Cbahi hospital accreditation guide october 2016

of 134
Hospital Accreditation Guide Oct-2016
Hospital Accreditation Process Guide
October 2016

of 134
Introduction
The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) Hospital Accreditation
Process Guide was developed to serve as a reference for hospitals during the preparation for
accreditation surveys as well as maintenance of accreditation. This guide is to be used in conjunction
with the third edition of CBAHI Hospital Accreditation Standards manual. It has been created to help
hospitals learn about the third edition of the national hospital accreditation standards’ survey process.
In addition, the guide has been designed to provide hospitals with an authoritative resource to use in
preparation for an accreditation survey. It addresses the activities required for conduction of a hospital
survey and form the basis for a successful accreditation survey. Additionally, it provides hospitals with
a means of ongoing self-assessment and continuous improvement.
CBAHI employs a dynamic development process to fulfill our mission as a driver for continuous
improvement. Any further modifications will be communicated to the hospitals through later editions
and amendments.
About CBAHI
What is CBAHI?
CBAHI, or the Central Board for Accreditation of Healthcare Institutions is a governmental organization
that promotes the quality, value, and optimal outcomes of health. CBAHI currently accredits in the
following areas:
 Hospitals
 Primary Healthcare Centers (PHC)
 Regional labs and blood banks
Mission
To promote quality and safety by supporting healthcare facilities to continuously comply with
accreditation standards.
Vision
To be the regional leader in improving the healthcare quality and safety.
Values
 Commitment to excellence
 Team spirit
 Integrity
 Professionalism

of 134
Registration with CBAHI
All hospitals are required to register with CBAHI. To register, the following steps are followed:
1. Access www.cbahi.gov.sa in the address bar
2. Choose "Health Care Facility" and click register.
3. You will be directed to other web page.
4. Start entering your hospital information.
After completing all required information, you are required to:
1. Type the security numbers as they appear on the left bottom of the page.
2. A message about completion of registration will be displayed specifying the Username and
Password.
3. Use the specified Username and Password to access the hospital portal.
Scope of Accreditation Surveys
The scope of the CBAHI survey includes all standards-related functions of the surveyed hospital. Each
assessment survey is tailored to the type, size, and range of services offered by the hospital. Applicable
standards from the hospital standards manual are determined by Healthcare Accreditation Department
(HAD) staff based on the scope of the services provided by the hospital undergoing a survey.
Additionally, the on-site survey team will consider the specific applicability of individual standards. The
following chapters are considered mandatory for all hospitals:
1. Leadership (LD)
2. Human Resources (HR)
3. Management of Information (MOI)
4. Medical Records (MR)
5. Quality Management and Patient Safety (QM)
6. Social Care Services (SC)
7. Patient and Family Rights (PFR)
8. Medical Staff (MS)
9. Radiology Services (RD)
10. Physiotherapy Services (PT)
11. Respiratory Care Services (RS)
12. Dietary Services (DT)
13. Nursing Care (NR)
14. Patient and Family Education (PFE)
15. Provision of Care (PC)
16. Anesthesia Care (AN)
17. Emergency Care (ER)
18. Critical Care (ICU – CCU-PICU)
19. Operating Room (OR)
20. Medication Management (MM)
21. Infection Prevention and Control (IPC)
22. Laboratory (LB)
23. Facility Management and Safety (FMS)

of 134
Goal of Accreditation Surveys
The goal of the survey is to determine if the hospital is in compliance with CBAHI Hospital
Accreditation Standards. Also where appropriate, CBAHI surveyors provide education and consultation
to the hospital’s staff throughout the survey to help them improve their clinical and administrative
processes.
Assessment of Compliance
The CBAHI expects substantial compliance with all applicable standards. The surveyors assess
compliance with standards through a combination of data sources that include at least one of the
following:
1. Interviews with hospital Leadership, clinical and support staff, patient and family. Observation
of patient care and services provided.
2. Building tour and observation of patient care areas, building facilities, equipment management,
and diagnostic testing services.
3. Review of written documents such as policies and procedures, orientation and training plans and
documents, budgets, and quality assurance plans.
4. Review of personnel files.
5. Review of patients’ medical records.
6. Evaluation of the hospital’s achievement of specific outcome measures (e.g., hospital-acquired
infection rates, patient satisfaction) through a review and discussion of monitoring and
improvement activities.
Accreditation Decision Rules
Hospitals are expected to be in continuous compliance to CBAHI standards. Full compliance is expected
upon the effective date of the standards including the effective date of any revisions thereto. The hospital
must meet all applicable standards at a satisfactory level to become accredited. Hospitals undergoing
their first survey need to demonstrate a track record of four months of compliance, while hospitals
undergoing their triennial survey need to demonstrate twelve months of compliance prior to survey (or
from the effective date of the new standards if less than 12 months). The effective date of the new
requirements in this edition will be January 2016.
All standards have one or more sub-standard(s). The sub-standards are the elements of the standards
that are reviewed and scored by the surveyor on site. Each sub-standard is scored on a three-point scale
based on the degree of compliance with the sub-standard’s requirements:
“0” = Insufficient compliance when < 50 % compliance with the sub-standard and/or compliance is
less than two months to the initial survey or less than six months for the triennial survey.
“1” = Partial compliance when ≥ 50 to < 80 % compliance with the sub-standard and/or compliance
is for two to less than four months only prior to the initial survey or six to less than twelve months
for the triennial survey.

of 134
“2” = Satisfactory compliance when ≥ 80 % compliance with the sub-standard or compliance is for
four months prior to the initial survey or twelve months for the triennial survey.
“NA” = Not Applicable indicates that the standard/sub-standard does not apply to the hospital.
The overall score of the hospital is automatically calculated by the software application using the
average (arithmetic mean) score of all applicable sub-standards, i.e. as the sum of all values divided by
the number of values added.
When one or more chapters, standards, and/or sub-standards of the standards manual are not applicable
in a particular hospital, they are indicated by “N/A”. Non applicable chapters and standards are not
scored and are not included in either the numerator or denominator of the overall score.
Scoring guidelines apply a similar method to sub-standards requiring a sample for assessment of
compliance. For example, if observations are positive in ≥ 80 % of cases, if interviewees provide proper
answers in ≥ 80 % or if the average of positive findings in personnel records or medical records is ≥ 80
%, the score of the sub-standard will be fully met.
The Accreditation Decision Committee shall recommend one of the following accreditation decisions:
Accredited:
Accreditation will be awarded when the surveyed hospital demonstrates an overall acceptable
compliance with all applicable standards at the time of the initial (or reaccreditation) on-site survey, and
there are no issues of concern related to the safety of patients, staff or visitors.
Accreditation will also be recommended when the healthcare facility has successfully addressed all
requirements following a conditional accreditation and does not meet any rules for other accreditation
decisions. The decision to grant accreditation is not always straightforward. In some cases though, the
Accreditation Decision Committee
may consider the need for more clarification and/or a follow up focused survey of specific
standards/areas of concern or noncompliance before a consensus decision to grant accreditation can be
reached. This will also give the hospital a period of time to come into acceptable compliance.
Scoring Guidelines:
 Overall score 85% or above and
 All essential safety requirements are in satisfactory compliance and
 No other issues of concern related to the safety of patients, visitors or staff.
Conditional Accreditation:
Conditional Accreditation is granted when the hospital demonstrates a tangible compliance with all
applicable standards at the time of the on-site survey but still has not met requirements for accredited
status. The hospital is required then to develop a “Standards Compliance Progress Report”, followed by
a “follow up Focused Survey”
if required before changing the accreditation status. The non-compliant standards may include essential
safety requirements and/or other standards/issues of concern related to the safety of patients, staff or
visitors.
Scoring Guidelines:
 Overall score 75% or above and less than 85% and/or
 Some of the essential safety requirements (but not exceeding 25% of them) are not in satisfactory
compliance.
Preliminary Denial of Accreditation (PDA):

of 134
Preliminary Denial of Accreditation (PDA) is a stage -rather than a final accreditation decision- that
precedes denial of accreditation. The aim of allowing this stage is to give some additional time for
review and/or appeal before the determination to deny accreditation. It results when there is one or more
of the following reasons to
justify denying accreditation:
 Presence of an immediate threat to the safety of patients, visitors or staff that is observed by
CBAHI surveyors during the on-site survey.
 Significant noncompliance with the accreditation standards at the time of the on-site survey.
 Failure of timely submission of the post survey requirements after conditional accreditation.
 The hospital has received conditional accreditation and was subjected to a follow up focused
survey but still could not meet the requirements for accreditation.
 Reasonable evidence exists of fraud, plagiarism, or falsified information related to the
accreditation process. Falsification is defined as the fabrication of any information (given by
verbal communication, or paper/electronic document) provided to CBAHI by an applicant or
accredited healthcare facility through redrafting, additions, or deletions of a document content
without proper attribution. Plagiarism is perceived by CBAHI as the deliberate use of other
healthcare facility original (not common-knowledge) material without acknowledging its source.
In this case, the hospital is required to respond to CBAHI by sending an official clarification
letter within five working days of the communication.
 Refusal by the hospital to receive the survey team and conduct a survey. In this case, the hospital
will receive upfront denial of accreditation and will be subject for exclusion from the national
accreditation program.
Denial of Accreditation:
Results when a health care facility shows a significant noncompliance with the accreditation standards
at the time of the on-site survey. It also results if one or more of the other reasons leading to preliminary
denial of accreditation have not been resolved. When the hospital is denied accreditation, it is prohibited
from participating in the accreditation program for a period of six months, unless the Director General
of CBAHI, for good reason, waives all or a portion of the waiting period.
Scoring Guidelines:
 Overall score less than 75% and/or
 More than 25% of the essential safety requirements are not in satisfactory compliance.
Special scoring considerations
 A selected group of standards have been assigned as Essential Safety Requirements (ESR)
indicated with a circular icon that contains the letters ESR in the standards manual. All ESRs
should be in full compliance for the hospital to be accredited. If more than 25% of ESRs are
partially or not met, the hospital will get Conditional Accreditation. The hospital is required then
to develop a “Standards Compliance Progress Report”, followed by a “follow up Focused
Survey” if required before changing the accreditation status.
 Criticality of the non-compliant standard(s) -i.e. the degree of severity and immediacy of risk to
patients, visitors or staff safety- has several levels. The most serious of which is when the
surveyor notices an immediate threat to safety or quality of care. Examples include:
o Healthcare provider is entering an isolation room without proper Personal Protective
Equipment (PPE).

of 134
o Expired catheter is being used during central line insertion or other invasive procedure.
o Bare electrical wire is hanging down without any protection.
o Incompatible blood sample is sent from the operating room while the operation is in
progress.
o A new-born is not properly identified.
When CBAHI surveyor notices an immediate threat whether linked or not linked to the standards or
the ESRs, the survey team leader will notify the hospital director and will include the findings in the
survey report. Consequently, the hospital will receive a preliminary denial of accreditation until the
issue is resolved through a Corrective Action Plan, and possibly a follow up focused survey for
verification.
Hospital Responsibilities
Hospital’s survey coordinator
When the hospital completes its survey application, the hospital should select a person to serve as
hospital’s survey coordinator to handle the logistics of the survey visit. The hospital’s survey coordinator
designated by the hospital will serve as the liaison with the Healthcare Accreditation Department (HAD)
and the survey team leader about the survey visit arrangements.
Survey Team
A list of survey team members, with their biographies, will be sent to the hospital prior to the survey
visit. The hospital should contact the Healthcare Accreditation Department (HAD) promptly if any
surveyor is deemed to be inappropriate due to conflict of interest or other valid reasons.
Note: CBAHI cannot honor requests for specific surveyors for the purpose of objectivity.
Travel Arrangements
The hotel and flight reservations will be arranged by CBAHI. All flights are booked to be the night
before the survey. A list of assigned surveyors together with their flights’ details and mobile numbers
will be sent to the hospital’s survey coordinator prior to the survey. The hospital should arrange ground
transportation from the airport to the hotel. The hospital should decide how to transport the team
members each day between their hotel and the hospital and to any remote sites they will visit as part of
the survey. The survey team leader and hospital’s survey coordinator should determine where and when
the team will be picked up or meet at the hotel. Additionally, the hospital should arrange transportation
from the hotel to the airport according to the departure time of surveyors.
Staff Involvement
A well-conducted survey requires important information from a broad range of staff for the deliberations
of the survey team. All survey team members interview different staff categories about a variety of
topics to ensure that the team has access to truly representative information related to implementation
of CBAHI standards from staff.
Conflict of Interest
CBAHI works to ensure the integrity and fairness of all businesses run by the employees working in the
central office as well as the surveyors. In addition, all healthcare facilities engaged in CBAHI

of 134
accreditation process are required to refrain from any actual or potential act or behavior that might create
a conflict of interest including:
 Proposing any fee, remuneration, gift, or gratuity of any value to CBAHI employees or surveyors
for performance of their duties or survey-related activities.
 Employing or contracting or having any financial relationship with CBAHI employees or
surveyors for the purpose of the provision of consulting or related services in any capacity, either
directly or through another party. This includes services provides in preparation for the survey,
assisting in preparation of the self-assessment, conducting mock surveys, helping in the
interpretation of the standards, and alike. All requests for consulting services utilizing one of
CBAHI associates shall be directed to CBAHI central office.
 Not declaring to CBAHI any business (including consulting) or recruiting relationship with one
or more of CBAHI surveyors either directly or through another party with whom he or she is
affiliated, at any time during the preceding three (3) years.
Survey Logistics
Hospitals should provide appropriate logistics that include the following:
 A workroom that is large enough for the survey team members to review documents and leave
computers and binders. The workroom needs to be furnished with a desk or table, access to
electrical outlets, and internet access.
 A workroom(s) for group meetings and interviews with staff as specified in the survey agenda.
 Assigning a counterpart for each surveyor who is a responsible person for the same specialty
during the survey.
Hospital Observers
When the hospital’s team includes an observer, who may represent a consulting firm or staff from other
hospitals, the hospital must inform CBAHI and obtain its official approval at least one week prior to the
survey. Observers must not participate in the survey activities.
CBAHI observers/mentors
One or more observers or mentors may join the CBAHI survey team as part of the surveyors’ training
process. Observers and mentors from CBAHI side will be included in the list of the surveyors sent by
hospital accreditation department prior to the survey.

of 134
CBAHI Survey Process
Overview
This section details the various activities of a hospital survey. For better understanding of the
accreditation survey process, the survey related activities are organized into the following three sections
in this guide:
 Pre-Survey Activities
 On-Site Survey Activities
 Post-Survey Activities
Pre-Survey Activities
Enrollment for Survey
The accreditation process begins with selection of the hospitals to be surveyed. Each year, CBAHI selects the
hospitals to be enrolled in the accreditation program. CBAHI sends a letter of enrollment to the selected hospitals
to start their application process.
Application for Survey
After completion of the enrollment process, hospitals selected for the accreditation process must
complete Survey Application Form available on the CBAHI website. The form contains information
regarding the organization and its facilities and services to enable establishment of a facility profile.
The form is divided into sections with guidelines to clarify the information required for every section.
The access to the e-App is provided by CBAHI to intended hospitals. The encoded data may be saved
in stages and updated as needed. The Survey Application Form is completed as follows:
 Visit www.cbahi.gov.sa/hsa
 Enter your user name and password
 Complete and submit the hospital demographic questionnaire
 Under the “Survey Process” menu, select “Apply for a new Survey”
o Select type of survey and the date
Not Applicable chapters
Update of Application Information
The hospitals are made aware that planning of the surveys is done according to the scope of services
they complete in the application form. If a hospital experiences significant changes after it submits its
application, the changes must be made in the application form within five (5) business days of this
change.
Note:
The requirement of updating the application information includes updates of the main contact persons
of the hospital to ensure an ongoing communication channel with the hospital and facilitate, when

of 134
needed, timely communication of possible updates of CBAHI accreditation policies or standards to
concerned facilities.
Application for Reaccreditation Survey
The update for a re-accreditation survey should be completed by accredited hospitals. This update for
re-survey must be completed and submitted to CBAHI twelve weeks prior to the accreditation
expiration.
Resources to Assist Hospitals
CBAHI will assign each hospital enrolled for a survey a HAD’s accreditation coordinator, who will
serve as a primary contact between the hospital and Healthcare Accreditation Department (HAD). This
individual will coordinate survey planning and will be available to the hospital to answer questions and
clarify issues related to the survey process. In order to assist hospitals for preparation of surveys,
hospitals are offered the following resources:
1. CBAHI Standards Manual
All hospitals receive a copy of the standards manual upon registration with CBAHI. This will facilitate
for the hospital to gain better understanding of the standards’ requirements as well as the accreditation
policies. The standard manual is divided into three parts:
 Part I -- Introduction and explanatory notes
 Part II -- CBAHI accreditation policies
 Part III -- Accreditation standards for hospitals
2. Accreditation Process Guide
The Accreditation Process Guide provides additional useful information to assist hospitals prepare for
a survey. Additionally, it emphasizes self-assessment and ongoing standards compliance and continuous
quality improvement. The hospitals are provided with this guide upon successful registration with
CBAHI.
3. Self-Assessment Tool (SAT)
A successful self-assessment will provide valuable information that may be used for modification and
improvement of the performance of the hospital. Upon receipt and review of the hospital’s application,
the hospital will receive electronic access to a self-assessment tool (SAT). The SAT will facilitate for
the hospital its self-assessment and follow up of the progress of implementation. The SAT is fully
explained in the accreditation maintenance section of this document as part of the post-survey activities.
4. Hospital Orientation Programs (HOP)
CBAHI provides orientation programs in different regions of the Kingdom of Saudi Arabia. It offers
hospitals an introduction to the standards and their implementation, the accreditation policies, as well
as the survey process to make the survey preparation successful. Dates and venues of the orientation
programs are communicated to the hospitals in a timely manner.
5. Mock Survey

of 134
Some hospitals will prefer to go for a Mock Survey but this is subject to the availability of adequate
resources at CBAHI and the requirement of its operational plans. CBAHI therefore is not obliged to
respond to all incoming mock survey requests.
6. Consultative Visit
CBAHI provides consultative visits upon request. These visits are optional and depend on the
availability of CBAHI resources. The consultative visits provide in-depth explanation of one or more
of the functions or areas covered by the standards.
7. Requests for Interpretation of Accreditation Standards and Policies
CBAHI responds to requested interpretation of an existing accreditation standard or policy. Requests
must be made in writing. Information on submitting a written request is available on the CBAHI website.
The requester can fill out a “contact us” form.
Survey Team Composition
Each accreditation survey is tailored to the type, size and range of services provided by the hospital. A
survey team is organized by CBAHI to conduct the on-site survey in order to determine the hospital’s
compliance with the standards’ requirements. The survey team size and composition is based on a
careful review of the following factors as provided in the application for survey:
 Size of the facility to be surveyed, based on average daily census;
 Complexity of services offered, including surgical and anesthesia services;
 Whether the facility has special care units or off-site clinics or locations.
Based on the above information, the CBAHI decides the length of the on-site survey and the number
and the disciplines of the surveyors. In a typical full survey of a hospital, the survey team would include
seven (7) surveyors who will be at the facility for three or more days. One of these surveyors will be
assigned as a team leader. Each hospital survey team is comprised of two teams as follows:
 The Core team, composed of three surveyors: administrator, nurse, and physician.
 The Specialty Team, composed of four surveyors: Pharmacist, Infection Control specialist,
Laboratory specialist, and facility management and safety specialist.
CBAHI may require a surveyor(s) to undergo a limited on-site survey when, in the judgment of CBAHI,
such an evaluation is warranted. This limited survey focuses on particular area(s) identified by CBAHI.
Examples may include, but not limited to, a specific issue such as a complaint or a sentinel event and
evaluating changes introduced by the hospital that were not available the time of a previous survey. The
survey team and the duration of the survey are determined by CBAHI on an individual bases. The scope
of the survey is limited to addressing the related issues. There is no set agenda.
Survey Team Members
The survey team members are experienced health professionals, who have been trained as surveyors.
Prior to the survey, the surveyors review information related to the hospital from the following:
 Application information
 Mid-term self-assessment and related corrective action plan(s)

of 134
 Offsite required documents
 Any other relevant documents as decided by CBAHI
These documents provide the surveyors an opportunity to verify whether the facts in the hospital
documents are consistent with the actual practice. These facts are taken into consideration while
evaluating the corresponding CBAHI standards.
Each member of the survey team is responsible about a set of chapters and occasionally with few
standards from other chapters in relation to his/her specialty. In general, the surveyors are allocated to
chapters as follow:
 Leadership & Quality Management Surveyor
o Leadership (LD)
o Human Resources (HR)
o Management of Information (MOI)
o Medical Records (MR)
o Quality Management and Patient Safety (QM)
o Social Care Services (SC)
o Patient and Family Rights (PFR)
 Medical Surveyor
o Medical Staff (MS)
o Radiology Services (RD)
o Physiotherapy Services (PT)
o Respiratory Care Services (RS)
o Dental Care (DN)
 Nursing surveyor
o Dietary Services (DT)
o Nursing Care (NR)
o Patient and Family Education (PFE)
 Chapters evaluated jointly by medical and nursing surveyors
o Provision of Care (PC)
o Anesthesia Care (AN)
o Burn Care (BC)
o Emergency Care (ER)
o Labor and Delivery (L&D)
o Hemodialysis (HM)
o Critical Care (ICU – NICU – PICU – CCU)
o Operating Room (OR)
o Oncology and Radiotherapy (ORT)

of 134
 Medication Management Surveyor
o Medication Management (MM)
 Infection Control surveyor
o Infection Prevention and Control (IPC)
 Laboratory surveyor
o Laboratory (LB)
 Facility Management and Safety surveyor
o Facility Management and Safety (FMS)
Survey Scheduling and Survey Agenda
The Healthcare Accreditation Department (HAD) handles all scheduling and survey agenda
arrangements for surveys in cooperation with the relevant hospital representative(s). Information
received from the hospital through the completion of the survey application form will guide the flow of
the survey. The agenda of the visit reflects the activities to take place during the survey. CBAHI
surveyors and hospital’s staff will participate in those activities. A survey agenda has been developed
for a survey that reflects a 3 days survey, which is the duration of most surveys carried out by CBAHI.
Hospitals with wider scope of services and larger bed capacity (such as tertiary care hospitals and
physically large facilities with multiple buildings and locations) may have a survey for 4 or 5 days with
a corresponding agenda of the same duration. The Healthcare Accreditation Department (HAD) will
communicate the survey agenda to the hospital at least three weeks (3) prior to the survey. For more
details on standard agenda items, please refer to Annex A. Please note that the prayer time difference in
the various regions of the Kingdom may affect the survey agenda for the business lunch time. For more
details on the hospital representatives and agenda item requirements, please refer to each activity
detailed in this guide. Scheduling and postponement of surveys are detailed in the accreditation policies
section of the standards manual.
The Self-Assessment Tool (SAT)
The self-assessment tool (SAT) has been developed to assist hospitals measure their compliance with
CBAHI standards, maintain a status of accreditation readiness, and oversee the quality and safety of
patient care. The tool is aimed at leadership working in a hospital. It is intended for use by the hospital
leadership, planners, hospital committees’ team members, and other personnel with a responsibility for
their facility’s plans, policies, and procedures. It has been designed to encourage participants to meet
together and discuss issues relating to compliance as well as non-compliance with CBAHI standards.
The tool is expected to provide hospitals with means of evaluating their plans, policies, procedures and
capabilities against current CBAHI standards. Additionally, it provides an opportunity for members of
the management team to reflect on their progress, think about areas for improvement and focus their
improvement activities on areas that are relevant to CBAHI standards. The CBAHI hopes that this tool
will enable the hospital to:
 Identify its own strengths and weaknesses
 Identify and take forward areas for improvement

