2. Human resource (HR)
POLICY
CREDENTIAL VERIFICATION
CREDENTIALING AND PRIVILEDGE
DOCUMENT
EMPOLYEE FILE
COPY OF CREDENTIALS
CREDENTIAL VERIFICATION (DATA FLOW REPORT)
CREDENTIALING AND PRIVILEDGING
TRAINING AS BASED ON JOB DESCRIPTION (STAFF ASSIGNED OUT OF
PROFESSION E.G. NURSE WORKING AS ANESTHESIA TECHNICIAN, THE SCORE
WILL BE AFFECTED)
BLS, ACLS, NRP, ALSO
JOB DESCRIPTION
SCFHS AND MOH LICENSE
3. Provision of Care (PC)
POLICY
BLOOD HANDLING/ADMINISTRATION
TRANSFUSION WITHOUT “NAT” TESTING –N/A we don’t have
Bllod bank –instead present the agreement
BLOOD UTILIZATION COMMITTEE
BLOOD TRANSFUSION REACTION
STAFF INTERVIEW
COMPETENCY AND AWARENESS OF P&P
CLOSED FILE
WRITTEN DOCTOR’S ORDER
CONSENT
PATIENT IDENTITY VERIFIED BY TWO STAFF
MONITORING AND DURATION
ADVERSE TRANSFUSION REACTION
OBSERVATION
AVAILABILITY OF POLICY IN AREAS
4. Provision of Care (PC)
POLICY
THROMBOEMBOLISM
VTE PROPHYLAXIS
Forms – completed?
OPEN FILE
SCREENING FORM VTE
OBSERVE
AVAILABILITY OF MECHANICAL PROPHYLAXIS
MULTIDISCIPLINARY Plan of care is documented in the
patient's medical record
5. Laboratory (LB)
POLICY
BLOOD BANK = IF HOSPITAL DOES NOT HAVE DONATION SERVICE,
WRITTEN AGREEMENT IS NEEDED
P&P ON LIMITING AND DETECTING BACTERIAL CONTAMINATION
DOCUMENT
EVIDENCE COMPLIANCE TO TRANSFUSION TRANSMITTED DISEASE
TESTING (TTDT)
OBSERVE
PRACTICE TO CONFIRM IMPLEMENTATION TO LIMIT BACTERIAL
CONTAMINATION IN PLATELET
6. Medication Management (MM)
POLICY
LOOK A LIKE, SOUND A LIKE DRUGS (LASA)
ERROR PREVENTION STRATEGIES AT EACH PHASE
DOCUMENT
UPDATED LIST (ANNUALLY) FOR LASA
MATERIALS AND ATTENDANCE RECORD THAT STAFF WERE EDUCATED
ON LASA MEDS.
OBSERVE
EVIDENCE PREVENTION DUE TO LASA MEDS – POSTERS/memo
Reminders
STAFF INTERVIEW
EVIDENCE OF IMPLEMENTATION OF ERROR PREVENTION STRATEGIES
DUE TO LASA
7. Medication Management (MM)
POLICY
MULTIDISCIPLINARY POLICY ON HANDLING MEDICATION ERRORS.
STAFF INTERVIEW
INTERVIEW PHYSICIAN ON HOW THEY ARE INFORMED OF MEDICATION
ERROR AND WHEN.
CLINICAL STAFF ON WHEN THEY REPORT MEDICATION ERRORS. MATCH
TIMEFRAME IN POLICY AND STAFF AWARENESS
8. Medication Management (MM)
STAFF INTERVIEW
STAFF ARE AWARE ON THE PROCESS
AND IMPORTANCE OF MEDICATION
ERROR REPORTING. (IF THERE IS LIST
OF TRAINED STAFF, HIGHEST POSSIBLE
NUMBER OF STAFF ATTENDEES)
9. Medication Management (MM)
OPEN FILE
SELECTED CASES OF REPORTED MEDICATION ERROR (REACHED THE PATIENT)
DOCUMENTED IN FILE. (CLOSED FILE- IT SHOULD BE REMOVED)
DOCUMENT
ROOT-CAUSE ANALYSIS OF ALL SIGNIFICANT OR POTENTIALLY SIGNIFICANT
MEDICATION ERRORS.
10. Medication Management (MM)
POLICY
SENTINEL EVENTS
DOCUMENT
EVIDENCE OF SENTINEL REPORTING TO RELEVANT AUTHORITIES
STAFF INTERVIEW
PHARMACY AND THERAPEUTIC COMMITTEE INTERVIEW ON REPORTING
SENTINEL EVENTS RELATED TO SERIOUS MEDICATION ERROR .
