Nursing Orientation

1. Quality Program and JCIA

2. Structure of the Quality Program
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3. CEO
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Quality
Department
Standing
Committee
Quality Council
Infection Control
Unit
Ad hoc Committee

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Standing Committees:
1. Mortality and Morbidity Committee.
2. Ethics Committee.
3. Medication Management & Use Committee
4. Infection Prevention and Control Committee
5. Credentialing and Privileging Committee.
6. Resuscitation and Continuous Education Committee.
7. Management of Information Committee.
8. Environmental and Safety Committee.
9. Patient Rights Committee.
10.Anesthesia and Surgical Care Committee.

5. JCI Accreditation Overview:
• Consists of Four Main Sections: (Total Standards 314)
1. Accreditation Participation Requirements. (12 standards)
2. Patient-Centered Standards. (159 standards)
3. Health Care Organization Management Standards. (126 standards)
4. Academic Medical Center Hospital Standards. (17 standards - Not
Applicable in IAH).
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6. Overview/ Patient-Centered Standards
• Patient-Centered Standards, Includes these chapters:
1. International Patient Safety Goals (IPSG): 11 standards / 33 Measurable Elements / 11 Policies.
2. Access to Care (ACC): 26 standards / 120 Measurable Elements / 17 Policies.
3. Patient-Centered Care (PCC): 22 standards / 94 Measurable Elements / 11 Policies.
4. Assessment of Patients (AOP): 39 standards / 170 Measurable Elements / 22 Policies.
5. Care of Patients (COP): 25 standards / 109 Measurable Elements / 25 Policies.
6. Anesthesia and Surgical Care (ASC): 16 standards / 56 Measurable Elements / 8 Policies.
7. Medication Management & Use (MMU): 20 standards / 80 Measurable Elements / 12 Policies.
Total Standards: 159
Total Measurable Elements: 662
Total Policies: 106
Total Requirements: 927

7. Overview / Health Care Organization Management Standards
• Health Care Organization Management Standards, Includes these chapters:
1. Quality and Patient Safety (QPS): 12 standards / 53 Measurable Elements / 5 Policies.
2. Prevention and Control Infection (PCI): 19 standards / 75 Measurable Elements / 11 Policies.
3. Governance, Leadership and Directions (GLD): 33 standards / 142 Measurable Elements / 19 Policies.
4. Facility Management and Safety (FMS): 24 standards / 94 Measurable Elements / 18 Policies.
5. Staff Qualifications Evaluation (SQE): 25 standards / 98 Measurable Elements / 12 Policies.
6. Management of Information's (MOI): 17 standards / 69 Measurable Elements / 8 Policies.
Total Standards: 130
Total Measurable Elements: 531
Total Policies: 73
Total Requirements: 734

8. Complaints

9. Policy PFR.3: Patient Complaints Policy
• IAH staff should respect and support the patient & patient’s family complaints in order to improve
patient’s quality of care.
• Any patient & patient’s family complaints should recorded as following criteria:
o For verbal complaints from patients cannot write, the recipient should write the complaints as it is on the complaints form.
o For telephone complaints, the recipient should fill complaints form with registration of the date, time and number of
internal telephone that used.
o In any case, where the individual filling the complaint is offensive, the supervisor should contacted immediately and meets
with the patient/ family.
• Unsolved complaints should delivered to the department manager to follow up the complaints and build
up solving criteria.
• When the complaints solved and replayed or unsolved complaints within six-business day should sent to
the quality department to record complaints in the complaints logbook.
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10. Policy PFR.3:
Patient Complaints Policy
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11. Consenting Process