of 134
 Understand more clearly the issues that are of interest to CBAHI
 Export the data for analysis and evaluation by CBAHI
How this self-assessment tool is constructed
The SAT is designed to walk the user through all the CBAHI hospital accreditation standards. The tool
is designed to include all standards arranged per chapters that parallel the CBAHI standards manual.
The tool allows the users to keep track of the specific planning and response considerations their hospital
has addressed. This SAT contains a number of sections under each chapter:
 A standard section that contains a standard with its related sub-standards drawn from current
CBAHI standards manual.
 An activity section that contains the activity (and related activities, if applicable) that will be
used to assess this sub-standard.
 A document description section that contains the name and the description of the document
required in this sub-standard (if applicable).
 A scoring section contains scoring points which you consider when reflecting on a sub-standard
statement.
 A comments box gives you space to record the assessment findings of your compliance, highlight
strengths and weaknesses and document your improvement plan.
How frequently should the self-assessment be performed?
CBAHI accreditation policies require hospitals to conduct self-assessment during preparation for an
initial survey and at the middle of an accreditation cycle of an accredited hospital, i.e., eighteen months
after awarding accreditation.
 During preparation for an initial survey, the SAT facilitates the process of evaluation of the
hospital’s readiness for an accreditation survey in addition to helping the hospital in preparation
for the survey.
o All registered hospitals with CBAHI should do self-assessment and submit to CBAHI
within 3 months of notification of their enrollment in CBAHI visit plan per that year.
o To be eligible for CBAHI visit you should have a SAT score of 70% or more and all
ESRs are in full compliance.
o If SAT score below 70% and/or ESRs are not in full compliance, the hospital will be not
eligible for CBAHI visit temporarily till re-submission of SAT again after more 3 months
to re-evaluate their readiness and hospital visit will be decided thereafter.
 Three months before the middle of an accreditation cycle (fifteen months after the accreditation
award), each accredited hospital will be notified regarding its due time for submission of its
SAT. The hospital has three months to conduct and submit its self-assessment. The hospital is
required to send CBAHI its self-assessment together with an action plan for standards that are
not in full compliance. The CBAHI requirements related to the mid-term self-assessment are
detailed in the accreditation policies section of the standard manual.
CBAHI considers that the self-assessment is an important part of the process of hospital improvement,
and is recommended to be an ongoing activity within the hospital. Hospitals are recommended to
perform the self-assessment more frequently (e.g., quarterly) to ensure ongoing compliance, look at
progress overtime, and consequently improve the quality and safety of services provided.
How to use this tool
There are three point rating scales which ask you where the hospital is with respect to the issues
underlying the sub-standards. The hospital staff record which standards the hospital has insufficient
compliance, partial compliance or satisfactory compliance. Each sub-standard is scored from 0–2 where

of 134
0 = insufficient compliance, 1 = partial compliance, and 2 = satisfactory compliance. Some standards
may not be applicable to your hospital. These standards should be marked as “NA” = Not Applicable.
The rating scales are expected to help you determine where to focus your improvement efforts. When
you repeat the self-assessment, the rating scales may also help you to monitor the progress you have
made over time.
The self-assessment results in the compilation of compliance reports. These reports are then used to
identify non-compliance areas as well as other opportunities for improvement. Initiating and maintaining
improvement steps are most effective when they are planned and implemented organization-wide. The
hospital leaders collaborate with relevant staff members to prioritize, plan and implement corrective
action plans that address all identified noncompliant areas. The action plan should identify all non-
compliant standards, the required interventions with defined dates, the responsible staff members, and
as applicable, monitoring measures that ensure sustainability of the implemented interventions. These
plans, when implemented and routinely monitored, contribute to the proper compliance with standards
and consequent provision of quality care.
How the hospitals can access the self-assessment tool
The SAT is freely available on the hospital portal to use. Upon registration, the hospital receives a user
name and password that are used to download the tool. This section is designed for users responsible for
self-assessment administration and completion of the online self-assessment. It provides step-by-step
instructions on how to complete a task.
The self-assessment is an internet based program that provides features for:
• Entering self-assessment findings
• Sending surveys to respondents for completion
Appearance may differ in other environments. If you require further assistance, contact the System
Administrator at had@cbahi.gov.sa
System requirements
The online self-assessment is best viewed in the latest Internet Explorer or Google Chrome. Minimal
system requirements include:
How to login and use
• visit http://www.cbahi.gov.sa/hsa
o Enter your user name number and password
• Select “Self-Assessment Tool” from the main menu.
 Fill the Self-assessment application form
 CBAHI will then approve your self-assessment application form and an email will be
sent to your facility informing you about the approved Self-assessment record
• Set your N/A chapters
• Click the transaction name link under “Transaction” column to begin your self-assessment.
 You will be required to specify an SAT surveyor for each of the specialties.
 Upon submitting the surveyor details for each of the specialty, an email will be sent to
the email you specified – informing them about their username and password - for each
of the specialty

of 134
 The assigned surveyor can now start scoring his own domain by logging in to:
http://www.cbahi.gov.sa/hsa by using the username and password in the email.
 After each of the surveyors for each specialty has finished scoring all their scorable items,
the “FINALIZE & SUBMIT” button on the same row with the same transaction will be
enabled – this means that all scorable items have been scored and can now be submitted
to CBAHI
 Click “FINALIZE & SUBMIT” and click “OK” to submit your “Self-Assessment”
 An email will be received by CBAHI about your SAT submission.

of 134
Off-Site Survey Activities
The hospital scheduled for the onsite survey shall send a list of the off-site required documents, listed
below, for the off-site review by the surveyors at least two (2) weeks prior to the date of the onsite
survey. The list shall be communicated, as a signed and scanned PDF document, with the Healthcare
Accreditation Department (HAD).
List of policies to be sent prior to the survey
# Document Name Related Standards
1. Policy for Development and Maintenance of Policies LD.20
2. Medical Records Documentation Policy MR.5
3. Information confidentiality, security, and integrity PFR.7, MOI.6
4. Committee Management Policy LD.9
5. Policy for Delegation of Authority LD.17
6.
Strategic Plan
LD.11.2, LD.11.3, LD.12.1,
LD.12.2, LD.12.3, LD.12.4,
LD.12.5, LD.12.6, LD.12.7,
LD.15.1, LD.15.2, LD.15.3,
LD.15.4, LD.15.5, LD.15.6,
LD.15.11
7. Policy for Contracted Services LD.21, IPC.1
8. Job Description Policy HR.3
9. Policy for Management of Personnel Files HR.4
10. Probationary Period Evaluation Policy HR.8
11. Regular Performance Evaluation Policy HR.9
12. Safe Disposal of Medical Wastes Policy LD.23, IPC.26
13.
Medical staff bylaws
MS.1.1, MS.1.2, MS.1.3,
MS.1.4, MS.1.5, MS.1.6
14. Multidisciplinary Medication Management Plan MM.4.1
15. Hospital Drug Formulary MM.8.1
16. Pharmacy Organization Structure MM.2.1
17. Pharmacy Scope of Services LD.28.2
18. Safety of the Building Management Plan FMS.1.1.1
19. Security Management Plan FMS.1.1.2
20. Life/Fire Safety Management Plan FMS.1.1.6
21. Internal Disaster Management Plan FMS.1.1.5
22. External Disaster Management Plan FMS.1.1.4
23. Hazardous Materials and Waste Management Plan FMS.1.1.3
24. Medical Equipment Management Plan. FMS.1.1.7
25. Utility Management Plan. FMS.1.1.8
26.
Civil Defense License/Assessment Report along with
corrective action plan.
FMS.4.1, FMS.4.2
27. Safety Committee Terms of Reference FMS.3.1, FMS.3.2, FMS.3.3
28.
Running construction/Renovation/Demolition works (if
applicable)
FMS.5.1

of 134
Role of the Visit Team Leader:
Responsibilities of the team leader include but not limited to:
 Review the uploaded hospital profile.
 Review hospital website (if any) for any additional information related to the survey.
 Ensure all logistical arrangements for survey visit via communication with HAD’s accreditation
coordinator.
 Coordinating with hospital visit coordinator to finalize the hospital chapter applicability.
 Coordinating with hospital visit coordinator to finalize the survey agenda.
 Clarify the purpose of the survey visit for the health care facility leaders.
 Ensure abidance by the agenda according to the allocated activities.
 Deal with any conflicts arising between surveyors and/or with the hospital.
 Communicate with hospital visit coordinator the required medical records and personnel files
prior to review sessions.
 Coordinate and arrange a new session “if needed”.

of 134
On-Site Survey Activities
Understanding the organization and assessing compliance is accomplished through a number of
activities specified in the survey agenda. The survey commences with an opening conference followed
by a review of documents’ session. A facility tour and departments/units’ visits are also conducted
during the on-site survey where the surveyors observe compliance with standards, interview staff, and
examine open patient medical records and additional documents. This is followed by reviewing a
selected sample of closed medical records as well as personnel files
Survey Team Arrival
 The surveyors arrive at the hospital early enough for a timely start to the survey activities as per
the survey agenda. Upon arrival, surveyors will present their CBAHI identification.
 The surveyors will meet in the designated room provided by the hospital.
Surveyor Planning Session:
 Only surveyors attend this meeting which will include the following activities:
 Discuss the aim of this meeting & the survey.
 Introduce team members.
 Discuss survey schedule.
 Review list of departments/units/areas/programs/services within the organization (scope of
services).
 Review the organization chart and map of the organization including items in the hospital
demographic date and hospital website (if any).
 Review list of discharged patients (with diagnosis).
 Prepare for the opening conference.
 Review the roles of hospital observers (if any).
 Liaise with hospital leaders to take permission for FMS chapter photos (if required).
 Review the non-applicable chapters/standards issues (if any).
 Team leader should address the following with colleagues:
o Hospital counterparts & interaction with them.
o Required documents, personnel files & medical records.
o Report significant issues or adverse events to Visit Team Leader (VTL).
o Scoring guideline.
o Keeping their laptops’ information safe.
o The importance of communication among team members.
o Time management.
o Be thorough in examination of the information provided and keep an open mind.

of 134
o Treat all information provided by other team members with confidence during the
review.
o Timely data entry.
o Daily team meetings (time & venue).
o Strengths & areas for improvement.
o Required materials for exit conference.
Opening Conference
Objectives
 To explain the scope of survey and what is expected from the hospital during the survey.
 To orient the surveyors about the hospital’s structure, scope of services, staffing, mission, and
vision.
 To officially start the on-site survey.
Participants
 From CBAHI: The entire survey team
 From Hospital: it may include
o Hospital Director
o Medical Director
o Nursing Director
o Administrative Director
o Operations Director
o Quality Improvement Director
o Surveyors' counterpart
Logistics
 A workroom that is large enough to hold all participants with data show facility.
Agenda:
 The team leader will introduce survey team members.
 The hospital leadership will introduce:
o The hospital scope of services
o Highlight the hospital improvement initiatives.
o The surveyors' counterpart to facilitate the smooth flow of the survey process.
Team leader may:
 Discuss any modification in the agenda with the hospital leaders.

of 134
 Request a short meeting with hospital director or medical director for further clarification of the
scope of activities that were doubted.
 Clarify any confusion regarding certain applicability and scope of services with the hospital
leaders.
Review of Documents
Objectives
 To evaluate compliance with standards that should be evidenced in written documents.
Participants
 From Hospital: Staff who are familiar with the hospital’s documents
Logistics
 A workroom that accommodates the surveyors together with staff familiar with the hospital’s
documents.
Procedures
 Documents required to be reviewed include, but not limited to, policies and procedures manuals,
plans, meeting minutes, and quality indicators. The required documents for review must be
current and approved by relevant leaders.
 To facilitate the review of documents, the documents required for review during the document
review session of the on-site survey must be available at the time of the survey. The hospital is
expected to organize the required documents in binders for easy access. The hospital is required
to organize the documents required for review for each surveyor in a separate binder. The binders
should be arranged according to the list provided in this guide in Annex B. At the discretion of
the survey team, surveyors may request additional documents for review during the survey.
 It shall be noted, by the hospital, that whenever a standard or a substandard listed in the CBAHI
Standards Manual requires a policy and procedure, the hospital shall prepare the required policy
and procedure for the document review session of the on-site survey listed below, whether or
not it is specified in the list of required documents.
 When the hospital elects to present the required documents in an electronic format, the hospital
should provide a printer to be used in case a surveyor requires a hard copy of any document.
 It is very much encouraged that the staff accompanying the surveyor (i.e., the surveyor
counterpart) are oriented to the document arrangement.
Surveyors Business Lunch:
o Survey team present their findings with special emphasis to cross-linked items.
o Team members may request colleagues from other chapters to assess/check doubtful
issue/s related to their specialty.

of 134
o Team members to present any major/significant issue encounter during the survey.
o Team members to report encountered difficulties in time management.
o Team members to clarify any activity-overlap issue.
o Team members present their next survey activities.
Surveyors End of the Day Meeting:
o Team members to present items for presentation at the debriefing session.
o Team members to present items for possible discussion during the upcoming
committees meetings.
o Team members present their next day survey activities.
Surveyors Debriefing
There should be no surprises in the survey report, because the surveyors will have already raised any
issues and the hospital is kept abreast of findings. During the survey, the surveyors maintain ongoing
communication with their counterparts from the hospital. This occurs informally as questions arise. The
surveyors present their findings to their counterparts for discussion and clarification. This allows for
direct face-to-face interaction with the surveyors, allows the hospital to clarify or explain possible
discrepancies or compliance issues, and allows for consultation and education. Additionally, the daily
debriefing and the closing conference, at the end of the survey, allow hospitals to challenge cited
deficiencies. Finally, the hospital will review a draft exit report for feedback or correction of any issues
of fact as a step before making the accreditation decision.
Medical Records Review (Closed and Open)
Objectives
 To gather information about compliance with the standards that require documentation in the
medical records.
 To assess the care processes provided to the patients.
Participants
 From CBAHI: The entire survey team with the exception of the FMS & LD Surveyors.
 From Hospital: At the discretion of the hospital, staff familiar with the contents of the medical
records.
Logistics
 Closed medical records are reviewed in the same workroom utilized during the documents
review session.
 Open medical records are reviewed during unit visits.
Procedures

of 134
 Surveyors will use both closed and open medical records. While closed records determine the
past practice and the frequency of a deficient practice, open patient records reflect services
provided at the time of the survey. See Annex C for standards requiring documentation in the
medical records.
 The selection of closed medical records for review is guided by the services provided by the
hospital and any available source of information during the period prior to the survey such as the
top diagnoses and procedures and patient discharge lists. The open medical records for review
are selected from a list of active records provided by the hospital.
Selection Criteria
 Physician Closed Medical Record Review
o A sample of medical records will be requested within the look-back period for the
survey (4 months prior to the 1st cycle of accreditation and 1 year for subsequent
accreditation cycles).and it will include –but not limited to- the following:
1. Dental case with high risk procedure
2. Day surgery patient
3. Two patients transferred to other hospital
4. Two major surgery patient
5. Two emergency patients with multiple consultations
6. ICU patient
7. NICU patient
8. CCU patient
9. Two hemodialysis patients
10. Two patients with outpatient visits
11. Two physiotherapy patients referred from inpatient
12. Patients involved in major incident
13. Two Interventional radiology procedure to check both RD and sedation standards.
If interventional RD is not applicable, ask for sedation files
 The laboratory surveyor will review (20) Closed MR;
o Five with a history of therapeutic phlebotomy/apheresis
o Five with a history of blood transfusion
o Five with a history of adverse transfusion event
o Five with a history of surgical pathology studies
 Nursing Closed Medical Record Review
o A sample of medical records will be requested within the look-back period for the
survey (4 months prior to the 1st cycle of accreditation and 1 year for subsequent
accreditation cycles).and it will include –but not limited to- the following:
1. Two terminally ill patient referred to home care (if applicable) or referred to any
other service
2. Two patient transferred to other organizations
3. Two surgical patient
4. Two Sedation patient discharge directly to home after the procedure
5. Two patient refused treatment

of 134
6. Two ICU patient
7. Two CCU patient
8. Two delivery patient
9. Two patient with nutritional risk
10. Two patient receiving therapeutic diet
Personnel Files Review
Objectives
 To evaluate standards related to human resources such as staffing, recruitment, staff
qualifications, job descriptions, orientation and education, and staff evaluation.
Participants
 From CBAHI: The entire survey team.
 From Hospital: At the discretion of the hospital, staff familiar with the contents of personnel
files.
Logistics
 Personnel files are reviewed in the same workroom utilized during the documents review
session.
Procedures
 Hospitals are required to have the requested personnel files (mentioned below as well as files
randomly selected during the survey) ready prior to the personnel files review session.
 The surveyors will provide the hospital with the randomly selected personnel files list required
to be reviewed during the session. The selection may include, but not limited to, medical and
administrative staff, new hires, nurses, technicians, and contractors. See Annex D for standards
requiring personnel files review.
 As the hospital may have more than one location for the filling of the processes under
assessment, the hospital should guide the surveyors about the different ways for their
documentation. Hospitals are encouraged to present the needed documentation in one location
to ensure comprehensiveness of personnel data and the employment history in the hospital.
These issues should be clarified prior to starting of the session.
 To facilitate the personnel files review, hospitals are required to ensure availability of the
following elements, as applicable, in the personnel files:
- Educational certificates
- Orientation and education
- License and registration
- Job Description
- Performance evaluation
- Credentialing of clinical staff
- Privileging of medical staff

of 134
Required Personnel Files
LD & QM Surveyor
 Hospital Director
 Head of Medical Department
 Finance Director
 Quality Director
 HR Director
 Medical Records Director
 Medical Records Staff
 Clinical Coder
 Part Time Department Head
 Duty Manager
 Head of Social Services
 Social Workers
 Patient Safety Officer
 Randomly selected files:
o Contracted Worker
o New Hire
o Admin Staff
o Medical Staff
o Nursing Staff
MD Surveyor
 Medical Director
 Head of OB/GYN
 Head of Anesthesia
 Head of OR
 Head of ICU
 Head of PICU
 Head of NICU
 Head of CCU
 Head of Hemodialysis
 Head of ER
 Head of Radiology
 Head of Burn Unit
 Head of Oncology & Radiotherapy
 Head of Respiratory Therapy
 Head of Physiotherapy
 Head of Dental
o Physician who perform sedation
o Anesthesiologist
o Psychiatrist
o Hemodialysis physician
o Hemodialysis nurse
o ER physician
o ER Nurse
o ICU physician
o PICU physician

of 134
o NICU physician
o CCU physician
o OB/GYN physician
o Burn Unit physician
o Oncology physician
o Respiratory Therapist
o Physiotherapist
o Dentist
o Dental Technician
o New hire
NR Surveyor
 Nursing Director
 Deputy nursing director
 Nurse involved in restraint
 Nursing assistant
 OR nurse manager
 ICU nurse manager
 PICU nurse manager
 NICU nurse manager
 CCU nurse manager
 OB/GYN nurse manager
 ORT nurse manager
 Hemodialysis nurse manager
 ER nurse manager
 Burn unit nurse manager
o Nurse involved in sedation
o ICU nurse
o PICU nurse
o NICU nurse
o CCU nurse
o OB/GYN nurse
o Midwifes
o Newborn nurse
o Hemodialysis nurse
o ER nurse
o Burn unit nurse
o ORT nurse
o Dietary supervisor
o Dietitian
o New hire
MM Surveyor
 Pharmacy Director
 Pharmacy Quality coordinator
 IV pharmacist
 IV technician
 TPN pharmacist
 TPN technician

of 134
 Chemotherapy pharmacist
 Chemotherapy technician
 Drug Information pharmacist
o Nurse compounding sterile products
o Medication administration nurse
o Selected pharmacy staff
o New hire
IC Surveyor
 IC Director
 IC Practitioners
 CSSD Supervisor
 CSSD staff
o Contracted worker
o Sample From Hospital
o New hire
LB Surveyor
 Lab director
 Lab supervisor
 Lab sections heads
 Lab technicians
 Blood bank technicians
 POCT technician
o POCT staff
o Contracted worker
o New hire
FMS Surveyor
 FMS Director
 Safety Officer
 Staff Handling Nuclear Material
 Security Staff
 House Keeper
 Store Keeper
 Biomedical Engineer
 Electrical Engineer
 Maintenance Engineer
 SFDA Liaison Officer
 HVAC System Maintenance Engineer
 Water System Maintenance Engineer/Technician
 PMG System Maintenance Engineer/Technician
o Maintenance staff

of 134
o Nursing Staff
o Contracted Worker
o New Hire

of 134
Facility Tour and Unit Visits
Objectives
 To interview staff to evaluate their education about the standards.
 To observe the implementation of standards and ensure that they are in place, e.g., condition of
the hospital (FMS chapter) and infection control practices (IPC chapter).
 To examine open medical records in patient care areas.
 To review additional documents in respective departments/services, e.g., pharmacy, laboratory,
infection control, and facility management and safety.
 To interview patients.
Participants
 From Hospital: Staff and management involved in the patient’s care or other services in the area
visited.
Logistics
 Hospitals should assign a counterpart for each surveyor to guide the surveyor to the various
survey sites.
Procedures
 During this activity, the surveyor moves through the hospital and visits all areas of the hospital
that affect the delivery of care and services. The From Hospital are interviewed, facilities are
observed, and records are checked to ensure compliance with certain standards’ requirements.
This activity also includes a facility tour conducted for review of infection control and facility
management and safety standards.
 The surveyors determine the units, departments, and other areas to be visited during the survey
process.
 At all times during the unit visits, the surveyors gather information with minimal disruption of
the daily activities of the hospital being surveyed.
 Hospitals are expected to have their key personnel present during their respective area visit. In
addition, the surveyors may request a particular staff category, when needed.
 Specialty-specific visits and a facility tour are also included in this activity. Surveyors will
interview individuals responsible for managing the following departments / committee(s) in
addition to review of related documents in their respective departments. Areas/departments
visited by surveyors during the specialty-specific visits include:
 Laboratory (LB chapter): laboratory department.
 Pharmacy (MM chapter): pharmacy, outpatient clinics, and any other area where a
medication may exist.
 Facility Management and Safety (FMS chapter): roof, kitchen, laundry, generator, electrical
room, medical gases room, workshops, main store, reverse osmosis plant, biomedical
workshop, procedures room, central sterilization, patient care rooms, bathrooms, waste

of 134
collection rooms, staircases, corridors, main entrances, emergency exits, isolation room,
ambulances, and nurse stations.
 Infection Control (IPC chapter): operating rooms, central sterilization, kitchen, infection
control unit, isolation rooms, staff health clinic, laundry, dental clinic, and any other areas
that may be used by patients.

