?
CBAHI Q & A
Blood administration:
 There must be a double check before administration
 we must have signed a consent
 There should be monitoring during blood transfusion(using monitoring
form)
Blood transfusion reaction:
Immediately stop the blood and call the physician and send OVR report about
what happened to the quality department and send the following to the blood
bank:
 Transfusion reaction report completed by attending physician and
nurse
 The remaining amount of blood unit .
 Blood sample from the other arm.
 The first urine sample from the pt. after the reaction
*The Most Responsible Physician orders restraint as follows:
 Reason for the use of restraints.
 The type of restraint
 The time limit for the use of restraints(max. for 12 hours)
*The Most Responsible Physician assesses the patient and decides on the
indication which can be:
 When the patient is Agitated ,Disoriented, Confused or Sedated/Unconscious
 For Body Alignment ,Extremity Restraint in diagnostic measures/treatments
or in Fall potential
 Potential self-harm
 When less restrictive interventions are ineffective.
*The physician reassess the patient every shift while the nure monitors the
patient every hour
| P a g e 17
Surveyor will ask staff about the rules and *We are trained through lectures how to deal with this case and how to do
regulations about cases of abuse and physical examination and how to report and to whom to report according to
neglect? our policy:
 Initiate the reporting process by contacting the Medical Director
and submitting a written report of his/her findings.
 Medical Director will, in turn, communicate with Social Services, if
needed, and contact the legal authorities after discussing the issue
with the family.
*we have screening questions in the initial screening form that is done
by nursing staff and then if they find any abuse or neglect signs or
sypmtoms ,the physician perform abuse and neglect assessment

CBAHI Q & A | P a g e 18
Code blue
Surveyor will ask nursing staff how to
announce code blue?
Surveyor will ask the nursing staff if they
are trained on how to use alarm system?
Staff will answer I will dial 222 and announce code blue as following:
“Attention Attention Attention (specify pediatric or adult) Code Blue
in (specify Exact Location and/or Room No.)”
N.B: Surveyor will notice the response of the team

Code blue team??

No. Team member Role
1 Cardiologist /ER physician/ICU (according (Team leader)
to Code blue team schedule)
(Pediatrician in pediatric Code blue)
2 Anesthesiologist/ER physician (Airway)
/Respiratory therapist
(according to Code blue team schedule)
4 ER Nurse (Monitor/
Defibrillator)
(Administer
medication)
5 ICU Nurse (Compressor)
(PICU/NICU nurse in pediatric code blue)
6 ICU Head/charge Nurse (Timer/Recorder)
(PICU/NICU nurse in pediatric code blue)
7 Security Officer

CPR Documentation is in CPR RECORD which is included in patient's medical

record

CBAHI Q & A | P a g e 19
RRT
Surveyor will ask medical staff about the
criteria for calling rapid response team?
How to announce for RRT??
What is RRT: Rapid response team
For Adult patients:(ICU Physician, ICU Charge nurse, the assigned nurse, the
attending physician (
For pediatric patients:( PICU Physician, P ICU Charge nurse, the assigned
nurse, the attending physician(
For Pregnant women: :( Obstetrician, DR Charge nurse, the assigned nurse,
the attending physician(

The criteria for calling RRT is as follows:

Patient type Adult EWS Pediatric EWS

Systolic arterial less than 80 mmHg or < 80 mmHg or > 140
blood pressure greater than 180 mmHg mm Hg
Heart rate less than 50 or greater than < 60 b/min or > 130
140 per minute. b/min
Respiratory rate less than 8 or greater than < 15 br/min or > 30
28 per minute br/min
Oxygen Acute change in oxygen  SpO2< 93%
saturation saturation less than 90%)  Oxygen therapy ≥
2 liter
Level of Acute change in the level of Acute change in level
consciousness consciousness of consciousness
Other warning  Acute onset of chest pain  Fits
signs that doesn’t  Seizures  Capillary refill > 2
incorporate in the  Acute change in urinary sec
scoring system: output less than 50 ml in 4
hours
 Significant bleeding

We announce RRT by calling 222 and announce RRT code as follows:

“Attention Attention Attention (specify pediatric or adult or
obstetrics) Rapid response team in (specify Exact Location and/or
Room No.)”
N.B: Surveyor will ask to announce RRT code and will notice the response of
the team

RRT Documentation is in RRT RECORD which is included in patient's medical

record
Out on pass *Out-on-pass is a temporary permission of a patient to leave the hospital in a
What is it? specified time.
How it is done and how it is documented *It is normally done upon a request from the patient/legal guardian.
in the Medical record? *The physician will assess the patient before he/she is allowed to go out of the
hospital to see if the patient condition permits out on pass and to assess if that
patient is included in out on pass criteria that is mentioned in policy.
*The MRP states the exact hours and date the patient is allowed to leave the
hospital.
*The physician and the patient will fill in the out on pass form to be
documented in the patient record

CBAHI Q & A | P a g e 20
Invasive procedures and Time out Process
What is the time out process: it is a Process that is implemented to prevent wrong patient, wrong site, and wrong
surgery/procedure during all invasive interventions performed in operating rooms or other locations, such as:
1. Endoscopy
2. Intensive care units(ICU-PICU-NICU)
3. Dental clinic
4. Procedure room of:
a. Emergency department
b. Obstetrics clinic
c. Ophthalmology clinic
d. Orthopedics clinic
e. Surgery Clinic