11. Quality Management (QM)
POLICY
PATIENT IDENTIFICATION
OBSERVE
VISIT MULTIPLE AREAS TO ENSURE CONSISTENCY OF PRACTICE
STAFF INTERVIEW
AWARENESS ON POLICY OF PATIENT IDENTIFICATION
12. Quality Management (QM)
POLICY
WRONG PATIENT, WRONG SITE, WRONG SURGERY
CLOSED FILE REVIEW AND OPEN FILE REVIEW
DOCUMENTATION OF VERIFICATION, SITE MARKING AND TIME-OUT
OBSERVE
TIME-OUT PROCEDURE IF THERE’S ONGOING OR (OTHERWISE, STAFF
INTERVIEW AND DOCUMENT REVIEW)
STAFF INTERVIEW
VERIFY ADHERENCE TO SURGICAL SAFETY PROTOCOL
13. Infection Prevention & Control
(IPC)
POLICY
ISOLATION PRECAUTION POLICY
ISOLATION PRECAUTION CARDS
POLICY ON SINGLE-USE /RE-USABLE N95 MASK
OBSERVE
1 NEGATIVE PRESSURE ISOLATION ROOM IN ER AND WARD
COMPREHENSIVE TRANSFER PLAN OF REFERRAL OF INFECTIOUS
CASES.
14. Infection Prevention & Control
(IPC)
OBSERVE
WASHING AREA/TOILET/SHOWER FOR NEGATIVE ISOL ROOM
AVAILABILITY OF TRASMISSION BASED PRECAUTION CARD
AVAILABILITY, FITTING TEST RESULT, DONNING/REMOVING OF
N95
STAFF INTERVIEW
KNOWLEDGE ON POLICY OF N95
15. Infection Prevention & Control
(IPC)
STAFF INTERVIEW
INFECTION PREVENTION & CONTROL
COMMITTEE
VERIFY COMMITTEE MEETING ON REGULAR BASIS AND
DISCUSSING CRITICAL ISSUES RELATED TO INFECTION
CONTROL AS APPLICABLE
16. Facility Management and Safety (FMS)
FIRE ALARM, SPRINKLER SYSTEM, CLEAN AGENT SYSTEM, WET CHEMICAL
SYSTEM, STAND PIPES AND HOSE REEL SYSTEM
DOCUMENT
FIRE ALARM, SPRINKLER SYSTEM, CLEAN AGENT SYSTEM, WET
CHEMICAL SYSTEM, STAND PIPES/HOSE REEL SYSTEM
INSPECTION SCHEDULE AND REPORT (CHECKLIST AND RECORD INCLUDED)
CLEAN AGENT SYSTEM
LIST OF DEVICES AND COMPONENTS
17. Facility Management and Safety (FMS)
OBSERVE
FIRE ALARM CONTROL PANELS NO ALARM/ERRORS
SMOKE DETECTORS OPERATIONAL, NUMBER TAGS, NOT OBSTRUCTED
TEST ONE ELEVATOR TO ENSURE IT LANDS ON ASSIGNED FLOOR
LEVEL
VISIT FIRE PUMP AREA: JOCKEY, ELECTRICAL & DIESEL PUMPS ARE SET
AUTO MODE.
18. Facility Management and Safety (FMS)
OBSERVE
WET CHEMICAL SYSTEM IN KITCHEN, INSPECTION TAG VERIFIED
INSPECT HOSPITALS STAND PIPES AND HOSE SYSTEM FUNCTIONING
CHECK THE PRESSURE IN AT LEAST ONE HOSE REEL THAT IT’S
FUNCTIONING AUTOMATICALLY
19. Facility Management and Safety (FMS)
FIRE EXITS
OBSERVE
FIRE EXITS ARE AVAILABLE, PROPERLY LOCATED IN THE HOSPITAL
TEST 3-5 FIRE EXITS TO MAKE SURE THAT THEY ARE NOT LOCKED BY
ANY MEANS OR NO OBSTRUCTIONS FROM BOTH ENDS
PANIC HARDWARE TO ALLOW OPENING IN DIRECTION OF
EVACUATION
CLEARLY MARKED WITH ILLUMINATED EXIT SIGN
20. Facility Management and Safety (FMS)
POLICY
NO SMOKING POLICY
OBSERVE
THROWN CIGARETTE BUTTS ON HOSPITAL’S PREMISES
NO OBSTRUCTION TO FIRE EXTINGUISHERS, FIRE ALARM BOXES AND
FIRE BLANKETS
21. Facility Management and Safety (FMS)
STORAGE AREAS
OBSERVE
CENTRAL SUPPLIES STORE PROPERLY AND SAFELY ORGANIZED
TEST EMERGENCY DOORS, OBSERVE EXIT SIGNAGE, INSPECT EXTINGUISHER,
ACCESS CONTROL, SAFE STORAGE
TO REMOVE CEILING TILES ON DIFFERENT LOCATION TO ENSURE FIRE
WALL IS INTACT
22. Facility Management and Safety (FMS)
POLICY
MEDICAL GAS SYSTEM
PROCEDURE OF SYSTEM OFFLINE
MODIFYING, ALTERING, COMMISSIONING, TESTING ANY PART
PROCEDURE OF ORDERING/REFILLING LIQUID OXYGEN
DOCUMENTING REPAIRS/ ALTERATION/ TEST/ FILLING LOGS/ CONSUMPTION
DOCUMENT
TESTING REPORT FOR HUMIDITY AND PURITY
23. Facility Management and Safety (FMS)
OBSERVE
OBSERVE THAT THE GAS CYLINDER ARE REGULARLY TESTED FOR GAS
TYPE, AMOUNT AND ANY LEAKS
SHUT OFF VALVES ARE AVAILABLE IN ALL UNITS CLEARLY MARKED
WITH ROOMS/AREA
PMG (piped medical gas) OUTLETS ARE ADEQUATE IN-PATIENT CARE
AREAD AND ARE TO BE ERROR PROOF.