of 134
CBAHI SURVEY / MEETINGS AND COMMITTEES:
No
.
Activity Venue/ Room Set-
up
Day Duration Chairperson
1. 1st
Day Surveyor planning
session
Conference Style
Room
1st
Day 30 minutes VTL
2. Opening Conference Hospital Auditorium 1st
Day 30 minutes VTL
3. Surveyors’ Business Lunch U Shape 1st
Day 60 minutes VTL
4. 1st
Day Surveyors End of the
Day Meeting
Conference Style
Room
1st
Day 60 minutes VTL
5. 2nd
session
Conference Style
Room
2nd
Day 30 minutes VTL
6. 2nd
Day Surveyors Debriefing Hospital Auditorium 2nd
Day 30 minutes VTL
7. 2nd
Day Surveyors’ Business
Lunch
U Shape8 2nd
Day 60 minutes VTL
8. 2nd
Day Surveyors End of the
Day Meeting
Conference Style
Room
2nd
Day 60 minutes VTL
9. Planning for Quality Interview Conference Style
Room
2nd
Day 30 minutes LD
10. Quality Management Interview
(Data Management Session)
Conference Style
Room
2nd
Day 90 minutes LD
11. Planning for Pharmacy and
Therapeutics Committee
Interview
Conference Style
Room
2nd
Day 15 minutes MM
12. Pharmacy and Therapeutics
Committee Interview
Conference Style
Room
2nd
Day 45 minutes MM
13. Planning for Environmental
Safety Committee Interview
Conference Style
Room
2nd
Day 15 minutes FMS
14. Environmental Safety
Committee Interview
Conference Style
Room
2nd
Day 45 minutes FMS
15. Planning for Infection Control
Committee Interview
Conference Style
Room
2nd
Day 15 minutes IPC
16. Infection Control Committee
Interview
Conference Style
Room
2nd
Day 45 minutes IPC
17. Planning for Contracts Review Conference Style
Room
2nd
Day 15 minutes IPC or FMS
18. Contracts Review Conference Style
Room
2nd
Day 45 minutes IPC or FMS
19. 3rd
session
Conference Style
Room
3rd
Day 30 minutes VTL
20. 3rd
Day Surveyors’ Business
Lunch
U Shape 3rd
Day 60 minutes VTL
21. Planning for Executive
Leadership Interview
Conference Style
Room
3rd
Day 30 minutes VTL

of 134
22. Executive Leadership
Interview
Conference Style
Room
3rd
Day 60 minutes VTL
23. Exit Conference Hospital Auditorium 3rd
Day 30 minutes VTL

of 134
Executive Leadership Interview Session
Aim:
 To clarify and discuss findings encounter during the survey.
 The survey team may also explore the leadership’s support for different functions within the
organization by forwarding, to the Executive Interview Session, survey activities related to
patient and family rights, outcomes of hospital committees, and departmental improvement
projects.
Attendees:
CBAHI:
 The entire survey team.
Hospital:
1. Governing Body representative
2. Hospital Director
3. Medical Director
4. Operations Director
5. Nursing Director
6. Quality Improvement Director
7. Others may be invited based on need (VTL will ifor the hpspita; QM
Duration: 60 minutes
Schedule: To be held on the 3rd
day of the survey, before compiling the Exit Report”.
Surveyor Planning for the interview:
The survey team must hold a planning session prior to the interview to arrange the questions
and/or clarification in a logical sequence. The VTL should alert the team to:
1. Link their questions to the survey activities
2. Have clear and specific questions without any unnecessary/lengthy introduction.
3. Not to be drifted toward presenting their final findings.
4. As needed, address their question to specific member of the panel
5. Manage the time properly and use polite gestures to stop the counterparts from dilatation.
Interview Session Agenda:
1. Introduction; the VTL shall iterate the aims of the interview session and introduce the survey
team.

of 134
2. Discussion; Survey team members who have forwarded survey activity(ies) to the session
will take turns in presenting their questions/inquiries as per the agreed upon sequence.
3. Closing; the VTL shall bring the meeting to closure by identifying the remaining activity in
the survey agenda, convening the projected time for the “Exit Conference”

of 134
Quality and Patient Safety Committee and Data Management Session
Aim: To have an overview on the hospital-wide quality improvement and patient safety program, including how
data and information are managed and communicated to end users to better hospital services.
Attendees: Current members of the committee with a minimum number to meet the quorum as per terms of
reference. According to the available specialties in the hospital, the following are the least number required to
attend:
1. Chairman of the committee
2. Quality Director
3. Medical Director
4. Nursing Director
5. Risk Manager
6. Medical Records Manager
7. Healthcare Information System Manager
8. Other specialties QI designees as per hospital 3 – 5 main services
9. Operations/Logistic representative
10. One project team (team leader and a team member)
Duration: 90 minutes (30 minutes for review of related documents + 60 minutes Interactive discussion)
Schedule: To be held on the 2nd
day of the survey. Avoid overlap with any other meetings to augment
membership attendance.
Agenda:
1. Introduction
2. Hospital presentation on the quality improvement and patient safety program to include:
a. QI program structure
b. QI program flow (how it is integrated with other hospital-wide programs)
c. Highlight on an improvement project
d. Performance indicators’ monitoring process
e. Key performance indicators’ reports submitted to the governing body
f. Risk management initiatives and data trends
g. Management of data and information processes
i. Information needs assessment process
ii. Information management structure
iii. Data management education and training
iv. Data and report flow and management
3. Open discussion between surveyor and hospital representative.
4. Other topics may be raised and discussed based on the surveyor findings during the hospital visit.
Required Documents:
The hospital is requested to have documentations related to its quality improvement program, patient safety
initiatives, risk management program and activities, data and information management process, and
improvement projects present during this session. These may include, but not limited to:
1. Terms of reference of the quality improvement committee, patient safety team or equivalent.
2. Committee membership list.

of 134
3. Minutes of meetings for the tracking period.
4. Managerial and clinical performance monitoring indicators
5. Patient safety indicators.
6. Improvement projects or programs (may include list of projects and teams if available)
7. Improvement activities based on information resulting from data analysis
8. Risk management program
9. Patient safety program
10. Key performance indicators’ reports submitted to the governing body
11. Incidents reporting system and data trends
12. Annual review of committee performance
13. Information needs assessment process and report
14. Information management related activities, education and reports

of 134
Infection Prevention and Control Committee Interview
Aim:
 To have an overview about the infection prevention and control program and to ensure it is implemented
in the hospital as a multidisciplinary process.
 To discuss the role of the committee in monitoring and supporting the IPC program.
Attendees:
 CBAHI: Infection Control Surveyor.
 Hospital: Current members of the committee with a minimum number to meet the quorum as per terms
of reference.
According to the available specialties in the hospital, the following are the least number required to
attend:
2. Infection Control Director
3. Infection Control Practitioner
4. Nursing Director
5. Infectious Disease Consultant
6. Other specialties as per hospital main services
Duration: 60 minutes (15 Min. for review of related documents + 45 Min. Interactive discussion)
Schedule: To be held on the late afternoon of the 2nd
day of the survey. Avoid overlap with quality and data
session or any other meetings to augment membership attendance.
Agenda:
1. Introduction
2. Discussion about the essential role of the committee and its outcome
3. Review of the required documents
Required Documents:
The hospital is requested to have documentations present at the IC review session
1. Terms of reference of the IC committee.
3. Meeting minutes.
4. Committee annual report
5. Surveillance report

of 134
Pharmacy and Therapeutics Committee Interview
Aim:
 To have an overview about the medication management program and to ensure it is implemented in the
hospital as a multidisciplinary process.
 To discuss the role of the committee in monitoring and supporting the medication management program.
Attendees:
 CBAHI: Medication Management Surveyor.
of reference.
According to the available specialties in the hospital, the following are the least number required to
attend:
2. Pharmacy Director
3. Nursing Director
4. Infectious Disease Consultant
5. Internal Medicine consultant
6. Surgery Consultant
7. Pediatrics Consultant
8. Ob/Gyn Consultant
9. Other specialties as per hospital main services
10. Logistic Representative
Duration: 60 minutes (15 Min. for Review of related documents + 45 Min. Interactive discussion)
Schedule: To be held on the afternoon of the 2nd
day of the survey. Avoid overlap with quality and data session
or any other meetings to augment membership attendance.
Agenda:
1. Introduction
2. Discussion about the essential role of the committee and its outcome
3. Review of the required documents
Required Documents:
The hospital is requested to have documentations present at the P&T review session
1. Terms of reference of the P&T committee.
3. Meeting minutes for the last twelve months.
4. Drug Formulary.
5. Relevant indicators (e.g. drug utilization review reports)

of 134
Environmental Safety Committee Interview
Aim:
 To have an overview on how the hospital manages its facilities and ensures safety of its employees,
patients, and visitors at all times.
 To discuss the activities of the safety committee and the optimal utilization of its functions in improving
a safe work and care environment at the hospital.
Attendees:
 CBAHI: Facility Management and Safety (FMS) Surveyor.
of reference and according to the available specialties in the hospital, it should include at least twelve
(12) members:
1. Biomedical Engineering director
2. Housekeeping manager
3. Infection Control representative
4. Laboratory representative
5. Medical staff (E.R)
6. Non-medical maintenance director
7. Nursing director
8. Quality director
9. Radiation safety officer
10. Risk manager
11. Safety Officer
12. Security officer
Duration: 60 minutes (15 Min. for Review of related documents + 45 minutes interactive discussion)
day of the survey. Avoid overlap with other meetings to
augment membership attendance.
Agenda:
1. Introduction
2. Discussion on the committee role and its outcome
3. Discussion on the required programs
4. Discussion on risk management process related to hospital and environmental hazards
Required Documents:
The hospital is requested to have documentations related to safety committee. These may include, but not
limited to:
1. Terms of reference of the Safety Committee.
3. Agenda and meeting minutes approved by the hospital director.
4. Attendance sheet.
5. Facility safety tour reports.
6. Corrective and preventive action plans and budgeting of long-term upgrading and replacement
resulted from facility tours.

of 134
7. Occurrence Variance Reports (OVRs) related to the FMS program with proper action plan to
avoid reoccurrences.
Contracted Services Interview Session
Aim:
 To have an overview on how outsourced and contracted services are planned, monitored, managed, and
improved in the hospital.
 To discuss the role of hospital stakeholders in ensuring the level of safety and quality of outsourced and
contracted services.
Attendees:
 CBAHI: Facility Management and Safety (FMS) and Infection Control Surveyors.
 Hospital: Hospital entity in charge of establishing and monitoring outsourced and contracted services
leaders, including:
1. Hospital director or his/her designee
2. Manager of hospital operations or equivalent
3. Manager of administrative and financial division or equivalent
4. Infection control representative
5. Laboratory representative
6. Manager of non-medical maintenance or equivalent
7. Manager of bio-medical engineering or equivalent
8. Manager of support services (housekeeping, laundry, and pest control – if outsourced)
9. Food services manager (if outsourced)
10. Nursing administration representative
11. Risk manager
Duration: 60 minutes (15 Min. for Review of related documents + 45 minutes interactive discussion)
day of the survey. Avoid overlap with other meetings to
augment membership attendance.
Agenda:
1. Introduction
2. Hospital presentation to address the following outline within the scope of the related standards
requirements:
h. Number of outsourced services/ contracts
i. List of contracted companies (within the hospital premises and off-site)
j. Company selection processes
k. Outsourced and contracted services performance monitoring tools and process
l. Roles and responsibilities in monitoring contracted services
m. Outsourced/contracted services’ performance monitoring reports and flow processes
n. Sample of outsourced/contracted services performance monitoring reports content
o. Sample of actions taken by hospital leadership based on contract monitoring reports
p. Risk management process related to a company with unsatisfactory compliance
q. New employees screening and immunization process for contracted workers
r. Contract renewal process

of 134
s. Contracts to manage constructions and renovation works
t. Open discussion
Required Documents:
The hospital is requested to have documentations related to safety committee. These may include, but not
limited to:
1. Policies and procedures to ensure the quality and safety of all contracted services, including
company/service selection criteria.
2. Policies and procedures indicating how to track and monitor all contracted services
3. Sample contract
4. List of laws and regulations relevant to the scope of contracted services (e.g. medical waste
disposal laws).
5. Number of renewed contracts and contracts that were aborted.
6. New employees screening and immunization process for contracted workers.
7. Laboratory services contract (if outsourced).
8. Contracts to manage constructions and renovation works.
9. Policy to address agent or contractor repairs.
10. Evidence for reporting medical supplies adverse effects.
11. Corrective and preventive action plans and budgeting of long-term upgrading and
replacement resulted from contracted services monitoring outcome.
12. Occurrence Variance Reports (OVRs) related to the contracted services program with proper
action plan to avoid reoccurrence.

of 134
Report Preparation session (before exit conference)
Objectives
 To prepare an initial exit report that can be shared with the hospital at the end of the on-site
survey
 To provide the hospital with the possible challenges and areas for improvement
 Provide the hospital with the list of non-compliant “ESR’s” that need immediate leadership
attention.
Participants
 From CBAHI: The entire survey team.
Logistics
 A workroom that can accommodate all the surveyors together
Procedures
 After each surveyor has completed scoring all the sub-standards under his scope of on-site
assessment, the whole team has to integrate their findings into one report that will be shared with
the hospital at the end of the on-site survey.
 The Visit Team Leader (VTL) shall be responsible to ensure integration of the findings and
recommendations for the sub-standards that are scored by more than one surveyor to ensure
accuracy and reliability of the initial report.
Closing Conference
Objectives
 To provide the hospital with an initial overview on the outcome of the survey.
 To allow the hospital to clarify or explain possible discrepancies or compliance issues.
 To provide the leaders with the hospital’s strengths and areas for improvements.
Participants
 From Hospital: Chief medical and administrative staff of the hospital. It is encouraged that
various From Hospital (especially those at supervisory levels) attend this session.
Logistics
 A workroom that is large enough to hold all participants.
Procedures
 At the conclusion of the on-site survey, after collection of final data, the surveyors hold a closing
conference at which they present key findings and the hospital’s areas for improvement. Exit
report will be provided to the hospital director including the draft of major findings in ESRs and

of 134
other standards in all specialties. Other information provided may include how the hospital could
have access to the detailed report and possible follow-up decisions or activities.
 As the surveyors are “fact finders” for the CBAHI, they do not render the final accreditation
decision, but instead they report findings to the CBAHI. Therefore, during the exit conference,
the surveyors will not state whether the hospital will be awarded an accreditation.
 Members of the leadership group are encouraged to take this opportunity to comment and
provide feedback on the findings for which there are issues of interpretation, as well as express
their perceptions of the survey.

of 134
Post Survey Activities
Accreditation Decision and plan for correcting ESR’s
Following completion of the survey, CBAHI renders an accreditation decision and delivers a report.
Types of possible accreditation decisions, follow up activities, required accreditation maintenance
activities are fully explained in part two of the standards manual. The surveyed hospital receives official
documents from CBAHI detailing the accreditation decision and any required follow-up activities within
thirty days after the conclusion of the survey. Hospitals will be able to access the survey report through
the use of their username and password through the hospital portal.
Survey Report
CBAHI provides a survey report to the hospital for on-site visits. The first page of the report contains
items such as the dates of the survey, the names of the surveyors, the services and sites assessed, and
the scope of the survey and the standards used. The main part of the report contains the findings of the
survey team for all sub-standards that had insufficient or partial compliance.
Survey Feedback
In order to evaluate and improve its performance, CBAHI appreciates each surveyed hospital’s
feedback. This feedback is very beneficial in ensuring the continuing growth and improvement of
CBAHI’s accreditation program. An email is sent to the hospital’s survey coordinator after the survey
visit has been completed requesting their feedback about CBAHI standards, survey process and
surveyors’ performance

of 134
Terms of Accreditation
The CBAHI accreditation is granted for a three years period. CBAHI will send a renewal letter to
accredited hospitals describing how to begin the renewal process before the accreditation expires.
Accreditation Maintenance
The maintenance of the accreditation process pertains only to hospitals already accredited. When a
hospital receives accreditation, the hospital is responsible for maintaining compliance with the CBAHI
standards for the full duration of the accreditation term. CBAHI reserves the right to review the
accreditation status where there is substantial evidence to suggest that accreditation standards are not
being met. CBAHI adopted procedures that facilitate maintenance of accreditation. These procedures
are intended to create an ongoing “maintenance of accreditation” signaling that once a hospital has
achieved accreditation, a process of continuous improvement maintains the accreditation status. The
maintenance of accreditation procedures are fully described in the accreditation policies part of the third
edition of the CBAHI standards manual. As part of accreditation maintenance procedures, the mid-term
self-assessment serves as an opportunity for a hospital to engage in a process of rigorous self-review
and improvement against CBAHI standards.
.

of 134
Annex A
Standard Survey Agenda

of 134
Note 1:
For the Medical and Nursing Surveyors’ Units Visit, please select the units from the following list and
specify it in the particular slot in the schedule, taking in consideration that both surveyors shall not be
visiting the same area at the same time. The sequence of units shall be determined based on the physical
layout of the organization that will allow a smooth flow and ideal utilization of the surveyor time. Please
note that this is a standard agenda so according to the hospital scope of services you may add or eliminate
some units.
Units to be visited by the medical surveyor:
1. ER;
2. OR;
3. Surgical Ward;
4. Medical Ward;
5. Pediatrics Ward;
6. ICU;
7. PICU;
8. NICU;
9. CCU;
10. OPD;
11. Physiotherapy;
12. Radiology;
13. Oncology;
14. Dental;
15. Hemodialysis;
16. L&D;
17. Burn Unit; and
18. Day Surgery.
Units to be visited by the nursing surveyor:
1. ER;
2. OR;
3. L&D;
4. Surgical Ward;
5. Medical Ward;
6. Pediatrics Ward;
7. ICU;
8. PICU;
Standard Survey Agenda

of 134
9. NICU;
10. CCU;
11. OPD;
12. Oncology;
13. Nursery; and
14. Burn Unit.
The information verification session at the third day of the survey is a specially designed session to
allow more flexibility for the surveyor if he/she wants to verify any of the information collected over
the three survey days
Note 2:
For the FMS Surveyors’ Units Visit, please select the units from the following two lists (external and
internal locations) and specify it in the particular slot in the schedule, surveyors shall not be visiting the
same area at the same time. The sequence of units shall be determined based on the physical layout of
the organization that will allow a smooth flow and ideal utilization of the surveyor time. Please note that
this is a standard agenda so according to the hospital scope of services you may add or eliminate some
units.
Exterior locations to be visited by the FMS surveyor:
1. Construction, renovation or demolition project;
2. Medical Waste Store Room;
3. Hospital roof;
4. Elevator Service Room;
5. Hospital gates/ Entrances / Handicap access;
6. Kitchen;
7. Laundry;
8. Ambulances;
9. Holding Areas;
10. Technical Rooms;
11. Electrical Rooms;
12. Central store;
13. Biomedical Engineering Workshop;
14. Generators;
15. Chillers;
16. Central Medical Gas Station;
17. RO Plant,
18. Fire Pumps;
19. Boilers;
20. Septic Tank; and
21. Parking area/ Handicap slots.

of 134
Interior locations to be visited by the FMS surveyor:
1. Hospital Lobby and gates;
2. Corridors/ Staircases/ Assembly Points;
3. Elevators;
4. MRI;
5. ICU/NICU/ isolation rooms;
6. Operating Rooms;
7. Emergency Room/ Triage Areas;
8. In-Patient Rooms/Bathrooms/ Special Needs Bathrooms;
9. Children Playroom;
10. Laboratory;
11. Radiology Department;
12. Nuclear Medicine;
13. Dermatology Clinic/ Laser room(s);
14. Delivery room;
15. Nursery;
16. Female wards;
17. Central sterilization service department;
18. Medical records;
19. Emergencies Command Center;
20. Nursing Stations;
21. Safety Department;
22. Sub-stores/ Pharmacy store;
23. Pantries and staff lounges;
24. Cardiology Units;
25. Dialysis Unit;
26. Dental Unit;
27. Data Center (servers room);
28. Clean utility;
29. Dirty utility; and
30. Janitorial closet.