How to prevent wrong patient, wrong site,

and wrong surgery/procedure?
By using:
Inside OR:
1. Patient identification by wrist band &
patient involvement in identification process
2. Site marking
3. Preoperative checklist
4. Time out(safe surgery checklist)

Outside OR:
1. Patient identification by registration receipt and
patient involvement in identification process
2. Invasive procedure record(time-out)
Organ donation
The surveyor will ask if The hospital
assigns trained staff to inform patients
and families about organ donation?
The patient's medical record is available
to the authorized care providers to
facilitate the exchange of information
Surveyor will ask medical staff about the
availability of medical record if he need.
1. The patient's physician will discuss the patient's terminal prognosis with
the family
2. In the presence of prospect donors, Saudi Center Organ Transplantation
(SCOT) representative is contacted by the Social Services Department of
the hospital/SCOT Coordinator by calling phone 800-122-5500.
3. The (SCOT) representative will convince the patient, next-of-kin or
designated decision maker regarding the program of Organ Donation
4. If there is a legally executed and currently valid donor card evidencing a
patient's willingness to donate his organ, the patient's legal next-of-kin
will be fully informed
5. In the absence of a donor card, consent must be obtained from the
legal next-of-kin on the approved SCOT consent form. Consent may be
obtained before or after death
6. The consent or the donor card will be inserted in the patient medical
record.
7. For further information kindly read the policy of organ donation: policy
code MDP-MS-CCD-025
Continuity of care
Yes medical record is available up on request in ER or OPD or inpatients area
within 30 minutes from request.

CBAHI Q & A | P a g e 21
Surveyor will ask the medical staff when Yes when I am on call I will stay inside the hospital premises
he is on call, Is he available inside the
hospital or not? N.B: Surveyor he will check the schedules of the department, at all times with
no significant variation during holidays or weekend days.
Handover
What are the used forms for handover and when do you endorse the patient to other healthcare provider?

CBAHI Q & A | P a g e 22
Internal transfer
Inpatient Unit-Unit transfer
Who is responsible?
What information should be available in
medical record during transfer?
Referral and consultation
When you will do consultation?
What information should be
documented?
When to reply for the consultation?
What is referral and does it differ from
consultation?
CBAHI Q & A
1. The most responsible physician assesses the need for transfer and
matches the condition of the patient with admission criteria of the unit.
2. Verbal or written agreement as received from the receiving unit is
documented in the patient’s medical record, including the name of the
receiving physician.
3. The most responsible physician assesses the transfer requirements, both
staff and equipment using the internal transfer criteria.
4. Summary of the patient medical and nursing assessment findings
including reason for transfer, diagnoses, clinical findings, and current
medications is available in the patient’s medical record before transfer.
5. Handover is done between the transferring staff and the receiving staff.
6. The physician and the nurse at the receiving unit assess the patient at
arrival to ensure safe and smooth handover.
Consultation is done in the following situations:
1. Patient’s condition requires expertise that falls outside the treating
physician’s delineated privileges.
2. Patient’s diagnosis is not clear.
3. There is doubt to decide the best management of the case.
4. Patient’s relatives start to argue about their patient and troubles are
expected, especially in seriously ill or terminal cases.
Information that will be documented in the medical record:
1. Date and time of consultation.
2. Name and designation of consulting physician.
3. Name and designation of consulted physician.
4. Urgency of consultation (24 hours for routine inpatient consults and one
hour or less for emergency cases)
5. Case summary
6. Rationale for consultation.
Reply within the following timeframes:
 In emergency consultations: 30 minutes
 Urgent (4 hours)
 Elective (24 hours)
Consulted physician will reply with his/her recommendations and the
consulting physician will reply as noted and sign.
Referral is to specialized assessment as dietician, physiotherapist or social
worker
 Physician will document the request of referral in referral form and
the requested allied healthcare staff will answer within 24 hours.
 The requested staff will assess the patient and writes a care plan
 The physician will reply as noted and sign the care plan of the
supportive service staff.
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Eternal transfer and transportation
needs
Surveyor will ask how to transfer patient
from emergency room to other hospital?
Discharge summary
Surveyor will ask medical staff what you
will do if the patient will be discharged
and he will continue the treatment or he
will follow-up in another hospital?
CBAHI Q & A
1. We will stabilize the patient's condition.
2. Send a fax to the hospital to which we will transfer the patient.
3. Give the patient a copy of discharge summary and reports of the
investigations done in our hospital.
4. Document an External transfer form and assess the patient's needs
and transportation requirements (staff & equipment).
5. Contact ER and arrange for ambulance via ambulance request form
6. Don’t forget the Monitoring of vital signs during transfer
7. Handover is done and documented before leaving the patient
(In the other hospital's ER when the patient is transferred by Alameen
ambulance,
In Alameen's hospital ER when the ambulance services are not ours)
The physician will answer that he/she will give the patient a copy of the
discharge summary.
 Discharge summary is typewritten.
 A copy is inserted in the medical record.
 A copy is given to the patient.
 If the patient will be transferred to another hospital a copy is given to
the hospital via ambulance services.
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