12. Policy PFR.5.1: Consenting Process Policy
• All adult patients have the right to make decisions regarding their treatment and to be provided sufficient
information in order to be able to make informed decisions regarding their healthcare.
• For minors and incompetent adults, the informed consent will be exercised through their parents or legal
representative according to national laws and regulations.
• The physician performing medical or surgical procedure is generally responsible for obtaining the patient's
informed consent prior to the treatment or procedure. The resident doctor can initiate the process and sign the
consent as a witness, which later should be signed by the consultant who is performing the procedure or his/her
assistant.
• All consents obtained must be saved in the patient’s medical record for at least 25 years.
• All consents obtained from patients should be in a very clear language and simple word and make sure that they
understood it fully.
• A consent form should be obtained for all the following list:
*General consent for hospitalization. *All Anesthesia types. *All surgical procedures (operations).
*Procedural Sedation (all sedation types). *Blood and blood products transfusion.
*Diagnostic and therapeutic catheterization and angiography. *Dialysis treatment.
*Diagnostic and therapeutic endoscopic procedures. *Chemotherapy treatment.
*Diagnostic and therapeutic radiological procedures that require contrast use.
*Minimally invasive procedures (lumber puncture, chest tube insertion, Bone Marrow Aspiration and Biopsy,…).
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13. Policy PFR.5.1: Consenting Process Policy
• Verbal/Telephone Consent is prohibited by hospital policy.
• Exceptions: Certain recognized exceptions to informed consent include:
o Life threatening emergency.
o And the patient has a life or health-threatening situation requiring immediate treatment such that any delay in treatment would likely result
in death, deterioration, or serious permanent impairment.
• Patient will be asked upon admission about whom to contact if IAH needs to grant consent while the
patient is not able.
• Patients who lack capacity to grant consent (consent will be granted through legal guardian) are but
not limited to:
o Mentally unable patients.
o Patients under 18 years old.
o Comatosed or patient on life saving equipment.
o Psychiatric patients.
o Sedated patients.
• Tubal ligation and Hysterectomy procedure (Married Patients) required consent to be signed by
patient and husband.
• If legal guardian not available and procedure is urgent (life saving) then HCP will perform the
procedure.
• If legal guardian not available and procedure not urgent we will request authorization for legal
guardian (via e-mail or fax). 13

14. Policy PFR.5.1: Consenting Process Policy
• Duration of Informed Consent:
o Informed consent may be considered to have continuing force and effect until the patient revokes the
consent, or until circumstances change to materially affect the nature of, the risks or benefits of, the
procedure and/or the alternatives to the procedure to which the patient consented.
- For example, if a patient has been admitted for a specific treatment or procedure, the consent should be valid through the
course of that admission unless the patient's condition or treatment changed significantly. In that event, the physician or
other health care providers should obtain a new informed consent.
- Informed consent should be documented within same admission prior to procedure, surgery and
treatment. After discharge and patient re-admitted to the hospital, the informed consent should be re
obtained and re documented by the physician.
• Informed consent for continuing therapy (such as: chemotherapy, repetitive blood or blood products
transfusions, peritoneal dialysis, and hemodialysis procedures) shall be obtained before each new
procedure described in the paragraph above. However, patients in certain therapeutic programs
involving a course of multiple treatments may consent to an entire course of routine therapy prior to
the first treatment, and a single consent form may be signed for the entire course of treatment (for the
same admission).
• Same chemotherapy protocol (Both inpatient & outpatient chemotherapy).
• Blood/Blood Products Transfusion/Dialysis for same admission.
• Revocation: A patient may revoke consent verbally or in writing. This should be communicated to
the patient's physician and documented in the medical record.
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15. Policy PFR.5.2: Informed Consent
• The Surgeon obtains informed consent for surgery from the patient or others who can grant consent before
surgery.
• The physician is obligated to provide all the required information before obtaining a signed consent of it.
• Consent must be obtained before Anesthesia or any procedural sedation.
• Consent form must be obtained before Blood transfusion or use of blood products.
• Consent must be obtained before any High-Risk procedure.
• Consents should be kept in the patients’ medical record for at least 25 years.
• Attachment:
o Informed Consent for Surgical/Invasive Procedure Form.
o Informed Consent for Anesthesia Form.
o Informed Consent for High-Risk Procedure/Treatment Form.
o Informed Consent for Use of Blood and Blood Products Form.
o Patient Refusal Blood/Blood Product Transfusion Form.
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