of 134
TYPE OF SURVEY – FACILITY NAME
DAY 1, Day of the week, DD MMM, YYYY (Morning)
Time/Activity LD MD NR IC MM LB FMS
08:00
To
08:30
Activity Surveyor Planning Session
Location
08:30
To
09:00
Activity Opening Conference
Location
09:00
To
12:00
Activity Document Review Document Review Document Review Document Review Document Review Document Review Document Review
Location
Counterpart(s)
12:00
To
13:00
Activity Surveyors' Business Lunch
Location

of 134
DAY 1, Day of the week, DD MMM, YYYY (Afternoon)
13:00
To
14:00
Activity Unit Visit Unit Visit Unit Visit Documents Review Unit Visit Documents Review Documents Review
Location(s) (Social Services) (Inpatient
Pharmacy)
Counterparts
14:00
To
15:00
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit
Lab Leadership
Interview
Facility Tour
Location(s) (Patient Affairs) (CSSD / Endoscopy
/ Laundry)
(ER /
Ambulance)
Counterparts
15:00
To
16:00
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Location(s) (Medical Supply /
Admission
Office/ Duty
Manager Office)
(Utility Rooms /
Waste Segregation
Areas / Morgue)
(OPD /
Outpatient
Pharmacy)
Counterparts
16:00
to
17:00
Activity Data Entry / Surveyor Meeting
Location Quality meeting room

of 134
08:00
To
08:30
Activity Surveyor Planning Session (list of “Closed Medical Records” should be provided at the end of session)
Location
08:30
To
09:00
Activity Day One Debriefing
Location
09:00
To
10:00
Activity
QM Department
Visit
Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Location(s) (NICU / PICU /
ICU/CCU)
(Pharmacy
Warehouse
/Narcotics)
Counterparts
10:00
To
11:00
Activity
QM Committee
Interview
Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Location(s) (Burn Unit / Regular
Ward/Staff Health
Clinic)
(IV Clean Room)
(TPN /)
Counterparts
11:00
To
Activity
Data Management
Session
Unit Visit Unit Visit
IC Committee
Unit Visit Unit Visit Facility Tour

of 134
12:00 Interview
Location(s) 11:00 to 11:30
(Chemotherapy)
Counterparts:
11:30 to 12:00
Pharmacy
Admin/QI Meeting
Counterparts
12:00
To
13:00
Activity Surveyors' Business Lunch
Location

of 134
13:00
To
14:00
Activity Unit Visit Unit Visit Unit Visit Unit Visit
P and T Committee
Interview
Unit Visit Facility Tour
Location(s) (Medical Records (OR)
Counterparts
14:00
To
15:00
Activity Unit Visit
Closed Medical Records
Review
Review
Unit Visit
Unit Visit
Review
Environmental Safety
Committee Interview
Location(s) (Inpatient Unit/ OPD/
Hospital Tour)
(ER)
(Dental / Kitchen)
(ICU / NICU)
Counterparts
15:00
To
16:00
Activity Unit Visit
Review
Review Contract Review Unit Visit
Review
Contract Review
Location(s) (Finance / Purchasing /
Academic Affairs / IT)
( Medical /Surgical)
Counterparts
16:00
To
17:00
Activity Data Entry / Surveyor Meeting
Location

of 134
08:00
To
08:30
Activity Surveyor Planning Session (list of “Personnel Files” should be provided at the end of session)
Location
08:30
To
10:00
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Location(s) HR Department (Dialysis /
Water Plants)
(L&D, OR,
Radiology,
Conscious Sedation
Area and
extemporaneous
preparations)
Counterparts
10:00
To
11:00
Activity
Personnel Files
Review
Personnel Files
Review
Personnel Files
Review
Personnel Files
Review and
Closed Medical
Records Review
Personnel Files
Review
Personnel Files
Review
Personnel Files
Review
Location
Counterparts
11:00
To
12:00
Activity Information Verification
Information Verification
Location(s)
12:00
To
13:30
Activity Business Lunch and Preparation for the Executive Leadership Interview
Location

of 134
13:30
To
14:30
Activity Executive Leadership Interview
Location
14:30
To
16:00
Activity Data Entry and Preparation of the Exit Report
Location
16:00
To
16:30
Activity Pre-Exit Conference Meeting with Hospital Leadership (Optional Session)
Location
Counterparts
16:30
To
17:00
Activity Exit Conference (Optional session if the facility opt to have “Pre-Exit Conference”)
Location

of 134
Annex B
Required Survey Documents

of 134
1. Leadership & Quality Management Surveyor (Closed Session)
Required Documents Related Standards
Policy on Policy
1. Policy for Development and Maintenance of Policies LD.20.1
Laws and Regulations
2. Laws and Regulations Worksheet e.g. HR.5.5, ORT.2.1,
FMS.4.1, etc.)
LD.3.1
3. Evidence of Hospital Compliance with Relevant Laws and
Regulations
LD.3.2, LD.2.3
Hospital Leadership /Governing Body
4. governing body formation document LD.1.1
5. Governing Body Bylaws or Similar Document LD.1.2
6. Administrative Policies and Procedures Manual LD.6.3, LD.6.1
7. Policy for Delegation of Authority LD.1.3
8. Governing Body Meeting Minutes LD.1.4
9. Reports from Hospital Director to Governing Body LD.2.5
10. Evidence that the Leadership Supporting Hospital Safety LD.2.7
11. Hospital Executive Committee LD.2.8, LD.5.1, LD.5.4, LD.5.5, LD.5.6,
LD.14.2, LD.14.3, LD.24.2
12. Evidence of Hospital Director Response to the Authorities LD.2.9
13. Reports and Communications about Performance Quality LD.10.3
14. Evidence of Community Leaders Participation in Planning LD.11.2
15. Key Performance Indicator Report LD.15.8
16. Policy for Vertical and Horizontal Communication LD.18.1
17. Policy for Handling Incoming External Requests LD.18.5
18. Evidence on Response to any Incoming Requests LD.18.6
19. Contracts Oversight Process LB.1.4
Hospital Scope of Services
20. Hospital Scope of Services LD.4.1, LD.4.2, LD.4.3, LD.4.4, LD.4.5,
LD.4.6
Hospital Strategic Plan
21. Mission Statement LD.7.1, LD.7.4, LD.7.5
22. Hospital Code of Conduct LD.8.1, LD.8.2, LD.8.3, LD.8.4
23. Document Identifying Relevant Community Leaders LD.11.1
24. Hospital Strategic Plan LD.11.2, LD.11.3, LD.12.1, LD.12.2,
LD.12.3, LD.12.4, LD.12.5, LD.12.6,
LD.12.7, LD.15.1, LD.15.2, LD.15.3,
LD.15.4, LD.15.5, LD.15.6, LD.15.11
Hospital Budgeting Process
25. Hospital Budgeting Process LD.13.2, LD.13.3, LD.13.4, LD.13.5
Hospital Staffing Plan
26. Hospital Staffing Plan LD.16.1, LD.16.2, LD.16.3, LD.16.4,
LD.16.5
Hospital Committees
27. Policy for Committee Management LD.9.1, LD.9.2, LD.9.3
28. Committee Terms of Reference (Sample) LD.9.3

of 134
29. Terms of Reference of Patient Rights/Patient Advocacy
Committee
PFR.1.1
30. Terms of Reference of Research Committee PFR.16.3
31. Medical Records/Forms Committee MR.16.2
Leadership & Quality Management Surveyor (Units Documents)
Human Resources
1. Human Resources Manual HR.1.3
2. Laboratory/facility policy on job description and samples
of job descriptions (lab staff)
HR.3.1
3. Policy for Delegation of Authority LD.17.1, LD.17.2
4. Policy for Management of Personnel Files HR.4.1
5. Policy for Credentialing and Privileging HR.5.1
6. Departmental and Job Orientation Program HR.7.1
7. Policy for Probationary Period Evaluation HR.8.1
8. Policy for Regular Performance Evaluation HR.9.1
9. Policy for Staff Complaint HR.14.1
10. Evidence of Staff Complaints Management HR.14.3
11. Evidence for Exit Interview HR.15.4
12. General Hospital Orientation Program / Employee
Handbook
PFR.2.1
Education and Training Department
13. Training Needs Assessment HR.10.1, HR.10.2
14. Policy for Continuing Education HR.11.1
15. Evidences of support of Staff Education HR.11.2
16. Continuing Education Program HR.11.3
Quality Management Department
17. Hospital Organization Chart QM.3.4
18. Departmental Scope of Services QM.1.1
19. Quality Improvement Plan/Program QM.4.1, QM.4.2, QM.4.3, QM.4.4,
QM.2.1, QM.2.2
20. Risk Management Program QM.13.1, QM.13.2, QM.13.4, QM.13.5,
QM.13.9, QM.13.10, QM.13.11,
QM.13.13
21. Terms of Reference of Patient Safety Committee QM.16.4, QM.16.9
22. Patient Safety Culture Assessment Report and Actions QM.16.5
23. Leadership Patient Safety Rounds QM.16.6
24. Policy for Incidents Reporting QM.14.1, QM.14.2
25. Terms of Reference for Quality Improvement
Committee/Council
QM.14.4, QM.14.6
26. Policy for Sentinel Events QM.15.1, QM.15.2
27. Reports of Sentinel Events QM.15.3, QM.15.4, QM.15.5, QM.15.6
28. Data Management Education/Training Program MOI.5.1, MOI.5.2, MOI.5.3
29. Performance Improvement Projects/Reports QM.12.1, QM.12.2, QM.12.3
30. Hospital Indicators Reports MOI.4.2, QM.10.1, QM.10.2, QM.10.3

of 134
31. Evidence on Systematic Approach of New or Modified
Processes
LD.19.1
32. List of Identified Customers and their Needs LD.19.2
33. Risk Assessment LD.19.4
34. Pilot Testing Report LD.19.5
35. New Process Indicators LD.19.6
36. Staff Training Records for New Processes LD.19.7
Patient Affairs
37. Patient and Family Rights Statement PFR.1.3, PFR.4.2, PFR.8.1, PFR.8.2,
PFR.8.3
38. Policy for Patient and Family Rights PFR.1.4, PFR.8.1, PFR.8.2, PFR.8.3,
PFR.8.4, PFR.17.5
39. General Hospital Orientation Program / Employee
Handbook
PFR.2.1
40. Policy for the Protection of Patient Belongings PFR.4.1, PFR.4.3
41. Policy for Information Confidentiality, Security and
Integrity
PFR.7.1, PFR.7.2
42. Terms of Reference of Research Committee PFR.7.2
43. Patient's Booklet/Handbook PFR.8.6
44. Policy for Patient Complaint PFR.14.1
45. Evidence of Patient Complaints Management PFR.14.3
46. Patient Satisfaction Program PFR.15.1, PFR.15.2
Social Services
47.
Policy For Refusal of Treatment PFR.11.1, PFR.11.2, PFR.11.3 PFR.11.4,
PFR.11.5
48. Policy on "No Code" PFR.12.1
49. Policy for Experimental Research PFR.16.1, PFR.16.2,
50.
Sample of patient's informed consent for participating in
research. PFR.16.4, PFR.16.5
Medical Records
51. Departmental Staffing Plan MR.1.3
52. Policy for Medical Records Documentation MR.5.1, MR.5.6
53. Policy for Medical Records Protection MR.6.3, MR.13.1, MR.13.3
54. Policy for Access to Medical Records MR.9.1
55. Medical Records Management Process MR.11.3, MR.15.1, MR.15.2
56. Policy for Medical Records Retention MR.12.1, MR.12.2
57. Policy for Release of Medical Records MR.14.1, MR.14.2, MR.14.3
58. Medical Records Review Reports MR.17.1, MR.17.2, MR.17.3, MR.17.4,
MR.17.5
IT
59. Policy for Data and Information Retention MOI.2.5, MOI.8.1, MOI.8.2, MOI.8.3
60. Policy for Information Confidentiality, Security and
Integrity
MOI.6.1, MOI.6.2, MOI.6.3, MOI.6.4,
MOI.6.9
Property Control
61. Evidence for Qualification of Medical Suppliers LD.23.2
62. Documents Reflecting Implementation of Safe
Management of Medical Supplies and Devices Process
LD.23.4, LD.23.9
63. Medical Supplies and Devices Inspection Reports LD.23.5
64. Evidence for Reporting Medical Supplies Adverse Effects LD.23.6

of 134
65. Risk Assessment QM.24.6
Hospital-wide
66. Departmental Organization Chart LD.26.1, LD.26.2
67. Departmental Mission Statement LD.27.1, LD.28.2
68. Departmental Scope of Services LD.28. 2
69. Annual Departmental Plan LD.15.9
70. Departmental Staffing Plan LD.30.2, LD.30.3, HR.2.1, HR.2.3, HR.2.4
71. Departmental Meeting Minutes LD.18.2
72. Policy for Development and Maintenance of Policies LD.20.1, LD.20.2
73. Policies and Procedures LD.20.3, LD.20.4
74. Interdepartmental Agreement LD.27.2
75. Departmental Manual LD.29.1
76. Multidisciplinary Policies and Procedures (Sample) LD.29.2
77. Departmental Request for Resources and Staffing LD.30.1
78. Performance Improvement Projects/Reports LD.31.1, LD.31.2, LD.31.4
79. Departmental Indicators Report LD.31.3
80. Evidences of rewarding recognized staff HR.15.1
81. Information System Downtime Procedures and Forms MOI.9.1

of 134
2. Medical Surveyor (Closed Session)
Medical Staff Bylaws
1. Medical Staff Bylaws MS.1.1, MS.1.2, MS.1.3, MS.1.4, MS.1.5,
MS.1.6
Medical Committees
2. Medical Executive Committee MS.3.1, MS.3.2, MS.3.3, MS.3.4, MS.10.3
3. Cardiopulmonary Resuscitation Committee PC.32.7, MS.18.1, MS.18.2, MS.18.4,
MS.18.5
4. RRT Committee Meeting Minutes PC.33.4
5. Credentialing and Privileging Committee MS.5.1, MS.5.2
6. Policy for Credentialing and Privileging MS.6.2, MS.6.6, MS.7.3, MS.7.4
7. Hospital Mortality and Morbidity Committee MS.12.1, MS.12.2, MS.12.3, MS.12.4,
MS.12.5, MS.12.6
8. Medical Records/Forms Committee MS.13.1, MS.13.2, MS.13.3, MS.13.4
9. Utilization Review Committee MS.14.1, MS.14.2, MS.14.3
10. Operating Room Committee MS.17.1, MS.17.2, MS.17.3, MS.17.4
11. Oncology and Radiotherapy Committee/Tumor Board ORT.5.1, ORT.5.2, ORT.5.3, ORT.5.4
12. Committee Terms of Reference (Sample) LD.9.3
Medical Staff Performance Evaluation
13. Documented Evidence of Peer Review MS.4.4
14. Policy for Unplanned Review of Medical Staff
Performance
MS.8.2
15. Credentialing and Privileging Committee MS.10.2
a.Policies for Patient Care Hospital-wide
16. Policy for Patient Assessment and Re-assessment PC.6.1
17. Policy for Care of Psychiatric Patient PC.27.3, PC.28.1, PC.28.2
18. Policy for Cardio-pulmonary Resuscitation PC.32.1, PC.32.2
19. Cardio-pulmonary Resuscitation (CPR) Form PC.32.3
20. Policy for Rapid Response Team PC.33.1
21. Policy for Care of Vulnerable Patient PC.34.1, PC.34.2
22. Policy for Patient Transfer PC.38.9, PC.39.1, PC.39.4
23. Policy for Informed Consent PFR.10.1, PFR.10.4
24. Policy for Moderate and Deep Sedation/Analgesia AN.13.1, AN.14.1, AN.14.2
a.Policies for Organ Donation
25. Policy for Organ Donation ICU.12.5, PC.43.1, PC.43.3, PC.43.4,
PFR.18.1, PFR.18.3, PFR.18.4, ICU.12.1,
ICU.12.2, PICU.13.2, CCU.13.1, CCU.13.2,
CCU.13.5
26. Policy for Organ Transplantation PC.43.2, PC.43.3

of 134
Medical Surveyor (Units Documents)
Hospital-wide
1. Departmental Staffing Plan HR.2.1, LD.30.2, HR.2.3, HR.2.4, LD.30.3
4. Handover Documentation PC.20.3
5. Evidence of Implementing the Research Outcomes PFR.16.6
6. Departmental Mission Statement LD.28.1
7. Departmental Scope of Services LD.28.2, LD.27.1
9. Part-time Department Head Evidence of Visits LD.25.3
12. List of Essential Medical Supplies and Devices LD.23.1
14. Departmental Mortality and Morbidity Meetings MS.11.1, MS.11.2, MS.11.3, MS.11.4,
MS.11.5
15. Medical Staff Privileging List MS.7.1
16. Medical Staff Bylaws PC.15.3
17. Clinical Practice Guidelines PC.18.2
18. Medical On-call Schedule PC.22.2
19. Safe Operation of Medical Equipment Training Records FMS.27.1, FMS.27.3
Day Surgery
20. Policy for Day Surgery OR.8.1, OR.8.2, OR.8.3
Emergency
21. Criteria for Accepting Patients in the Hospital PC.2.1
22. Emergency Department On-call Schedule ER.2.1
23. Policy for Consultation ER.2.3, ER.13.1, ER.13.5
24. Emergency Department Policies and Procedures ER.9.1, ER.9.2, ER.9.4, ER.10.1
25. Clinical Practice Guidelines ER.9.3
26. Laboratory policy and procedures on reference
laboratory services
ER.11.2
27. Departmental Indicators Report ER.14.1
OR
28. Policies for the Provision of Anesthesia AN.3.1, AN.3.2, AN.8.1, AN.11.1
Hemodialysis
29. Medical On-call Schedule HM.3.9
30. Admission and Discharge Criteria HM.4.1, HM.4.2
31. Policy for Patient Care in Hemodialysis HM.5.1
ICU
32. ICU On-call Schedule ICU.3.1
33. Departmental Scope of Services ICU.4.1
34. Admission and Discharge Criteria ICU.4.2, ICU.4.3, ICU.4.4
35. Handover Documentation ICU.5.1
36. Policy for Handover ICU.11.4
37. Policy for Patient Assessment and Re-assessment ICU.11.1

of 134
38. Evidence-Based Criteria for Intubation, Weaning off
ventilator and Extubation
ICU.11.3
39. Policy on "No Code" ICU.11.6
40. ICU Policies and Procedures (Sample) ICU.11.7
PICU
41. PICU On-call Schedule PICU.4.1
42. Departmental Scope of Services PICU.5.1
43. Admission and Discharge Criteria PICU.5.3, PICU.5.2, PICU.5.4
44. Handover Documentation PICU.6.1
45. Policy for Handover PICU.12.4
46. Policy for Patient Assessment and Re-assessment PICU.12.1, PICU.12.2
PICU.12.3
48. Policy for Organ Donation PICU.12.6, PICU.13.1, PICU.13.3,
PICU.13.4, PICU.13.5
49. PICU Policies and Procedures (Sample) PICU.12.7
NICU
50. NICU On-Call Schedule NICU.4.1
51. Handover Documentation NICU.6.1
NICU.12.3
53. Policy for Handover NICU.12.4
54. Departmental Scope of Services NICU.5.1
55. Admission and Discharge Criteria NICU.5.2, NICU.5.3, NICU.5.4
56. Policy for Patient Assessment and Re-assessment NICU.12.1
57. Policy for Organ Donation NICU.12.7
58. NICU Policies and Procedures (Sample) NICU.12.8
CCU
59. CCU On-call Schedule CCU.4.1
60. Departmental Scope of Services CCU.5.1
CCU.12.3
62. Handover Documentation CCU.6.1
63. Multidisciplinary Patient Care Team Meeting Minutes CCU.7.1
64. Admission and Discharge Criteria CCU.5.2, CCU.5.3, CCU.5.4
65. Policy for Handover CCU.12.4
66. Policy for Patient Assessment and Re-assessment CCU.12.1
67. CCU Policies and Procedures (Sample) CCU.12.7
Radiology
68. Radiology Department Policies and Procedures RD.1.2, RD.3.1, RD.9.1, RD.9.2
69. Departmental Scope of Services RD.2.1
70. Radiology On-call Schedule RD.2.3
71. Radiology Request Form RD.4.1, RD.4.2
72. Policy for Reporting Critical Radiology Results RD.6.1, RD.6.2, RD.6.3, RD.6.4
Burn
73. Burn Unit On-call Schedule BC.2.1, BC.3.3
74. Admission and Discharge Criteria BC.6.1, BC.6.2
75. Burn Unit Policies and Procedures BC.8.1
L&D

of 134
76. OB/Gyn On-call Schedule L&D.2.1, L&D.2.3, L&D.2.4
77. Admission and Discharge Criteria L&D.5.1, L&D.5.2, L&D.5.3
78. L&D Policies and Procedures L&D.6.1, L&D.6.2
ORT
79. Departmental Organization Chart ORT.3.1
80. Oncology and Radiotherapy Policies and Procedures ORT.6.1
81. Admission and Discharge Criteria ORT.8.1, ORT.8.2
Respiratory
82. Respiratory Care On-call Schedule RS.1.1
83. Respiratory Care Policies and Procedures RS.2.1
a.Physiotherapy
84. Policies for Physiotherapy PT.2.1, PT.2.2
85. Policy for Patient Assessment and Re-assessment PT.3.2, PT.3.5
Psychiatry
86. Admission and Discharge Criteria PC.27.2

of 134
3. Nursing Surveyor (Closed Session)
Nursing Organization
1. Nursing Organization Chart LD.26.1, LD.26.2, NR.1.5
2. Nursing Education Program NR.1.5
3. Nursing Quality Plan NR.1.5
5. Departmental Scope of Services LD.28.2
Nursing Director
6. Hospital Executive Committee NR.2.1, NR.2.2
7. Pharmacy and Therapeutics Committee Meeting Minutes NR.2.3
8. Infection Control Committee Meeting Minutes NR.2.3
9. Quality Management Committee Meeting Minutes NR.2.3
10. Multidisciplinary Policies and Procedures (Sample) NR.3.1, NR.3.2, NR.3.5
11. Policy for Nursing Care Delivery NR.3.8
Nursing Staffing Plan
13. Departmental Staffing Plan LD.30.2, LD.30.3, HR.2.1, HR.2.3, HR.2.4,
NR.6.1, NR.6.2, NR.6.3, NR.9.1, ICU.8.1,
ICU.8.2, ER.4.1
Nursing Policies
14. Policy for Admission PC.3.1
15. Patient and Family Education Policy PFE.1.1
16. Policy for Handover ICU.11.4, PICU.12.4, NICU.12.4, CCU.12.4
17. Emergency Department Policies and Procedures PC.3.2
18. Policy for Patient Assessment and Re-assessment PC.6.1, ICU.11.1, NICU.12.1, PC.7.2,
PC.13.1, PC.13.2
19. Policy for Management of Suspected Abuse, Neglect, or
Domestic Violence Cases.
PC.13.3
20. Policy for Pain Management PC.14.2
21. Policy for Restraints PC.29.1, PC.29.2
22. Policy for Out On-pass PC.35.1, PC.35.2, PC.35.3, PC.35.4
23. Multidisciplinary Policies and Procedures (Sample) NR.3.6, LD.29.2
24. Policy for Nursing Scheduling NR.7.1
25. Par Level Policy NR.12.2
26. Departmental Meeting Minutes PFE.1.7
27. Policy for Care of Vulnerable Patient PFR.5.5
28. Policy for Nutritional Assessment DT.2.2
29. Policy for Psycho-Social Assessment SC.2.2, SC.2.4
Orientation, Training, and Competency
30. Policy for Nursing Competencies Assessment NR.5.2
31. Cross Training Policy NR.8.1
32. Cross-trained Nurses List NR.8.2
Departmental Staffing
33. Departmental Staffing Plan BC.5.1, CCU.9.1, L&D.4.1, PICU.9.1,
PICU.9.2, CCU.9.2, NICU.9.1, NICU.9.2