24. Facility Management and Safety (FMS)
STAFF INTERVIEW
UTILITY MANAGER(S)/ ENGINEER(S) ARE AWARE OF THE AVERAGE
DAILY CONSUMPTION RATE OF OXYGEN AND MEDICAL AIR
STAFF RESPONSIBLE FOR VALVE SHUT OFF IS AWARE OF THE RISK
ASSOCIATED BREAKING VALVE BOX COVER AND ROOMS AFFECTED BY
CLOSING THE VALVE
25. Facility Management and Safety (FMS)
POLICY
RADIATION SAFETY POLICY AND PROCEDURE
OBSERVATION
ALL RADIO-ACTIVE MATERIALS ARE CLEARLY LABEL AND SAFELY AND SECURELY STORED.
DOSIMETERS ARE AVAILABLE TO ALL STAFF WITH REPLACEMENT DURING TESTING PERIOD
26. Facility Management and Safety (FMS)
DOCUMENT
LICENSE FROM NATIONAL AUTHORITIES FOR DEALING WITH RADIO-ACTIVE
MATERIALS (KACST, KA, CARE)
STAFF INTERVIEW
STAFF HANDLING RADIO-ACTIVE MATERIALS INTERVIEW AND EVALUATE THE
IMPLEMENTATION OF THE RADIATION SAFETY POLICY.
INTERVIEW STAFF ON HOW REGULARLY TESTED FOR PERMISSIBLE RADIATION
LEVELS
27. Medical Staff (MS)
POLICY
PRIVILEGING POLICY
DEFINITION OF TEMPORARY/ EMERGENCY PRIVILEGES
DOCUMENT
IN UNITS IT IS REQUIRED TO HAVE COPY OF PRIVILEGES FOR
THE PHYSICIANS WORKING IN THE AREAS
28. Medical Staff (MS)
EMPLOYEE FILE
PHYSICIAN PERSONNEL FILE
IMPLEMENTATION OF GRANTING TEMPORARY/EMERGENCY
PRIVILEGES
IMPLEMENTATION OF PRIVILEGING PROCESS IN CASE OF
REQUESTING NEW PRIVILEGES
29. Anesthesia Care (AN)
EMPLOYEE FILE
PHYSICIAN PERSONNEL FILE
QUALIFICATION AND PRIVILEGES
CLOSED FILE
DOCUMENT EVIDENCE THAT ANESTHESIOLOGIST IS PRESENT
THROUGHOUT OR
INTRAOPERATIVE ANES SHEET, DISCHARGE RECOVERY SHEET
ANESTHESIA CONSULTATN ADMINISTER & SUPERVISE PATIENT
WHO HAD MAJOR OR HIGH-RISK SURGERY
30. Anesthesia Care (AN)
MODERATE/DEEP SEDATION
EMPLOYEE FILE
PHYSICIAN PERSONNEL FILE (NON-ANESTHESIOLOGIST)
EVIDENCE OF TRAINING OR SPECIFIC PRIVILEGES ON
MODERATE SEDATION
MEDICAL STAFF PERSONNEL FILE
EVIDENCE OF TRAINING
31. ESSENTIAL SAFETY REQUIREMENTS ( ESR Program)
Survey Agenda
(please specify)
ESSENTIAL SAFETY REQUIREMENTS SURVEY VISITS
ime Activity Counterparts
08:00 am – 8:30 am Morning Planning
08:30 am – 10:00 am Documents Review
10:00 am – 10:45 pm
Unit Visit
Inpatient Ward Isolation
Room Conscious
Sedation area
10:45 am – 11:30 pm
Unit Visit
(ICU)
11:30 am – 12:00 pm
Unit Visit
Pharmacy
Laboratory
12:00 pm – 12:30 pm
Unit Visit
(Medical Gases and Compressors
Rooms)
12:30 pm– 01:00 pm Surveyors’ Business Lunch
01:00 pm – 02:00 pm
Unit Visit
(Radiology)
02:00 pm – 02:30 pm
Unit Visit
(Kitchen, Server Rooms)
02:30 pm – 03:00 pm
Unit Visit
(Elevator Mechanical Room, Electrical
Room, Fire Alarm Control Room)
03:00 pm – 03:30 pm Closed Medical Record Review
03:30 pm – 04:00 pm Personnel File Review
04:00 pm – 04:30 pm Data entry
04:30 pm – 05:00 pm Exit report