of 134
Nursing Surveyor (Units Documents)
Hospital-wide
2. Handover Documentation PC.20.3, QM.21.2
3. Safe Operation of Medical Equipment Training Records FMS.27.3, FMS.27.1
4. Performance Improvement Projects/Reports LD.31.4
5. Nursing Schedule NR.7.2
6. Par Level Policy NR.12.2
7. Periodic Preventive Maintenance (PPM) Records QM.19.3
8. Policy for Nutritional Assessment DT.2.6
9. Dietary Manual DT.4.4, DT.4.5
10. Information System Downtime Procedures and Forms MOI.9.1
11. Sample of Hazardous Materials Inventory List FMS.14.2
ORT
12. Oncology and Radiotherapy Policies and Procedures ORT.4.2, ORT.6.1
Emergency
13. Policy for Patients Triage in Emergency Room ER.8.1
14. Patient's Booklet/Handbook PFR.8.6
15. Red Crescent Services Communication Sheet/Log ER.15.1
OR
16. Policies for the Provision of Anesthesia AN.12.1
17. Policies for Patient Care in Operating Room OR.2.2, OR.5.1, OR.5.2, OR.6.1, OR.6.2,
OR.7.1, OR.7.2
ICU
18. ICU Policies and Procedures (Sample) ICU.2.2, ICU.11.7
19. Handover Documentation ICU.5.2
20. Multidisciplinary Patient Care Team Meeting Minutes ICU.6.1
21. Tools and Equipment Availability and Functionality Daily
Check Sheet/Log
ICU.10.3
22. Policy for Monitoring Critically-ill Patients ICU.11.2
23. Policy on "No Code" ICU.11.6
a.PICU
24. PICU Policies and Procedures (Sample) PICU.2.2, PICU.12.7
25. Handover Documentation PICU.6.2
26. Multidisciplinary Patient Care Team Meeting Minutes PICU.7.1
Check Sheet/Log
PICU.11.3
28. Policy for Patient Assessment and Re-assessment PICU.12.1, PICU.12.2
NICU
29. NICU Policies and Procedures (Sample) NICU.2.2, NICU.12.8
30. Handover Documentation NICU.6.2
31. Multidisciplinary Patient Care Team Meeting Minutes NICU.7.1
Check Sheet/Log
NICU.11.3
33. Policy for Monitoring Critically-ill Patients NICU.12.2
CCU
34. CCU Policies and Procedures (Sample) CCU.2.2, CCU.12.5

of 134
35. Handover Documentation CCU.6.2
36. Multidisciplinary Patient Care Team Meeting Minutes CCU.7.1
Check Sheet/Log
CCU.11.3
38. Policy for Patient Assessment and Re-assessment CCU.12.1, CCU.12.2
Conscious sedation areas
39. Policy for Moderate and Deep Sedation/Analgesia AN.19.1

of 134
4. Infection Control Surveyor (Closed Session)
IPC Department
1. Hospital Organization Chart IPC.2.2
2. Infection Control Department Organization Chart IPC.3.1, LD.26.1, LD.26.2
3. Lectures Attendance Sheets IPC.8.1
4. Environmental Microbiological Culture Log IPC.24.6
5. Reports of Communicable Diseases to MOH IPC.35.2
6. Anti-biogram Report IPC.37.1
13. Departmental Staffing Plan LD.30.2, LD.30.3
Infection Control Plan / Program
14. Infection Control Plan/Program IPC.5.1, IPC.5.2, IPC.5.3, IPC.5.4, IPC.5.5
15. Infection Control Annual Plan IPC.6.1, IPC.6.2, IPC.6.3, IPC.6.4, IPC.6.6,
IPC.15.2
Infection Control Manual
17. Infection Control Manual IPC.7.1, IPC.7.2, IPC.7.3
18. Policies and Procedures (Sample) LD.20.3, LD.20.4
19. Care Bundles Elements IPC.40.1
Management of Medical Supplies and Devices Process
LD.23.8
21. Policy for Management of Infection Outbreaks IPC.11.1, IPC.11.2
22. Outbreak Management Report IPC.11.1, IPC.11.2
23. Policy for Handling of Sharps IPC.12.1, IPC.12.2
24. Policy for Standard and Transmission-based Precautions IPC.14.1, IPC.15.6
25. Policy for Personal Protective Equipment IPC.15.8, IPC.32.2
26. Policies and Procedures for Endoscopy Unit IPC.17.1
27. Policy for Reprocessing of Single-Use Items IPC.22.1, IPC.22.2
28. Policy for Housekeeping IPC.23.1, IPC.23.2
29. Pest Control Program IPC.24.5
30. Blood/Body Fluids Spills Management Program IPC.25.1
31. Process for Safe Disposal of Medical Supplies IPC.26.1
32. Policy for Handling Bodies Postmortem IPC.27.1, IPC.27.3
33. Policy for Kitchen Environment and Infection Control IPC.28.10, IPC.29.1
34. Policy for Linen Management IPC.30.1
35. Infection Control Guidelines for Demolition and
Construction
IPC.31.1
36. Hand Hygiene Program IPC.33.1
37. Policy for Reporting of Communicable Diseases IPC.35.1
38. Policy for Use of Aseptic Technique Policy IPC.38.1
39. Policy for Ventilator-Associated Pneumonia (VAP) IPC.39.1
40. Policy for Catheter-associated Urinary Tract Infection IPC.41.1

of 134
41. Policy for Catheter-associated Blood Stream Infection IPC.42.1
42. Policy for Prevention of Multi-drug Resistant Organisms IPC.43.1
43. Waste Management Plan FMS.15.1
44. Dental Infection Control Guidelines DN.6.1
45. Burn Unit Infection Control Policies BC.9.1
46. CCU Infection Control Guidelines CCU.12.6
47. NICU Infection Control Guidelines NICU.12.5
48. PICU Infection Control Guidelines PICU.12.5
49. ICU Infection Control Guidelines ICU.11.5
Infection Control Surveillance
51. Policy for Infection Control Surveillance IPC.9.1, IPC.9.2, IPC.9.3, IPC.9.4, IPC.10.2
52. Infection Control Indicators Report IPC.10.1, IPC.39.2, IPC.41.2, IPC.42.2,
IPC.43.2,
53. Infection Control Performance Improvement Projects IPC.10.4, IPC.10.5
55. Care Bundle Report IPC.40.2
57. Periodic Departmental Performance Improvement Reports LD.31.6
58. Infection Control Surveillance Report IPC.9.1, IPC.9.2, IPC.9.3, IPC.9.4
59. Hand Hygiene Compliance Reports IPC.33.3
60. Hospital Indicators Reports QM.10.1
Staff Health and Safety
61. Staff Health Clinic Scope of Services IPC.36.1
62. PPD Conversion Rate Documents IPC.36.8
63. Policy for Employee Immunization IPC.36.2, IPC.36.3
64. Occupational Health and Safety Program HR.13.1, HR.13.2, HR.13.3, HR.13.4
Infection Control Surveyor (Units Documents)
OR
1. Cleaning Schedule OR.14.1, OR.14.12, OR.14.13
2. Policy for Traffic Control in the Operating Room OR.14.3
3. Engineering Control Records OR.14.5, OR.14.6, OR.14.8, OR.14.14
4. Disinfecting Anesthesia Machines Guidelines OR.14.13
5. Handling Patients with Transmissible Diseases OR.14.16
6. Policy for Use of Flash Steam Sterilizer IPC.21.8
7. Flash Steam Sterilizer Log IPC.21.8
Hemodialysis
8. Hemodialysis Infection Control Guidelines HM.7.1
9. Patient Screening and Immunization Program HM.8.1, HM.8.2, HM.8.3
10. Staff Health Screening and Immunization
Program
HM.8.7
11. Water Quality Check Policy HM.9.1, HM.9.2, HM.9.3, HM.9.4, HM.9.5,
HM.9.7, HM.9.8
12. Water Quality Check Sheet/Log HM.9.1
CSSD

of 134
13. Policies and Procedures for CSSD IPC.18.2
14. CSSD Sterilization Records IPC.19.4, IPC.19.5
15. Engineering Control Records IPC.20.3
16. FMS Report on Sterilizers Maintenance IPC.21.5, IPC.21.6
17. Chemical and Biological Indicators Log IPC.21.7
18. Material Safety Data Sheets (MSDS) IPC.21.9
Kitchen
19. Engineering Control Records IPC.28.5, IPC.28.8
20. Kitchen Staff Health Log IPC.29.3, IPC.29.4
21. Dietary Manual DT.6.1, DT.6.2
Mortuary
23. Morgue Housekeeping Log IPC.27.4
24. Endoscopy
ICU
26. Tools and Equipment Cleaning and Disinfection
Check Sheet/Log
ICU.10.4
27. Cleaning Schedule ICU.13.1
28. Care Bundles Elements ICU.13.3
PICU
Check Sheet/Log
PICU.11.4
30. Cleaning Schedule PICU.14.1
31. Care Bundles Elements PICU.14.3
NICU
Check Sheet/Log
NICU.11.4
33. Cleaning Schedule NICU.13.1
34. Care Bundles Elements NICU.13.3
35. NICU Policies and Procedures (Sample) NICU.13.3
CCU
Check Sheet/Log
CCU.11.4
37. Cleaning Schedule CCU.14.1
38. Care Bundles Elements CCU.14.3
Burn Care
39. Engineering Control Records BC.9.2
Hospital-wide
40. Infection Control Posters and Flyers IPC.8.2
41. Engineering Control Records IPC.15.1, IPC.15.3
42. Purchasing Orders of CSSD Machines IPC.16.1
43. IPC Monitoring Reports of Housekeeping Services IPC.23.2
44. Medical Waste Containers Cleaning Log IPC.26.7, IPC.26.9
45. Construction, Demolition, and Renovation Work
Permit
IPC.31.2
46. Infection Control Risk Assessment (ICRA) IPC.31.3
47. Infection Prevention and Control Training Record IPC.32.3

of 134
48. Evidence that the Leadership Supporting Patient
and Staff Safety
LD.2.7

of 134
5. Medication Management Surveyor (Closed Session)
Organization and Management
1. Pharmacy Department Organization Chart LD.26.1, LD.26.2
2. Departmental Scope of Services LD.27.1, LD.28.2, MM.4.5
5. Multidisciplinary Medication Management Plan or Policy MM.4.1
6. Pharmacy On-call Schedule MM.4.6
Policies and Procedures
7. Policies and Procedures LD.20.3, LD.20.4
9. Multidisciplinary Medication Management Policies and
Procedures
MM.4.2, LD.29.2
Patient Specific Information
10. Policy for Accessibility of Patient Specific Information MM.1.1
Staffing Plan and Performance Measurement
11. Pharmacy Staffing Plan and workload statistics MM.3.2
12. Departmental Staffing Plan LD.30.2, LD.30.3
13. Continuing Education Program MM.3.7
14. Performance Improvement Projects/Reports LD.31.1, LD.31.2
High Alert Medications
15. High-alert Medications and Hazardous Chemicals
Multidisciplinary Plan
MM.5.1
16. High-Alert Medications and Hazardous Chemicals List MM.5.2
LASA Medications
17. Policy for Handling Look-alike/Sound-alike Medications MM.6.1
18. Hospital List of Confusing Drug Names, MM.6.2
Storage of Pharmaceuticals and Hazardous Chemicals
19. Policy for Non-formulary Medication Management MM.9.1
20. Policy for Proper Storage and Control of Medications MM.11.1, MM.11.2
21. Policy for Storage and Control of Refrigerated and Frozen
Medications
MM.12.1
22. Policy for Storage and Handling of Hazardous Medications
and Chemicals
MM.13.1
23. Multi-dose Vial Stability Guidelines MM.14.1
24. Crash Cart Medication Management System MM.15.1
25. Policy for Floor Stock Medications Assignment MM.16.1
26. Policy and Procedures on Patient’s Own Medications
Management
MM.17.1
27. Policy for Proper Storage of Narcotics and Controlled
Medications
MM.18.1
28. Policy for Out-of-stock, Shortage, and during Disaster
Medication Management
MM.10.1

of 134
29. Pharmacy Emergency Preparedness Plan MM.10.4
30. Hazardous Materials Management Plan FMS.14.6
Ordering and Prescribing
31. Policy and Procedures for Prescribing Medications MM.20.1
32. Policy and Procedures on Specific Types of Medication
Orders
MM.21.1
33. Policy and Procedures on Prescribing Privileges MM.19.1
34. Guidelines on Antibiotics Prescribing MM.22.1
35. Policy for Prescribing Non-formulary Medications MM.24.1
36. Policy and Procedures on Prescribing Formulary
Medications for Off-label Indications.
MM.24.2
37. Policy for Telephone and Verbal Orders MM.23.1, MM.23.3, QM.25.1, QM.25.2,
MM.23.4, QM.25.3
38. List of Approved and Prohibited Abbreviations and Symbols MOI.7.1, MOI.7.2, MOI.7.3, MOI.7.4,
MOI.7.5
Preparing and Dispensing
39. Aseptic Technique and IV Admixture Manual MM.26.1
40. Policy on Preparation and Dispensing of TPN. MM.27.1, NICU.12.6
41. Guidelines on Stability and Compatibility of TPN MM.27.8
42. Policy for Preparation and Dispensing of Chemotherapy. MM.28.1
43. Policy for Non-sterile Pharmaceutical Compounding MM.29.1
44. Policy for Obtaining Medications After Working Hours MM.33.1
45. Policy for Handling Recalled, Discontinued and Damaged
Medications
MM.34.1
Drug Administration
46. Document that defines nurses and other clinical staff
authorized to administer medications
MM.36.1
47. Policy for Medication Verification before Administration MM.37.1
48. Policy for Monitoring Patient Response to Medications MM.39.1
Drug Monitoring
49. Policy for Handling Adverse Drug Reactions (ADRs) Reports MM.40.1, MM.40.2
50. Policy for Handling Medication Errors, Near-misses, and
Hazardous Situations
MM.41.1, MM.41.2
51. Medication Errors Reporting System MM.41.5
Contracted Services
52. TPN Outsource Contract and Contract Service Monitoring MM.27.9
53. Chemotherapy Outsource Contract and Contract Service
monitoring
MM.28.16
54. Extemporaneous Preparations Outsource Contract and
Contract Service Monitoring
MM.29.6
Drug Formulary
55. Hospital Drug Formulary MM.8.1, MM.8.4, MM.8.5, MM.8.6,
MM.8.7, MM.8.8, MM.8.9

of 134
Medication Management Surveyor (Units Documents)
Inpatient/Outpatient Pharmacy
1. Patient Medication Profile MM.25.1, MM.31.6
2. Extemporaneous Preparations Manual
(Formulation Book)
MM.29.4
3. Extemporaneous Preparations Log Book MM.29.5
4. Outpatient Education Materials MM.35.2
Pharm Admin/QI
5. Pharmacy Department Organization Chart MM.2.1
6. Non-formulary Drug Request Form MM.9.2, MM.24.3, MM.24.5
7. Policy for Floor Stock Medications Assignment MM.11.13
8. Floor Stock Inspection Records MM.11.13
9. Reports of Medication Quality to Saudi FDA MM.11.15
10. Crash Cart Check Sheet MM.15.7
11. Un-approved Indication Request Form MM.24.4, MM.24.5
12. Pharmacy Monthly Inspection of Nursing Units
Performing IV Admixture.
MM.26.13
13. Pharmacy Monthly Evaluation of Nursing Staff
Performance of IV Admixture
MM.26.14
14. List of Approved Medications to be Accessible to
Non-pharmaceutical Staff
MM.33.3
15. Pharmacy On-call Schedule MM.33.4
16. Drug Recall File MM.34.2
17. ADR file and Analysis of ADR Reports MM.40.7
18. Medication Errors Reporting System MM.41.7
19. Root-cause Analysis of Significant Medication
Errors
MM.41.8
20. Reports of Serious ADRs to Saudi FDA MM.40.9
21. Reports of Sentinel Events MM.41.12
22. Internal Disaster Plan (pharmacy preparedness
plan)
FMS.17.2
25. Performance Improvement Projects/Reports LD.31.4
26. Periodic Departmental Performance
Improvement Reports
LD.31.6
27. Information System Downtime Procedures and
Forms
MOI.9.1
IV Clean Room
28. Parenteral Drugs Stability and Compatibility
Guidelines
MM.26.11
29. Hospital Guidelines on Safe Recycling of Un-used
Sterile Compounded Preparations
MM.26.15

of 134
30. Operational Efficiency and Maintenance
Certificate of LAFH
MM.30.7
31. Cleaning Schedule MM.30.8
Chemotherapy
32. Chemotherapy Stability and Compatibility
Guidelines
MM.28.10
Hospital-wide
33. Temperature Log Sheets (refrigerators, freezers,
etc.)
MM.11.9, MM.12.4, MM.12.8
34. List of Hazardous Medications And Chemicals MM.13.2
36. Pharmacy Interventions for Incomplete, Illegible,
or Unclear Orders
MM.20.7
Hospital-wide - Crash Cart
37. Crash Cart Medication Management System MM.15.6
38. Crash Cart Check Sheet PC.31.3, PC.31.4, PC.31.5
Hospital-wide - High Alert/LASA
39. Evidence of Implementation of Standard
Concentrations of IV Infusions
MM.5.4
40. Staff education material and attendance record
for LASA medications
MM.6.3
Hospital-wide - Narcotics
41. Narcotics Documents for Inventory,
Endorsement and Accountability
MM.18.4, MM.18.5, MM.36.5

of 134
6. Laboratory Surveyor (Closed Session)
- Laboratory Organization Structure
1. 1 Laboratory scope of services LB.1.1, LB.1.2, LD.28.1, LD.28.2
2. 2 Laboratory organizational chart LB.1.5, LD.26.1, LD.26.2
3. 3 Departmental Meeting Minutes LD.18.2
4. Internal Disaster Plan FMS.17.2
Laboratory Customer Focus
5. Departmental Scope of Services LD.27.1
7. Point-of Care-Testing program LB.28.1
8. Assignment POCT coordinator LB.28.2
9. Blood Supply/Exchange Agreements LB.62.1
10. Laboratory policy on Turn Around Time LB.19.1
11. Evidence of establishing TAT in agreement with all
relevant clinical departments
LB.19.2
Laboratory Facilities and Safety Program
12. Laboratory safety and infection control manual LB.17.1,FMS.14.6, FMS.15.1
13. Laboratory safety and infection control training
program
LB.17.2
14. Laboratory policy and procedures on monitoring
the safety and infection control
LB.17.3
Laboratory Personnel
16. Departmental Staffing Plan LD.30.2
17. Laboratory/facility policy on job description and
samples of job descriptions (lab staff)
LB.3.1, LD.30.3
18. Policy for Delegation of Authority LD.17.2
19. Laboratory training and competency assessment
program
LB.5.1
Laboratory Purchasing and Inventory
20. Laboratory policy and procedure on receipt
inspection and testing of materials/services
LB.6.1
21. Laboratory policy and procedure on tracking and
inventory management of supplies and reagents
LB.6.2
22. Laboratory policy and procedure on reagents and
solutions labeling
LB.7.1
23. Laboratory policy and procedure on supplies and
reagents storage
LB.7.2
24. Laboratory policy and procedures on water types LB.7.3
laboratory services
LB.27.1
Laboratory Equipment
27. Laboratory/Facility Policy and/or process
description on critical equipment selection
LB.8.1

of 134
28. Laboratory policy, process and procedure on
equipment validation
LB.9.1
29. Laboratory policy and procedures on the selection
and monitoring of blood storage devices
LB.58.1, LB.58.2, LB.58.3, LB.58.4,
LB.58.5, LB.58.6
30. Laboratory policy and procedures on standardizing
of laboratory instruments
LB.12.1, LB.12.2
31. Laboratory policy and procedure on calibration
and adjustment of blood shakers
LB.38.1, LB.38.2
Laboratory Process Management Plan
32. Lab audit trail system LB.4.1
33. Laboratory policy, process and procedure on test
method validation
LB.10.1
34. Laboratory policy and procedure on
methods/instrument correlation
LB.13.1
35. Laboratory policy and procedures on controlling
the quality of test methods
LB.14.1, LB.14.2
36. Laboratory services and specimen collection
manual
LB.18.1
37. Evidence of services and specimen collection
manual distribution
LB.18.2
38. Laboratory/hospital policy and procedure on
specimen labeling
LB.21.1
39. Laboratory/hospital policy and procedures on
sample packing, handling, transporting and
tracking
LB.22.1
40. Laboratory policy for minimum test/service-
requesting information
LB.20.1
41. Laboratory policy and procedures on specimen
receipt and inspection
LB.23.1
42. Laboratory specimen retention policy LB.30.1, LB.30.2, LB.30.3
43. Laboratory policy on donor identification LB.33.1
44. Laboratory policy on predonation
information/education
LB.33.2
45. Laboratory policy on donor selection criteria LB.34.1, LB.34.2, LB.34.3, LB.34.4,
LB.34.5, LB.34.6
46. Laboratory policy on platelet pheresis donors
selection criteria
LB.35.1, LB.35.2, LB.35.3, LB.35.4
47. Laboratory policy for blood donor consent LB.36.1
48. Laboratory policy and procedure on venipuncture
site preparation
LB.39.1
49. Laboratory policy and procedure on collection
labeling and handling of donor specimen
LB.41.1
50. Laboratory policy and procedure on donor care LB.39.3
51. Laboratory policy process and procedure on self-
exclusion and third party information
LB.39.4

of 134
52. Laboratory policy and procedure on donor
notification of significant findings
LB.37.1, LB.37.2, LB.37.3
53. Laboratory policy process and procedure on
therapeutic procedures
LB.57.1, LB.57.2, LB.57.3, LB.57.4
54. Laboratory policy and procedure on handling RBC
components
LB.42.1, LB.42.2, LB.42.3, LB.42.4,
LB.42.5
55. Laboratory policy and procedure on handling PC
components
LB.43.1, LB.43.2, LB.43.3, LB.43.4,
LB.43.5, LB.46.3
56. Laboratory policy and procedure on handling FFP
components
LB.44.1, LB.44.2, LB.44.3, LB.44.4,
LB.44.5
57. Laboratory policy and procedures on handling
Cryoprecipitate
LB.45.1, LB.45.2, LB.45.3, LB.45.4,
LB.45.5
58. Laboratory policy and procedures on handling
platelet apheresis
LB.46.1, LB.46.2
59. Laboratory policy and procedures on handling LR-
RBC
LB.47.1, LB.47.2, LB.47.3
60. Laboratory policy and procedures on handling LR-
PC
LB.48.1, LB.48.2, LB.48.3
61. Laboratory policy and procedures on irradiated
cellular blood products
LB.49.1, LB.49.2, LB.49.3, LB.49.4
62. Laboratory policy and procedure on handling
thawed FFP units
LB.59.1, LB.59.2, LB.59.3, LB.59.4,
LB.59.5
thawed CRYO units
LB.60.1, LB.60.2, LB.60.3, LB.60.4
immunohematological testing of donor samples
LB.50.1, LB.50.2
65. Laboratory policy, process and procedures on
transfusion transmitted disease testing
LB.51.1
66. Laboratory policy, process and procedures on
limiting and detecting bacterial contamination in
PC
LB.51.2
unsuitable units
LB.52.1, LB.52.2
68. Laboratory policy and procedure on labeling of
blood and blood components
LB.53.1, LB.53.2
69. Laboratory policy and procedure on group/type
conformation of RBC components
LB.54.1, LB.54.2
70. Laboratory policy and procedure on the release of
blood and blood components to the available
inventory
LB.55.1, LB.55.2, LB.55.3, LB.55.4
71. Laboratory policy and procedure on the release of
incompletely tested blood/blood components
LB.56.1, PC.25.5, LB.56.2, LB.56.3
72. Multidisciplinary and/or Blood Utilization
Committee Approved Policies and Procedures on
Handling, Use and Administration of Blood and
Blood Components
PC.25.1, PC.25.2, PC.25.3, PC.25.4,
PC.25.6, PC.25.8, PC.25.9, PC.25.10

of 134
requesting/sending blood/blood products from/to
outside facilities
LB.62.2
74. Laboratory policy and procedure on receipt and
inspection of incoming blood/blood components
LB.62.3
75. Laboratory policy and procedure blood bank
reagents quality control
LB.61.1, LB.61.2, LB.61.3, LB.61.4,
LB.61.5, LB.61.6
76. Laboratory policy and procedures on pre-
transfusion testing of the recipient sample
LB.63.1, LB.63.2, LB.63.3, LB.63.4
77. Laboratory policy on the selection of RBC
components for transfusion
LB.64.1
78. Laboratory policy on the selection of plasma
components for transfusion
LB.64.2
79. Laboratory policy on the selection of blood/blood
components for patients with special
requirements
LB.64.3
80. Laboratory policy and procedures on compatibility
testing
LB.65.1, LB.65.2, LB.65.3, LB.65.4
81. Laboratory policy and procedures on
intrauterine/neonatal testing and transfusion
LB.66.1, LB.66.2, LB.66.3, LB.66.4,
LB.66.5
82. Laboratory policy and procedure on issuing blood
and blood products for transfusion
LB.67.1, LB.67.2, LB.67.3, LB.67.4
83. Laboratory policy and procedure on emergency
blood release
LB.68.1, LB.68.2, LB.68.3, LB.68.4,
LB.68.5
84. Blood utilization committee terms of
reference/formation order and meeting minutes
MS.15.1, LD.9.3, MS.15.2, MS.15.3,
MS.15.4, MS.15.5, MS.15.6
85. Laboratory policy on gross examination of surgical
pathology specimens
LB.71.1, LB.71.2
86. Laboratory policy and procedure on daily review of
technical activities in anatomical pathology
LB.72.1
87. Multidisciplinary/tissue review committee
approved policies and procedures on intra-
operative surgical pathology.
LB.73.1
intra/extra-departmental consultations
LB.74.1, LB.74.2
89. Laboratory policy on review of previous
cytology/histology material and solving disparities
LB.76.1, LB.76.2
90. Tissue review committee terms of
reference/formation order and meeting minutes
MS.16.1, MS.16.2, MS.16.3, MS.16.4,
MS.16.5, MS.16.6
91. Written description of the laboratory report LB.24.1
critical laboratory results reporting and
documentation
LB.25.1, LB.25.2

of 134
amending/correcting reported results
LB.26.1
94. Laboratory policy on compiling surgical pathology
reports
LB.75.1
ranges and cut-off values
LB.11.1
Laboratory Documents and Records
96. Master list or table of contents of laboratory policy
and procedures manual(s)
LB.15.1, LD.29.1, LD.29.2, LD.20.3,
LD.20.4
97. Laboratory policy and procedure on the control of
deviations and exceptions
LB.16.1, LB.16.2, LB.16.3
98. Laboratory policy on documents and records
management
LB.29.1, LB.29.2, LB.29.3, LB.29.4,
LB.29.5
Laboratory Information Management
99. Information System Downtime Procedures and
Forms
MOI.9.1
Laboratory Nonconforming Events Management
100. Laboratory policy and procedure on recognizing
and handling adverse donor reaction
LB.40.1
101. Hospital or transfusion committee approved policy
and procedure on recognizing, handling and
reporting adverse transfusion events.
LB.69.1, LB.69.3
102. Laboratory policy and procedure on investigating
suspected transfusion reaction
LB.69.2
on the investigation of post-transfusion infection
LB.70.1
on look back investigation
LB.70.2
Laboratory Assessments
105. Laboratory Quality Management Plan/Program LB.31.1
selection, data collection, reporting, and
monitoring of quality indicators
LB.31.2
107. Laboratory quality indicators reports LB.31.3, LD.31.3, LB.31.4, LB.31.5
108. Laboratory policy process and procedures on
Proficiency Testing (PT)
LB.32.1
Laboratory Continual Improvement Process
109. Laboratory Quality Management Plan/Program LB.31.6
110. Performance Improvement Projects/Reports LB.31.7, LD.31.1, LD.31.2, LD.31.4
111. Periodic Departmental Performance Improvement
Reports
LD.31.6

of 134
Laboratory Surveyor (Units Documents)
Patient Care Unit
1. POCT QC, training and competency assessment
records
LB.28.1
General Lab
2. Laboratory Staff Schedule LB.1.3
3. Records of approving exceptions to policies LB.16.1, LB.16.2, LB.16.3
4. Laboratory safety and infection control audit
reports
LB.17.3
6. Computer or paper record of complete audit trail
(who perform the task)
LB.4.1
7. Computer or paper records of complete audit trail
(When and where the task performed)
LB.4.2
8. Laboratory personnel training and competency
assessment records on newly acquired equipment
or method
LB.5.1
9. Safe Operation of Medical Equipment Training
Records
FMS.27.1
10. Records of receipt, inspection, and testing of
incoming critical material and service
LB.6.1
11. Computer or paper records of tracing materials LB.6.2
12. Reagents and materials storage temperature
monitoring record
LB.7.2
13. Water testing records LB.7.3
14. Laboratory equipment selection records LB.8.1
15. laboratory equipment receipt, installation and
identification records
LB.8.2
16. Evidence for Qualification of Medical Suppliers LD.23.2
17. Laboratory equipment validation records LB.9.1
18. Laboratory method validation records LB.10.1
19. Laboratory records of establishing/validating
reference ranges and cut off values
LB.11.1
20. Laboratory instruments standardization records LB.12.1
21. Laboratory methods/instruments correlation
records
LB.13.1
22. Laboratory methods/instruments quality control
records
LB.14.1
23. Proficiency Testing Reports LB.32.1
24. Computer or paper lab report LB.24.1
25. Records and report of critical lab results LB.25.1, LB.25.2
26. Records and reports corrected/amended lab
results
LB.26.1
27. Reference lab agreement, reports and records of
send-out tests
LB.27.1
Sample Collection/Reception
28. Laboratory specimen receipt/reject records LB.21.1
29. Records of accepting sub-optimal specimens LB.23.1
Donor Collection

of 134
30. Whole Blood donation records LB.33.1, LB.34.1, LB.34.2, LB.34.6,
LB.36.1
31. Apheresis donation records LB.35.1, LB.36.1
32. Notification letters for donors with significant
findings
LB.37.1, LB.37.2, LB.37.3
33. Records of monitoring, calibration and adjustment
of blood shakers
LB.38.1, LB.38.2
34. Confidential unit exclusion records LB.39.4
35. Adverse donation event reports LB.40.1
36. Therapeutic procedures records LB.57.1
Components Production
37. RBC preparation records LB.42.1
38. RBC transportation records LB.42.3
39. RBC QC records LB.42.5
40. PC preparation records LB.43.1
41. PC transportation records LB.43.3
42. PC QC records LB.43.5
43. FFP preparation records LB.44.1
44. FFP transportation records LB.44.3
45. FFP QC records LB.44.5
46. CRYO preparation records LB.45.1
47. CRYO transportation records LB.45.3
48. CRYO QC records LB.45.5
49. Platelet pheresis collection records LB.46.1
50. Platelet apheresis QC records LB.46.2
51. LR-RBC preparation records LB.47.1
52. LP-RBC QC records LB.47.2
53. LR-PC preparation records LB.48.1
54. LP-PC QC records LB.48.2
55. Blood irradiator dosimetry assessment record LB.49.2
56. Records of ABO/Rh testing of donor samples LB.50.1
57. TTDT Records LB.51.1
58. Testing records and validation documents of the
employed bacterial detection method
LB.51.2
59. Records of identification and discard of unsuitable
units
LB.52.1
60. Records of ABO/Rh-D conformation of RBC
components
LB.54.1
61. Records of releasing blood/blood components to
the available inventory
LB.55.1, LB.55.2, LB.55.3, LB.55.4
Transfusion Services
62. Records of receiving/sending blood/blood
products from/to outside facilities
LB.62.1, LB.62.2, LB.62.3
63. Records of monitoring blood storage devices LB.58.3, LB.58.4, LB.58.5, LB.58.6
64. Blood bank reagents QC records LB.61.1, LB.61.2, LB.61.3, LB.61.4,
LB.61.5, LB.61.6
65. Patient's Pre-transfusion testing records LB.63.4
66. Patient's transfusion records LB.64.1, LB.64.2, LB.64.3, LB.65.3,
LB.68.5

of 134
67. Intra-uterine and neonatal testing and transfusion
records
LB.66.1, LB.66.2, LB.66.3, LB.66.4,
LB.66.5
68. Blood/blood component issue records LB.67.4
69. Emergency blood release records LB.68.1, LB.68.2, LB.68.4, LB.68.5
70. Records of releasing incompletely tested
blood/blood components
LB.56.1
71. Records of investigating and reporting adverse
transfusion events
LB.69.2, LB.69.3
72. Records of reporting, investigating and follow-up
post-transfusion infection
LB.70.1
73. Records of Look Back investigations LB.70.2
Anatomical Pathology
74. Records of daily review of all technical activities in
anatomical pathology
LB.72.1
75. Training and competency assessment records of
non-medical personnel performing gross
examination
LB.71.2
76. Records and reports of intra-operative surgical
pathology
LB.73.1
77. Intra/inter departmental consultation reports LB.74.1, LB.74.2
78. Records and reports of solving disparities in
anatomical pathology
LB.76.2

of 134
7. Facility Management and Safety Surveyor (Closed Session)
Hospital Leadership
1. Evidence that the Leadership Supporting Hospital
Safety
LD.2.7
2. Evidence for Reporting Medical Supplies Adverse
Effects
LD.23.7
Management of Medical Supplies and Devices
Process
LD.23.8
4. Periodic Departmental Performance
Improvement Reports
LD.31.6
5. An evidence of acquiring the necessary
equipment
FMS.1.2
6. Hospital Expenditure on Safety Management
Program
FMS.1.4
7. Documented Communications from the FMS
Program Director
FMS.2.4
Departmental Planning
8. FMS Departmental Organization Chart FMS.2.1
14. Multidisciplinary Policies and Procedures
(Sample)
LD.29.2
Facility Management and Safety Program
19. Facility Management and Safety Program FMS.1.1, FMS.1.3
20. Radiation Safety Policy FMS.9.1
21. FMS Departmental Organization Chart FMS.2.3
22. Safety Liaison Officers List FMS.2.5
23. Evidence of Liaison Officers Activity FMS.2.5
Fire Safety Plan
24. Procured Furniture Specs Sheet FMS.19.1
25. OR Fire Drill Report OR.13.5
26. Floor layouts showing installed fire rated walls FMS.19.3
27. Fire extinguishers training schedule FMS.19.5
28. Fire Extinguishers Inventory and Distribution FMS.20.1
29. Fire Extinguishers Inspection Reports FMS.20.4
30. Fire Alarm Inspection Schedule and Reports FMS.21.1
31. Fire Alarm Testing Schedule and Reports FMS.21.2
32. Fire Alarm Maintenance Schedule and Reports FMS.21.3
33. Fire Alarm System Distribution FMS.21.4
34. Sprinkler system maintenance and inspection
schedule and reports
FMS.22.1

of 134
35. Clean agent system maintenance and inspection
FMS.22.2
36. Wet chemical system maintenance and inspection
FMS.22.3
37. Stand Pipes and Hose System Maintenance and
Inspection schedule and reports
FMS.22.4
38. Policy for No Smoking FMS.24.1
Safety of The Building Plan
39. Civil Defense License (for private hospitals) FMS.4.1
40. Civil Defense inspection report (for governmental
hospitals)
FMS.4.1
41. Approved hospital action plan for Civil Defense
findings
FMS.4.2
42. Policy for safety and security during construction,
renovation, or demolition
FMS.5.1
43. Security, safety and infection control inspection
reports during construction work
FMS.5.1
44. Evidence of penalties incurred on contractors for
violating the construction policy
FMS.5.1
Security Management Plan
45. Policy for Preventing Children and Neonates
Abduction
FMS.11.3
46. Policy for Lost and Found Items FMS.11.3
47. Policy for Safe Keeping of Patient Belongings FMS.11.3
48. Policy for Involvement of Police in Certain Cases FMS.11.3
49. Policy for Incidents of Violence FMS.11.3
50. Policy for Women and Child Abuse FMS.11.3
51. Staff Security Training Schedule and Records FMS.11.4
52. Policy on How to Deal with a Bomb Threat FMS.12.1
53. External Disaster Plan FMS.13.4
54. Internal Disaster Plan FMS.13.4
55. Policy for No Smoking FMS.13.4
56. Security Rounds Policy and Reports FMS.13.6
Hazardous Materials and waste Management
Plan
57. KACST License for Radioactive Materials FMS.9.3
58. TLD Monitoring Records FMS.9.7
61. Hazardous material exposure Report/OVR FMS.14.6
62. Waste Management Plan FMS.15.1
63. Oncology and Radiotherapy Quality Control
Records
ORT.10.1
External Disaster Management Plan
64. External Disaster Plan and Action Cards FMS.16.1
65. External disaster drill report and action plan FMS.16.2
Internal Disaster Management Plan
66. Ambulance Function Log book ER.15.6
67. Internal Disaster Plan and Action Cards FMS.17.1

of 134
68. Internal Disaster Plan including pharmacy
preparedness plan
FMS.17.2
69. Sample of Department-Specific Disaster Plan FMS.17.2
70. Fire Drills Schedule FMS.18.1
71. Fire Drills Reports FMS.18.2, FMS.18.3
72. Improvement initiatives related to fire drills FMS.18.4
73. Full fire drill report and action plan FMS.18.5
Biomedical Equipment Management Plan
74. Departmental Staffing Plan FMS.25.1
75. Dialysis Equipment Maintenance Plan and
Records
HM.6.2
76. Preventive maintenance records for radiology
department equipment
RD.10.1
77. Biomedical Equipment Management Plan FMS.25.2
78. Medical Equipment Inventory List FMS.25.2
79. Sample of Preventive Work Orders FMS.25.2
80. Sample of corrective and preventive work orders
with action taken
FMS.25.6
81. Service Reports for Contracted Maintenance
Services
FMS.25.7
82. Department Specific Medical Equipment Failure
Back-up plan
FMS.25.9
83. Medical Equipment Upgrading/Replacement Plan FMS.25.10
84. Policy for New Equipment Inspection FMS.26.1
85. Sample of inspection records for medical
equipment received
FMS.26.1
86. Policy for Proper Tagging of Medical Equipment FMS.26.2
87. Policy for Removal of Equipment from Service FMS.26.3
88. Policy for Agent and Contractors Repairs FMS.26.4
89. Policy for Eliminating the use of Electric Extension
Cords
FMS.26.5
90. Policy for Use of Cellular Phones in Critical Areas FMS.26.6
91. Safe Operation of Medical Equipment Training
Records
FMS.27.3
92. Infusion pumps and vital signs monitors
preventive maintenance schedule and records
QM.20.1
93. License for the Provision of Radiotherapy Services
from Relevant Authorities
ORT.2.1
Utilities Management Plan
94. Utility Management Plan Including Utility Failure FMS.28.2, FMS.28.3
95. Annual Testing of Utility Failure Plan with Action
Plan
FMS.28.4
96. Utilities' distribution drawings and layouts FMS.28.5
97. Utility systems performance statistical data with
improvement recommendations
FMS.28.5
98. Water System Preventive Maintenance Schedule
and Records
FMS.37.1
99. Evidence of Implementing Utility Management
Plan
FMS.37.2

of 134
Facility Management and Safety Surveyor (Units Documents)
Hemodialysis
1. Dialysis Equipment Operation Manuals HM.6.1
2. Dialysis Equipment Maintenance Plan and Records HM.6.2
3. Dialysis Equipment Maintenance Folder HM.6.4
4. Dialysis Staff Training Records HM.6.5
5. Reports of malfunctioning machines HM.6.6
6. Water Treatment and Distribution Maintenance Records HM.6.8
7. Water chemical testing records HM.9.6
Oncology
8. Oncology and Radiotherapy Safety Plan ORT.7.1
Radiology
100. Utility 52-week Maintenance Schedule and
Reports
FMS.29.1
101. Thermal Inspection Reports FMS.30.2
102. Emergency Circuit Diagram FMS.31.1
103. Generators’ testing records FMS.31.2
104. PMG maintenance schedule and records FMS.32.1
105. Compressed medical air system humidity and
purity testing reports
FMS.32.3
106. Policy and Procedure on Effective Use of Medical
Gas System
FMS.32.2
107. Policy for Handling Various Types of Compressed
Gases
FMS.33.1
108. HVAC contract and contractor profile FMS.34.1
109. HVAC System Maintenance Schedule and Records FMS.34.2
110. HVAC filters, ducts and grills cleaning /
replacement records
FMS.34.3
111. HEPA filters monthly monitoring and replacement
records
FMS.34.4
112. Air Change Per Hour Monitoring Records FMS.34.5
113. Evidence of Air-Flow/Pressure Monitoring FMS.35.1, FMS.35.2, FMS.35.3,
FMS.35.4, FMS.35.5, FMS.35.6,
FMS.35.7, FMS.35.8, FMS.35.9
114. Sewage disposal policy FMS.38.1
115. Laundry Equipment Maintenance Schedule and
Records
FMS.39.1
116. Engineering Control Records FMS.39.2
117. Kitchen Equipment Maintenance Schedule and
Records
FMS.39.2
118. Kitchen Cold Rooms Temperature Monitoring Log FMS.39.2
119. Periodic Preventive Maintenance (PPM) Records FMS.39.2
120. Cooking filters weekly cleaning records FMS.39.2
121. Pantries’ equipment preventive maintenance
records
FMS.39.2

of 134
9. Radiology Equipment Maintenance Folder RD.10.2
10. Shielding Certificate of the X-ray Room FMS.9.5
11. Annual Testing Records of Lead Aprons FMS.9.6
12. Log book for radiation dosimetry. RD.8.6, RD.8.7,
Laser
13. Laser Safety Manual FMS.10.4
ER
14. Ambulance Function Log book ER.15.5
Hospital-wide
15. Safe Operation of Medical Equipment Training Records FMS.27.1

of 134
Annex C
Medical Records Review Tool

of 134
Closed Medical Record Review
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
HR.13.4
The program includes, but is not limited to, the following:
HR.13.4.1 Pre-employment medical evaluation of new employees.
HR.13.4.2
Response to the health problems of the employees through direct treatment (e.g., a staff clinic) or
referral.
HR.13.4.3 Periodic medical evaluation of staff members.
HR.13.4.4 Screening for exposure and/or immunity to infectious diseases.
HR.13.4.5 Staff preventive immunizations.
HR.13.4.6 Management of exposure to blood borne pathogens and other work-related conditions.
HR.13.4.7
Measures to reduce occupational exposures and hazards, including the use of protective equipment
and clothing, stress management, and ergonomics.
HR.13.4.8
Staff education on the risks within the hospital environment as well as on their specific job-related
hazards (e.g., lifting techniques, safe use of medical devices, and detecting, assessing, and reporting
risks).
HR.13.4.9
Documentation and management of staff incidents (e.g., injuries or illnesses, taking corrective
actions, and setting measures in place to prevent recurrences).
HR.13.4.10
There is appropriate record keeping and management (e.g., employee health records that are filed
separately).
PC.6.2
The hospital implements a policy and procedure that defines the assessment process and its scope and content for
all categories of patients (adults, geriatrics, pediatrics, pregnant women, trauma patients and others).
PC.6.3
The hospital implements a policy and procedure that defines the assessment process and its scope and content for
all disciplines (physicians, nurses, physiotherapists, social service and others).
PC.6.4 The policy defines the staff categories qualified by license, certification, and experience to assess patients.
PC.8.1 The hospital has criteria to identify patients requiring discharge planning before or upon admission
PC.9.1
The hospital implements a policy that defines the time frame for completing the medical, nursing, and other
assessments required for different care settings and services.
PC.10.1
Each patient undergoes an initial medical assessment that includes a health history and physical examination,
covering the following:
PC.10.1.1 Main complaint.
PC.10.1.2 Details of the present illness.
PC.10.1.3 Systems review.
PC.10.1.4 Past history including previous admissions and surgeries.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
PC.10.1.5 Allergies and prior adverse drug reactions.
PC.10.1.6 Drug history.
PC.10.1.7 Family history.
PC.10.1.8 Psycho-social history.
PC.10.1.9 Economic factors.
PC.10.1.10 Pain (screening followed by assessment if required).
PC.10.1.11 Risk for fall (screening followed by assessment if required).
PC.10.1.12 Physical status and functionality (screening followed by assessment if required).
PC.10.1.13 Complete physical examination.
PC.10.1.14 Diagnostic test(s) as indicated by the patient’s condition.
PC.10.1.15 Need for additional or specialized assessment as indicated by the patient’s
PC.10.1.16 Need for discharge planning as indicated by the patient’s condition.
PC.10.1.17 Provisional diagnosis.
PC.10.3
Medical assessment is performed by the most responsible physician or a member of the team who is qualified by
license, certification, and experience.
PC.10.6 The medical assessment is documented in the patient’s medical record.
PC.17.1
All patients are reassessed at appropriate intervals to determine:
PC.17.1.1 Response to treatment.
PC.17.1.2 Compliance with treatment.
PC.17.1.3 Complications and side effects.
PC.17.1.4 Plan for continued treatment or completion of treatment.
PC.17.3
Nursing reassessment must be performed on every shift with a frequency dictated by the patient’s condition,
response to treatment, and physician’s order.
PC.17.5
The hospital defines situations where re-assessments are performed more infrequently (e.g., long stay patients
mainly requiring a nursing care).
PC.24.5
When required, the hospital provides referral and transfer services to other facility that can provide palliative care
(e.g., bed or resources availability).
PC.24.6
When applicable, the hospital provides or arrange for a nursing home care (e.g., inability to refer, or patient/family
wish).
PC.25.2
Only physicians order blood and in accordance with a policy clarifying when blood and blood products may be
ordered.
PC.25.3
The physician obtain informed consent for transfusion of blood and blood products. Elements of patient consent
include:
PC.25.3.1 Description of the transfusion process.
PC.25.3.2 Identification of the risks and benefits of the transfusion.
PC.25.3.3 Identification of alternatives including the consequences of refusing the treatment.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
PC.25.3.4 Giving the opportunity to ask questions.
PC.25.3.5 Giving the right to accept or refuse the transfusion.
PC.25.4
Two staff members verify the patient’s identity prior to blood drawing for cross match and prior to the
administration of blood.
PC.25.6 Blood is transfused according to accepted transfusion practices from recognized professional organizations.
PC.25.8 Patients receiving blood are closely monitored.
PC.25.9 Transfusion reactions are reported and analyzed for preventive and corrective actions.
PC.25.10
Side effects or complications are immediately reported to the medical staff and blood bank and the transfused unit
is sent to the blood bank for further investigations.
PC.33.3 Activities of the rapid response teams are documented.
PC.38.1 The patient and the family are involved in the discharge process with clear follow up instructions.
PC.38.2 Discharge is based on the patient’s condition and relevant policies or criteria.
PC.38.3 Patients' needs after discharge are assessed as early in the care process as possible.
PC.38.4 The discharge process identifies the post-service needs and supports continuity of care after discharge.
PC.38.5 The post-service needs are communicated to relevant staff members.
PC.38.6 Staff members ensure coordination with various departments involved in the discharge process.
PC.38.7
Whenever required, staff members ensure coordination with outside organizations and post-service providers as
appropriate to the patient's needs.
PC.38.8 Staff members ensure that all patients’ needs are met prior to discharge.
PC.39.2
Transfer is based on the patient's health needs for continuing care and the resources available for both referring
and receiving organizations.
PC.39.3
The most responsible physician determines the need for transfer, the most suitable time for transfer, resources
required during transfer, and whether the receiving organization can meet the patient’s health and supportive
needs.
PC.39.5
There is a written acceptance for transfer of responsibility for the patient's care by the receiving
provider/organization.
PC.39.6
The hospital communicates with all potential receiving organizations and necessary arrangements are made
whenever applicable.
PC.40.1 The most responsible physician assesses the transportation needs of the patient according to his condition.
PC.40.2 Transportation needs of the patient are communicated to the relevant staff.
PC.40.4 The most responsible physician ensures that all patient’s health needs during transportation are met.
PC.40.5 Adequate equipment and supplies are available during transportation.
PC.40.6 A qualified staff member accompanies the patient during transportation.
PC.40.7 The patient is monitored as appropriate during transfer.
PC.40.8 Handover is completed to staff at the receiving organization

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
PC.41.1
A summary of the patient's condition (e.g., a discharge summary) is sent with the patient to the receiving
organization. The summary includes:
PC.41.1.1 Reason for the patient’s admission.
PC.41.1.2 Patient diagnosis.
PC.41.1.3
Brief summary of hospitalization and services provided (therapies, consultations, procedures to
date).
PC.41.1.4 Medication list and time of last dose(s) given.
PC.41.1.5 Patient condition and physical status at the time of transfer.
PC.41.1.6 Rationale for transfer.
PC.41.1.7 Results of the patient’s diagnostic investigations (e.g., laboratory and radiology).
PC.42.1 Whenever required, follow up appointments are arranged for the patient prior to discharge.
PC.42.3 The hospital provides a discharge summary for all inpatients upon discharge.
PC.42.4 A copy of the discharge summary is kept in the patient’s medical record.
PC.42.5 A copy of the discharge summary is given to the patient.
PC.42.7 The discharge summary is complete and typewritten.
NR.10.2
The scope and content of the nursing assessment is defined in hospital policies and may include:
NR.10.2.1 History of the patient’s main complaint.
NR.10.2.2 Drug allergies.
NR.10.2.3 Physical condition.
NR.10.2.4 Psychosocial status.
NR.10.2.5 Pain assessment.
NR.10.2.6 Nutritional Status.
NR.10.2.7 Discharge planning.
NR.10.2.8 Skin assessment.
NR.10.2.9 Fall risk assessment.
QM.14.5 Patients receive response when involved in significant incidents with documentation in the medical records.
QM.18.2 The process consists of three phases: verification, site marking, and time out.
QM.18.3
A pre-procedure verification of the patient information is carried out including the patient’s identity, consent, full
details of the procedure, laboratory tests and images, and any implant or prosthesis.
QM.18.4
The surgical/procedural site is marked before conducting the surgery/procedure.
QM.18.4.1
The site is marked especially in bilateral organs and multiple structures (e.g. fingers, toes, and
spine).
QM.18.4.2 The site is marked by the individual who will perform the procedure.
QM.18.4.3 The patient is involved in the marking process.
QM.18.4.4 The marking method is consistent throughout the hospital.
QM.18.4.5 The mark is visible after the patient is prepped and draped.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
QM.22.1 All patients are assessed for pressure ulcers on admission using a standard risk assessment tool.
QM.22.2 All patients are re-assessed for pressure ulcers every twenty four hours.
QM.22.3 The hospital implements evidence-based interventions that prevent pressure ulcers.
QM.23.1 Patients are assessed for the risk of fall on admission
QM.23.2
Patients are reassessed for the risk of fall after a change in risk factors (e.g., post-operatively, after receiving
sedating medications) and upon transfer from another unit.
PFR.9.2 The disclosure process is documented in the patient’s medical record.
PFR.11.3 Patients are informed about available care and treatment alternatives.
PFR.12.2 Patient/family decision about the resuscitative order is documented in the patient’s medical record.
AN.2.2 Qualified anesthesiologist is present inside the operating room throughout the operation.
AN.2.3
Anesthesia consultant administers and supervises anesthesia for major/specialized operations or high risk patients,
AN.2.3.1 Pediatric operations.
AN.2.3.2 Cardio-pulmonary operations.
AN.2.3.3 Neurosurgery operations.
AN.2.3.4 Transplant operations.
AN.6.2
The pre-anesthesia assessment includes:
AN.6.2.1
Patient interview and physical examination, including airway assessment and limited intra-vascular
access.
AN.6.2.2 Medical history including anesthesia, drug and allergy history
AN.6.2.3
Other additional pre-anesthesia evaluation if applicable and as required in accordance with the
standard practice prior to administering anesthesia (e.g., stress tests or additional specialist
consultations).
AN.6.2.4 Notation of anesthesia risk according to established standards of practice (ASA classification).
AN.6.2.5 Anesthetic plan and discussion of the risks and benefits.
AN.6.2.6 Documentation of an informed consent.
AN.6.2.7 Appropriate pre-medication and prophylactic antibiotic orders (if indicated).
AN.6.3
The anesthesiologist reassesses the patient immediately prior to induction of anesthesia focusing on the
physiologic stability and readiness of the patient for anesthesia. Findings are documented in the patient’s medical
record.
AN.7.1
The planned anesthesia care is documented in anesthesia record for each patient during anesthesia. The following
information must be documented:
AN.7.1.1 Age, sex, weight, height, and pre-operative vital signs.
AN.7.1.2 The anesthetic agent.
AN.7.1.3 The dosage, time, and route of administration of all medications and anesthetic agents used.
AN.7.1.4 The techniques used to administer the anesthesia.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
AN.7.1.5 If blood is used, the amount of blood, rationale for administration, and the time given.
AN.7.1.6 Investigations carried out e.g. blood glucose, blood gases.
AN.7.1.7 Unusual events or complications.
AN.7.1.8 The patient’s status at the end of the procedure.
AN.7.1.9 Intravenous fluids given.
AN.7.1.10 The anesthesiologist and anesthesia assistant(s).
AN.8.2 The patient’s physiological status is continuously monitored and documented during anesthesia.
AN.17.1
The pre-sedation assessment is performed by a qualified physician and includes:
AN.17.1.1 History and physical examination.
AN.17.1.2
History of medication allergy and adverse experience with sedation and analgesia as well as with
anesthesia.
AN.17.1.3 History of systemic illness or major organ impairment.
AN.17.1.4 Verification of the patient (NPO) status.
AN.17.1.5 American Society of Anesthesiologists (ASA) physical status class.
AN.17.1.6 Vital signs.
AN.17.1.7 Age and weight.
AN.17.1.8 ECG findings.
AN.17.2 The pre-sedation assessment is documented in the patient’s medical record.
AN.19.4
When patients are directly discharged home:
AN.19.4.1 The physician writes a discharge order.
AN.19.4.2
Patients are discharged in the company of a responsible adult who assumes responsibility and is
capable of taking care of the patient.
AN.19.4.3 Patient/family education and follow-up care instructions are provided prior to discharge.
OR.4.2
In emergency situations where a complete medical assessment cannot be documented, a brief note is written by
the most responsible physician.
OR.8.4 The most responsible physician writes a discharge order.
OR.8.6 Patient/family education and follow-up care instructions are provided prior to discharge.
OR.10.3 The report of the examination is signed by the pathologist and made part of the medical record.
OR.11.1 A post-operative plan of care is written by the responsible surgeon.
OR.11.2
The post-operative plan of care includes:
OR.11.2.1 Post-operative monitoring parameters and its frequency.
OR.11.2.2 Wound care.
OR.11.2.3 Care of drains and catheters.
OR.11.2.4 Special patient positioning requirements.
OR.11.2.5 Nutritional instructions.
OR.11.2.6 When to start mobilization.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
OR.11.2.7 Special referrals (e.g. physical therapy, respiratory therapy)
OR.11.2.8 A new order for all required medications.
OR.11.2.9 Any other post-operative care needed including required follow up.
ICU.6.4 Care is coordinated amongst the multidisciplinary team members and documented in the patient’s medical record.
ICU.7.2
A summary of the intensive care stay is written by the ICU physician and made available at the time of discharge
from intensive care to a lower acuity level.
ICU.12.3
The intensive care unit reports all cases of potential deceased Donors after Brain Death (DBD) to SCOT on a
timely manner.
ICU.12.4
The intensive care unit reports all cases of potential deceased Donors after Circulatory Death (DCD) to SCOT on
a timely manner.
NICU.8.1
A summary of the neonatal intensive care stay is written by the NICU physician and made available at the time
of discharge from critical care to a lower acuity level.
NICU.8.3
When the patient is discharged from the unit, the neonatal intensive care unit physician ensures that the receiving
team is well informed about the patient’s status and ongoing patient needs
NICU.8.3.1
The patient’s plan of care and medications are written in detail by the physician including how to
continue them on the floor.
NICU.8.3.2 Any special care requirements are documented in the medical record.
CCU.7.4 Care is coordinated amongst the multidisciplinary team members and documented in the patient’s medical record.
CCU.8.2
A summary of the coronary care stay is written by the physician and made available at the time of discharge from
critical care to a lower acuity level.
CCU.13.3 The CCU reports all cases of potential Donation after Circulatory Death (DCD) to SCOT in appropriate time.
CCU.13.4 The CCU reports all cases of potential Donation after Brain Death (DBD) to SCOT in appropriate time.
LD.9.1
The following information must be available in patients' records before discharge from the delivery room:
L&D.9.1.1 Completed assessment and reassessment.
L&D.9.1.2 Completed partogram.
L&D.9.1.3 Secured cardio-tocography.
L&D.9.1.4 Initial neonatal assessment.
L&D.9.1.5
Delivery summary including method of delivery, date and time of delivery, name and designation
of the healthcare professional who conducted the delivery and any assistants, type of anesthesia
or sedation used during delivery, neonatal outcome, status of placenta and membranes, any
postpartum instructions, and postpartum observations and discharge criteria.
HM.3.1 Hemodialysis procedures are ordered by a qualified nephrologist.
HM.3.2 Comprehensive assessment and reassessment is performed for each patient in the hemodialysis unit.
HM.3.3
The need for dialysis and choice of modality are based on sound clinical principles and a thorough clinical
evaluation of the clinical condition and any associated co-morbidities.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
HM.3.4
Informed consent is obtained for all dialysis patients after providing adequate information about the different
modalities and the modality that is most appropriate for the patient’s needs. The consent is updated regularly (e.g.,
yearly) and when the risk level is changing.
HM.3.5
Multi-disciplinary plan of care is developed for each patient in coordination with other relevant health
professionals (e.g., physician, nurse, dietitian, pharmacist, and social worker).
HM.3.6 There is an appropriate multi-disciplinary patient education plan.
HM.3.8 Plan of care is documented in the patient’s medical record
HM.8.5 Staff and employees have checkups for Hepatitis B, Hepatitis C, and HIV upon hiring and annually.
HM.8.6
Staff and employees susceptible to Hepatitis B are immunized with Hepatitis B vaccine and tested for antibodies
to evaluate response, and all non-responders are given a second series of the HBV vaccine.
ER.10.3 The transfer of responsibility is documented at times of shifts, handovers, referral and admission.
ER.11.3 Results of investigations are available to the emergency staff within a defined time frame.
ER.13.2
Levels of consultations are identified including Immediate (life, limb, or function threatening) and emergent
consultations.
ER.13.3 Level of consulted physicians and the ways of communications are included.
ER.13.4 Timelines of phone response and physical presence to different types of consultations are included.
RD.9.3 Findings of patient assessment and monitoring are documented in the patient’s medical record.
DT.1.3 Activities conducted by the dietician as part of the process of care is documented in the patient’s medical record.
DT.2.1
Nutritional screening is conducted by qualified From Hospital (e.g., registered nurse) to determine the patient’s
need for comprehensive nutritional assessment by a licensed dietitian
DT.2.3
Comprehensive nutritional assessment is performed by a qualified dietitian for:
DT.2.3.1 All patients identified at nutritional risk during the initial screening or assessment.
DT.2.3.2 All patients identified at nutritional risk during the course of treatment.
DT.2.3.3 All patients prescribed for a therapeutic diet.
DT.2.4 Patients identified at nutritional risk are referred to a licensed dietitian for comprehensive nutritional assessment.
DT.2.5 Nutritional assessment is preferably completed within twenty four hours of referral.
DT.2.7 The nutritional screening and assessment findings are documented in the patient’s medical record.
DT.3.1
The dietitian, in collaboration with other clinical staff, develops an appropriate nutritional plan of care for patients
with nutritional disorders.
DT.3.2 Patients cultural and food preferences are respected to the extent possible.
DT.3.3
The nutritional plan allows for consideration of:
DT.3.3.1
Enteral tube feeding for malnourished or patients at risk of malnutrition and have inadequate oral
intake and a functioning gastrointestinal tract
DT.3.3.2 Parenteral nutrition for patients with a non-functioning gastrointestinal tract.
DT.3.3.3 Therapeutic diet prescribed for specific health conditions.
DT.3.4 Patients are reassessed for response by the dietitian at regular intervals and adjustments are made accordingly.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
DT.3.5 The nutritional plan is documented in the patient’s medical record.
DT.4.3 The dietary manual is used as the basis for diet orders and for planning therapeutic diets.
DT.5.1 Therapeutic diets are prescribed by the most responsible physician based on the patient’s needs.
DT.5.3
The plan for a therapeutic diet must emphasize:
DT.5.3.1 Total calories required.
DT.5.3.2 Any restrictions.
DT.5.3.3 The route and frequency of feeds.
DT.5.3.4
When required, education about nutritional needs is provided to the patient and family upon
discharge.
DT.5.4 Discharge diets are prescribed by the most responsible physician in collaboration with the supervising dietitian.
DT.5.5 Patients are educated on their nutritional needs upon discharge.
DT.5.6 Education is documented in the patient’s medical record.
PT.3.1
Functional screening is conducted by qualified From Hospital (e.g., registered nurse) to determine the patient’s
need for a comprehensive functional assessment by a licensed therapist.
PT.3.3
Comprehensive functional assessment is performed by a qualified therapist for each patient identified at functional
risk during the initial screening or assessment.
PT.3.4 Functional assessment is completed within twenty four hours of referral.
PT.3.6 Functional screening and assessment findings are documented in the patient’s medical record.
PT.4.1
The physiotherapist, in collaboration with other clinical staff, develops a suitable plan of care for patients with
functional disorders.
PT.4.2 The plan of care meets the medical needs of the patient.
PT.4.3 The plan of care has measurable goals.
PT.4.4 Patients are educated about the plan of care and the procedures and rehabilitative exercises.
PT.4.5
Patients are reassessed by a physiotherapist at regular intervals, their response to the plan of care is monitored,
and adjustments are made accordingly.
PT.4.6
The plan of care is documented in the patient’s medical record as part of multidisciplinary team planning,
whenever applicable.
DN.3.1 Patients are educated and informed about the nature of the problem.
DN.3.2 Patients are educated and informed about treatments and procedures required.
DN.3.3 Patients are educated and informed about time needed to complete the course of treatment.
DN.4.1
Comprehensive assessment is performed for each patient to include:
DN.4.1.1 History of allergic reactions.
DN.4.1.2 Chronic illnesses (e.g., congenital heart disease, rheumatic heart and diabetes).
DN.4.1.3 Infectious diseases.
DN.4.1.4 Hematological diseases (e.g., hemophilia).
DN.4.1.5 Chief complaints.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
DN.4.1.6 The need for antibiotic prophylaxis.
DN.4.1.7 Radiological procedures needed.
DN.4.1.8 Treatment plan including procedure(s) to be performed.
DN.4.1.9 Dose of local anesthesia, the tooth treated and the material used.
DN.4.2 The assessment findings and the treatment plan are documented in the patient’s medical record.
DN.5.1 Informed consent is obtained for all high-risk procedures.
DN.5.2
General anesthesia and moderate or deep sedation are performed safely and according to the hospital’s related
policies and procedures.
MR.5.5
Medical record completion is a requirement within thirty days of patient discharge and before any elective vacation
or period of absence of the staff member entering the notes in the medical record.
MR.5.7 The most responsible physician is responsible for the completion of his own records.
MR.7.1 There is a discharge summary for all discharged patients.
MR.7.2
The discharge summary is complete and includes:
MR.7.2.1 The reason for the patient’s admission.
MR.7.2.2 The patient’s diagnosis.
MR.7.2.3
Brief summary of hospitalization (therapies, consultations, interventions and results of any
important diagnostic testing).
MR.7.2.4 A list of medications used.
MR.7.2.5 Any surgery or procedures performed and their outcome.
MR.7.2.6 The patient’s condition at discharge.
MR.7.2.7 All medications to be taken by the patient after discharge.
MR.7.2.8 Any special care the patient requires after discharge.
MR.8.1
The hospital uses the International Statistical Classification of Diseases and Related Health Problems, 10th
Revision, Australian Modification (ICD-10-AM) for diagnosis coding.
MR.8.2 The hospital uses Australian Classification of Health Interventions (ACHI) for procedure coding.
MR.10.3
The different sections of the medical record are organized chronologically (e.g., the physician orders start with
the initial set written when the patient was admitted to the hospital and end with the discharge order).
MR.10.4
During each hospitalization episode, both in-patient and outpatient medical records are separated into different
sections in the patients’ medical record (e.g., for doctors’ orders, nursing notes, progress notes).
MR.16.1
The hospital uses standardized forms in medical records, generated based on hospital needs and the needs of
healthcare professionals.
IPC.26.10 Labor working in medical disposal are well trained and vaccinated against blood borne pathogens.
IPC.29.3 Personnel with respiratory infections or gastroenteritis are restricted from handling food.
IPC.29.4
Stool tests and cultures are performed routinely upon hiring, every six months, and after returning back from
vacation.
IPC.36.4 All employees have baseline screening for hepatitis B, C, HIV, and tuberculosis.

of 134
Sub-Std
No.
Sub-Standard
MRN
(1)
MRN
(2)
MRN
(3)
MRN
(4)
MRN
(5)
MRN
(6)
MRN
(7)
MRN
(8)
MRN
(9)
MRN
(10)
AVG
IPC.36.5
The immune status of newly hired staff against hepatitis B, measles, mumps, rubella, and varicella is determined
by serological testing. Appropriate vaccine(s) is administered to those who are susceptible.
IPC.36.6
Response to hepatitis B vaccination is monitored in vaccinated employees four weeks after completing vaccine
series. Non-responders to hepatitis B vaccine are offered at least a second series of the vaccine.
IPC.36.7
Newly hired staff are screened for tuberculosis upon contracting with PPD test, and the test is repeated annually
for those who are non-reactive.
IPC.36.12 The screening, immunization, and post exposure management data are kept in staff medical records
LB.57.1 The process ensures all therapeutic procedures are ordered and justified by an authorized physician.
LB.57.2
The process ensures the blood bank medical director or designee is responsible for reviewing therapeutic
procedures orders for appropriateness and evaluating patient clinical and laboratory data before approving the
procedure.
LB.57.3 The process ensures therapeutic procedures are explained to the patient and consented.
LB.71.1
Surgical specimens are subjected to gross examination by a qualified pathologist or another qualified individual
under the supervision of a qualified pathologist.
LB.73.1
There is a process for the provision of intra-operative surgical pathology services which addresses:
LB.73.1.1 Scheduling of cases.
LB.73.1.2 Specimen acceptance, accessioning, processing and testing.
LB.73.1.3 Documentation of direct verbal communication with the surgeon.
LB.73.1.4 Inclusion of the frozen section results with the final surgical pathology report.
LB.74.1
There is a process for intra-departmental and extra-departmental consultations that addresses circumstances for
the inclusion of the consultation in the final pathology report.
LB.74.2 The process addresses circumstances for separate filing of the consultation report.
LB.75.1
There are implemented guidelines for compiling surgical pathology reports, addressing the following elements:
LB.75.1.1 Gross description (type, number, dimensions).
LB.75.1.2 Essential processing information and performed studies.
LB.75.1.3 Other relevant report elements necessary for the management of the patient.
LB.76.1 There is a policy mandating the inclusion of review results with the current patient report.

of 134
Open Medical Record Review
PC.6.5
The initial assessment aims to identify the general patient’s medical and nursing needs and a provisional diagnosis
so that care and treatment can be initiated.
PC.7.1
The hospital implements a policy that defines the criteria and process for screening patients for pain, functional
limitations including risk for fall, and malnutrition.
PC.7.3 When pain is present from the initial screening, the patient receives a comprehensive pain assessment.
PC.7.4 Patients with functional impairment are referred for functional assessment.
PC.7.5 Patients identified as malnourished or at risk for malnutrition are referred for a nutritional assessment.
PC.8.2 A proposed discharge date is set soon after admission.
PC.9.2
Medical and nursing assessments are completed and documented within the first 24 hours of admission for routine
elective cases.
PC.9.3
Medical and nursing assessments are completed and documented earlier whenever indicated by the patient’s
condition and the hospital policy.
PC.9.4
Assessments completed within 30 days prior to admission or an outpatient visit can be used with a documented
update of any significant changes.
PC.9.5 Assessments completed more than 30 days prior to admission or an outpatient visit must be repeated.
PC.9.6
Medical and nursing assessments are completed and documented for all patients prior to surgery, anesthesia or
invasive procedures.
PC.10.2
The most responsible physician ensures all patients under his care have a complete medical assessment with all
diagnostic tests and referrals as required to reach a final diagnosis.
PC.10.5
Diagnostic tests (e.g., laboratory and radiology) are appropriately and timely ordered to aid in reaching a final
diagnosis.
PC.11.1 The nursing assessment is performed by a staff nurse.
PC.11.3 The nursing assessment must be timely and complete.
PC.11.4 The nursing assessment is documented in the patient’s medical record.
PC.12.1 There are criteria implemented to identify patient groups who need additional or specialized assessments.
PC.12.2
Additional assessment includes, but is not limited to, the following categories:
PC.12.2.1 Patients in severe or chronic pain.
PC.12.2.2 Children.
PC.12.2.3 Frail and elderly.
PC.12.2.4 Suspected victims of abuse, neglect, and domestic violence.
PC.12.2.5 Drug abuse.
PC.12.2.6 Psychiatric disorders.
PC.12.2.7 Women in labor.
PC.12.2.8 Terminally ill and dying patients.

of 134
PC.12.3 Specialized assessment includes patients with dental, hearing, eye or speech defects.
PC.12.4
When additional or specialized assessments are required, they are completed and documented in the patient’s
medical record.
PC.14.1 The hospital addresses pain (acute/chronic) assessment and management as a patient’s right.
PC.14.3 Patients in pain receive pain assessment and management according to the policy.
PC.14.4 The process of pain assessment and management is documented in the patient’s medical record.
PC.15.1
Each patient has one qualified physician responsible for the overall care rendered to that patient and is referred to
as the most responsible physician (MRP).
PC.15.4
The most responsible physician provides the principal care plan and coordinates when required for additional
plans of other healthcare providers.
PC.15.5
Transfer of patient responsibility from one physician to another is guided by a hospital policy and is documented
in the patient’s medical record.
PC.16.1 The plan of care is developed through a collaborative approach between the healthcare team(s), patient, and family.
PC.16.2 The plan of care is based on the assessment findings and aimed to meet all patients’ needs.
PC.16.3 The patient and family are involved in developing the plan of care.
PC.16.4 The plan of care contains the measurable goals/desired outcomes towards discharge.
PC.16.5
The plan of care is completed within 24 hours of admission or earlier based on the patient’s condition and needs.
(Nursing plan of care is completed whenever possible before the end of the shift).
PC.16.6 The plan of care is reviewed by the most responsible physician on a daily basis.
PC.16.7
The plan of care is modified as appropriate upon any significant change in the patient’s condition or when new
treatments are added or discontinued.
PC.16.8 The plan of care includes a provisional date of discharge set within 24 hours of admission.
PC.16.9 The plan of care is documented in the patient’s medical record.
PC.17.2
Medical reassessment must be performed at least once daily, including weekends and holidays, and in response
to any significant change in the patient’s condition.
PC.17.4 Reassessments are documented in the patient’s medical record.
PC.18.3 Clinical practice guidelines, pathways, and protocols are documented in the patient’s medical record.
PC.19.1 The hospital implements a policy for the assessment and management of patients undergoing invasive procedures.
PC.19.2
The policy defines all essential requirements that must be documented in the patient’s medical record including,
but are not limited to:
PC.19.2.1 Date and time of the procedure.
PC.19.2.2
Name, designation and signature of the physician performing the procedure and the names of all
assistants.
PC.19.2.3 Location of the procedure.
PC.19.2.4 Nature and indication of the procedure.
PC.19.2.5 Any anesthesia or analgesia used with dosage and type.
PC.19.2.6 Patient monitoring.
PC.19.2.7 Procedure outcome.

of 134
PC.19.2.8 Complications.
PC.19.2.9 Laboratory specimens.
PC.19.2.10 Specific post procedural orders.
PC.19.3 Invasive procedures are documented in the patient’s medical record (or in an appropriate form) as per the policy.
PC.20.1
Information about the patient's care and response to treatment is shared between medical, nursing, and other care
providers (e.g., patient rounds, multidisciplinary teams, case management for patients requiring complex care).
PC.21.1 There is a physician’s order form where physicians document all orders relating to the patient car
PC.21.2 Only physicians are allowed to write in the physician order form (except for telephone and verbal orders).
PC.21.3 Physician orders include medications and non-medication orders.
PC.21.4 All orders are acknowledged by the nurse in charge of the patient, dated and timed.
PC.22.4
Medical and other relevant staff who are on call respond promptly to incoming consultations and care related
requests.
PC.23.1 There is a nursing pre-operative checklist that is completed by the assigned nurse.
PC.23.2 The checklist uses the "Yes", "No" and "Not Applicable" format.
PC.23.3 Patients are not transferred to the operating room if the checklist is not completed except in dire emergencies.
PC.23.4
The assigned nurse endorses all the findings of the pre-operative checklist to the receiving nurse in the operating
room.
PC.23.5
The receiving nurse in the operating room reviews all the findings of the pre-operative checklist with the assigned
nurse and confirms in writing.
PC.23.6
The nursing pre-operative checklist contains the following elements as a minimum:
PC.23.6.1 The nursing pre-operative checklist contains the following elements as a minimum:
PC.23.6.2 Evidence of completed relevant consents.
PC.23.6.3 Evidence of completed history and physical examination by medical and nursing staff.
PC.23.6.4 Evidence of site marking.
PC.23.6.5 Availability of results of requested investigations.
PC.23.6.6 Availability of requested blood or blood products.
PC.23.6.7
Evidence of removal of dentures and loose objects such as eye lenses, eyeglasses, and removable
nails.
PC.23.6.8 Evidence of removal of jewelry and patient's valuables.
PC.24.1
The hospital assesses and responds to the unique needs of end of life patients, including psychological, spiritual,
social, and cultural assessment.
PC.24.2
The hospital provides an effective palliative care for terminally ill patients (e.g., management of pain and
management of other distressing symptoms).
PC.24.3 Family members are involved in care decisions.
PC.24.4 Family members are educated on how to care for their patient.
PC.26.1 Patients are screened for the risk of developing venous thromboembolism.
PC.26.2 Patients at risk receive prophylaxis according to current evidence-based practice.

of 134
PC.27.3
The need for psychiatric care and choice of modality are based on sound clinical principles and a thorough clinical
evaluation of medical condition and co-morbidities.
PC.29.3 Patients are restrained only after an order by the most responsible physician or designee.
PC.29.4 The restraint order should be renewed at least every 24 hours.
PC.29.5 Patients are restrained as described in the relevant policy.
PC.30.1
The most responsible physician assesses and decides on the indication, the most suitable type, and the time
required for applying restraints.
PC.30.2
The most responsible physician performs periodic assessment and reassessment as dictated by the patient’s
condition (particularly, blood circulation to the limbs restrained).
PC.30.6 Nursing staff provide periodic monitoring of the restrained patient.
PC.30.7 Patients are reassessed on a frequent basis (at least hourly and as appropriate).
PC.30.8 Appropriate interventions are performed when the patient’s circulation is being impaired.
PC.34.4 Patient’s medical record reflects the use of these policies and plans.
PC.36.1
The consulting physician completes a consultation request that defines:
PC.36.1.1 Date and time of consultation.
PC.36.1.2 Name and designation of consulting physician.
PC.36.1.3 Name and designation of consulted physician.
PC.36.1.4
Urgency of consultation (24 hours for routine inpatient consults and one hour or less for emergency
cases).
PC.36.1.5 Case summary.
PC.36.1.6 Rationale for consultation.
PC.36.2
The consulted physician indicates in writing:
PC.36.2.1 Date and time of consultation visit.
PC.36.2.2 Name and designation.
PC.36.2.3 Opinion and recommendations, including the need to transfer the patient under his name.
PC.36.3
The consulting physician approves and follows up the implementation of the plan of care as set by the consulted
physician.
PC.37.1
The most responsible physician assesses the need for transfer and matches the condition of the patient with
admission criteria of the unit.
PC.37.2
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
PC.37.3 The most responsible physician assesses the transfer requirements, both staff and equipment.
PC.37.4
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.
PC.37.5 The physician and the nurse at the receiving unit assess the patient at arrival to ensure safe and smooth handover.
NR.10.1 The nursing assessment is timely completed by a registered nurse.
NR.10.3 The nursing assessment identifies nursing care needs for each patient upon admission.

of 134
NR.10.4
All patients are reassessed at appropriate intervals (at least on every shift) to determine their response to treatment
and to plan for continued treatment and discharge.
NR.10.5 The nursing assessment is documented in the patient’s medical record.
NR.11.1 A nursing plan of care is developed for all inpatients.
NR.11.2 The nursing plan of care is consistent with the medical plan of care.
NR.11.3
The nursing plan of care is reviewed on every shift, upon any significant change in the patient’s condition, and
when new treatments are added or current treatments are discontinued.
NR.11.4 The nursing plan of care is documented in the patient’s medical record.
QM.18.6 The hospital documents its processes for preventing wrong patient, wrong site, and wrong surgery/procedure.
QM.21.1
Patient care information is appropriately documented in a clearly understandable form to all care providers within
and between care settings.
QM.25.4
The complete verbal or telephone order or critical test result is written down by the receiver of the order or test
result.
PFE.3.2 Staff use the assessment findings for planning and delivery of education as appropriate to the plan of care.
PFE.4.1 Patients and families are educated about informed consent.
PFE.4.2 Patients and families are educated about participation in the care process and decisions.
PFE.4.3 Patients and families are educated about any financial implications of care decisions.
PFE.5.1
The hospital provides the patient with the necessary education and information about the primary illness and all
possible complications.
PFE.5.2
The hospital provides the patient with the necessary education and information about infection control practices,
adding emphasis on basic hand washing.
PFE.5.3
The hospital provides the patient with the necessary education and information about the required treatments and
procedures.
PFE.5.4
The hospital provides the patient with the necessary education and information about the appropriate and safe use
of the medical equipment or appliances.
PFE.5.5
The hospital provides the patient with the necessary education and information about any surgical procedure
needed and its benefits and potential risks.
PFE.5.6
The hospital provides the patient with the necessary education and information about the pre-operative
preparations needed and their importance.
PFE.5.7
The hospital provides the patient with the necessary education and information about post-operative care (e.g.,
breathing exercises, diet, and wound care).
PFE.5.8
The hospital provides the patient with the necessary education and information about the necessary medications,
the frequency, potential side effects, and food-drug interactions.
PFE.5.9
The hospital provides the patient with the necessary education and information about radiological procedures,
their benefits, and the potential risks involved.
PFE.5.10
The hospital provides the patient with the necessary education and information about the rational and benefits of
any dietary restrictions.

of 134
PFE.5.11
The hospital provides the patient with the necessary education and information about the conditions in which the
patient needs to seek medical assistance and how to access it if necessary.
PFE.5.12 The hospital ensures that the patient has his follow up clinic appointments
PFE.5.13
The hospital provides the patient with the necessary education and information about how to carry out activities
of daily living.
PFE.5.14
The hospital provides the patient with the necessary education and information about community resources for
additional care and how to access emergency services if necessary.
PFE.5.15 The hospital ensures that the patient can always state the name of his most responsible physician.
PFE.6.1
Clinical staff and health educators obtain feedback from the patient and/or family to ensure proper understanding
(e.g., demonstrates learning, verbalizes understanding).
PFE.7.1 The educational needs assessment and planning is documented in the patient's medical record.
PFE.7.2 The patient's response to education is documented in the patient's medical record.
PFR.3.3 The hospital mandates a written consent to photograph patients.
PFR.10.2
The informed consent process includes explanation of the nature of the treatment or procedure, expected benefits
and risks, alternative courses of action, and the likely consequences of not undergoing the treatment.
PFR.10.3
The informed consent is always obtained before any invasive surgery/ procedure, sedation/ anesthesia, and
transfusion of blood and blood components.
PFR.10.5
When a patient is incapable of giving informed consent (e.g., minors or mentally incompetent patients), consent
is sought from the patient’s next of kin or guardian.
PFR.11.6 The relevant discussion is documented in the patient’s medical record.
AN.5.1
Informed consent for anesthesia is obtained from the patient/family after explaining the anesthesia plan, risks,
benefits, and alternatives.
AN.5.2 The consent process is documented and witnessed.
AN.6.1
The pre-anesthesia assessment should be completed and dated in less than thirty days prior to the scheduled
surgery/procedure date. A review and update of the patient’s current condition is documented in the medical record
before conducting the procedure.
AN.9.3 Upon arrival to the recovery room, the patient is properly handed over and re-evaluated.
AN.9.4 The patient’s status and time of arrival to the recovery room are documented.
AN.11.2
There is a recovery from anesthesia record for documentation of monitoring findings and services provided in the
recovery room.
AN.12.3 Patients are discharged from the recovery room when the discharge criteria are met.
AN.12.4 Patients are discharged from the recovery room by a qualified anesthesiologist or another qualified individual.
AN.12.5 Time of discharge from the recovery room and the handover process to unit staff are documented.
AN.16.1
Informed consent is obtained after the physician educates the patient regarding the risk and benefits of the sedation
and the consent is signed by the patient, guardian, or next of kin if the patient is unable to sign.
AN.18.1
Patients are monitored during and after moderate and deep sedation/analgesia, including the following parameters:
AN.18.1.1 Vital signs.
AN.18.1.2 Oxygen saturation.

of 134
AN.18.1.3 Skin color.
AN.18.1.4 Level of consciousness/response to stimuli.
AN.18.1.5 ECG findings.
AN.18.2
Patient monitoring is continued during the recovery period until the patient is stable and adequate function is
restored.
AN.18.3 Findings of monitoring are documented in the patient’s medical record.
AN.19.3
When patients are transferred back to the unit:
AN.19.3.1 Patients are discharged to the unit by a qualified physician.
AN.19.3.2 The physician writes a follow up instructions for the nurses.
OR.4.1
Prior to surgery, the most responsible physician performs medical assessment and ensures documentation of the
following:
OR.4.1.1 History and physical examination.
OR.4.1.2 Pre-operative diagnosis.
OR.4.1.3 Diagnostic tests (laboratory, radiology, etc.) as ordered.
OR.4.1.4 Signed informed consent.
OR.4.1.5 Planned procedure.
OR.7.6 The count process is documented in the count sheet.
OR.9.1
There is always an operative report that includes:
OR.9.1.1 Pre and post-operative diagnosis.
OR.9.1.2 The name of the surgeon and assistants.
OR.9.1.3 The operation/procedure performed.
OR.9.1.4 Description of the surgery/procedure and findings.
OR.9.1.5 Presence or absence of intra-operative complications.
OR.9.1.6 Surgical specimens removed and sent to histopathology.
OR.9.1.7 Amount of blood loss.
OR.9.2
The operative report is documented before the patient leaves the recovery room to support the continuity of patient
care.
OR.9.3 The operative report is signed/authenticated by the surgeon performing the procedure.
OR.11.3 The post-operative plan of care is available in the patient's medical record before discharge from recovery.
OR.11.4 Each patient is assessed after surgery and reassessed at intervals appropriate to the patient’s condition.
OR.11.5 Medical, nursing, and other care plans are documented in the patient’s medical record.
OR.12.1 Pain is assessed by the most responsible physician or his designee after surgery.
OR.12.2 Pain medications are adjusted according to the patients’ response.
ICU.4.5
In an open ICU setting, the Most Responsible Physician (MRP) is the admitting consultant whereas in a closed
ICU setting, the MRP is a member of the medical staff in the ICU.
ICU.5.3
There is a documented evidence of handover between intensive care nurse and the unit/ward nurse at the time of
transfer to a lower acuity of care.

of 134
ICU.7.1
The ICU physician and the primary physician jointly make the decision to admit and discharge patients from the
unit.
ICU.7.3
There is a documented evidence of handover between the intensive care unit physician and the unit/ward physician
at the time of transfer to a lower acuity of care.
ICU.7.4
When the patient is discharged from the unit, the intensive care unit physician ensures that the receiving team on
the floor is well informed about the patient’s status and ongoing patient needs.
ICU.7.4.1
continue them in the floor.
ICU.7.4.2
Any special care requirements are documented (e.g., to watch for drainage tubes, tracheotomy care,
and wound care) in the patient’s medical record.
ICU.11.2 There are policies and procedures for monitoring of patient circulation, respiration, and oxygenation.
PICU.6.3
There is a documented evidence of handover between pediatric intensive care nurse and the unit/ward nurse at the
time of transfer to a lower acuity of care.
PICU.7.4 Care is coordinated amongst the multidisciplinary team members and documented in the patient’s medical record.
PICU.8.1
The PICU physician and the primary physician jointly make the decision to admit and discharge patients from the
unit.
PICU.8.2
A summary of the intensive care stay is written by the pediatric ICU physician and made available at the time of
discharge from pediatric intensive care to a lower acuity level.
PICU.8.3
There is a documented evidence of handover between the pediatric intensive care unit physician and the unit/ward
physician at the time of transfer to a lower acuity of care.
PICU.8.4
When the patient is discharged from the PICU, the pediatric intensive care unit physician ensures that the receiving
team on the floor is well informed about the patient’s status and ongoing patient needs.
PICU.8.4.1
PICU.8.4.2
Any special care requirements are documented (e.g., to watch for drainage tubes, tracheostomy
care, and wound care) in the patient’s medical record.
PICU.12.2 There are policies and procedures for monitoring of patient circulation, respiration, and oxygenation.
NICU.6.3
There is a documented evidence of handover between neonatal intensive care nurse and unit nurse at the time of
transfer to a lower acuity of care.
NICU.7.3 Care is coordinated amongst the multidisciplinary team members and documented in the patient’s medical record.
NICU.8.2
There is documented evidence of handover between the neonatal intensive care physician and the unit physician
at the time of transfer to a lower acuity of care.
NICU.12.2 There are policies and procedures for monitoring of patient circulation, respiration, and oxygenation.
CCU.5.5
In an open CCU setting, the Most Responsible Physician (MRP) is the admitting consultant, whereas in a closed
CCU setting the MRP is the CCU physician/intensivist.
CCU.6.3
There is a documented evidence of handover between the CCU nurse and the unit nurse at the time of transfer to
a lower acuity of care.
CCU.8.1
The physician in charge of the coronary care unit together with the most responsible physician jointly make the
decision to admit and discharge patients from the unit.

of 134
CCU.8.3
There is a documented evidence of handover between the coronary care physician and the unit physician at the
time of transfer to a lower acuity of care.
CCU.8.4
When the patient is discharged from the unit, the coronary care unit physician ensures that the receiving team on
the floor is well informed about the patient’s status and ongoing patient needs.
CCU.8.4.1
CCU.8.4.2 Any special care requirements are documented in the patient’s medical record
CCU.12.2 There are policies and procedures for monitoring of patient circulation, respiration, and oxygenation.
HM.3.7 Patients are properly monitored during and after dialysis.
HM.5.2 Policies and procedures are implemented as evidenced in the daily practice and the patient’s medical record.
HM.8.1 All patients are screened for Hepatitis B, Hepatitis C and HIV at the beginning of dialysis
HM.8.2
Patient whose laboratory tests for HBsAg, anti HBs, HCV, or HIV are negative should be re-screened every 3-6
months.
HM.8.3 Patients susceptible to hepatitis B are immunized with Hepatitis B vaccine.
ER.2.3 There is an established policy on how to call consultants for opinions.
RD.5.1
The radiology department defines and implements the format and content of radiology reports (paper or
electronic). Essential elements of the report include:
RD.5.1.1 Patient identification.
RD.5.1.2 Type of the procedure.
RD.5.1.3 Identification of the ordering physician.
RD.5.1.4 Reporting date and time.
RD.5.1.5 Identification of the reporting radiologist.
RD.5.2
The radiological studies are reported by the radiologist within defined time limits.
RD.5.2.1 Immediate reporting for emergency cases.
RD.5.2.2 Urgent cases are reported within twenty four hours.
RD.5.2.3 Routine cases are reported within forty eight hours.
BC.7.2 Care is coordinated with the different disciplines participating in the plan of care.
BC.9.3
Policies and procedures relating to infection control are implemented as evidenced in the daily practice and the
patient’s medical record.
RS.4.1
The plan of care is developed through an evidence-based and collaborative approach among the team members
involved.
RS.4.2 Comprehensive assessment and reassessment are performed for each patient
RS.4.3 The plan of care and the response to treatment are documented in the patient’s medical record.
SC.2.1
Psychosocial screening is conducted by qualified From Hospital (e.g., registered nurse) to determine the patient’s
need for comprehensive psychosocial assessment by a licensed social worker.
SC.2.3 Psychosocial assessment is preferably completed by a qualified social worker within twenty four hours of referral.
SC.2.5 The psychosocial screening and assessment findings are documented in the patient’s medical record.

of 134
SC.3.1
The social worker works collaboratively with clinical staff (physicians, nurses, and other clinical staff) to develop
a suitable plan of care that meets the psychosocial needs of the patient and ensures the continuity of care.
SC.3.2
Patients are reassessed by social worker at regular intervals, their response to the plan of care is monitored, and
adjustments are made accordingly.
SC.3.3 The plan of care is documented in the patient’s medical record as part of multidisciplinary team planning.
SC.4.7 Social worker participates with the treating team in discharge planning.
SC.5.1
The social worker documents relevant information in the patient’s medical record , which include:
SC.5.1.1 Reason for referral.
SC.5.1.2 Patient/family assessment and reassessment findings.
SC.5.1.3
Plan of care including goals and interventions such as counseling, education, and facilitation of
resources.
SC.5.1.4 Evaluation of the plan of care.
SC.5.1.5
Regular progress notes that include the patient/family understanding, care progress, and needs for
different or additional services.
MOI.7.2 The hospital implements a list of approved and prohibited abbreviations and symbols.
MR.2.4 There is patient identification on each page of the medical record.
MR.3.3
The patient demographic information (identification information) of the master patient index is recorded on the
front sheet of the medical record.
MR.4.1
The medical record contains sufficient information to identify the patient and his care provider, support the
diagnosis, justify the treatment, and document the results of care provided.
MR.5.2 All entries in the medical records must be legible, indelibly verified, dated, and authenticated.
MR.5.4
The author of each entry must be identified and authenticated by official stamp, signature, written initials, or
computer entry.
MR.6.2
The hospital has processes to manage the different parts of the medical records.
MR.6.2.1
The different parts of multiple records are cross referenced to the patient's unique identifier to
enable records linkage.
MR.6.2.2 The different parts can be easily located when not stored together.
MR.6.2.3 The hospital ensures that all information are available and accessible when needed.
MR.10.2
Medical records are organized into sections. (e.g., a section for test results, operative reports, consultations,
discharge summary).
IPC.14.1
There are policies and procedures that address standard and transmission-based precautions.
IPC.14.1.1
The policies and procedures address separating patients with communicable diseases and those who
are colonized or infected with epidemiologically important organisms from other patients, staff,
and visitors.
IPC.14.2
The transfer of patient outbound or inbound should secure the prevention of spread of Methicillin-resistant
staphylococcus aureus (MRSA) or other epidemiologically significant organisms.
IPC.14.2.1
All patients for transfer outbound known to have MRSA or other epidemiologically significant
organisms must be reported upon requesting the transfer with the supporting document.

of 134
IPC.14.2.2
All patients transferred to the hospital must be kept under contact transmission-based precaution
unless proving otherwise.
MM.17.3
There is proper documentation of patient’s own medications in the medical record (ordering, dispensing, and
administration records).
MM.19.2
Only individuals permitted by the hospital and relevant laws and regulations prescribe or order controlled and
narcotic medications.
MM.19.4
The hospital implements its policy on prescribing privileges such as those for controlled and narcotic substances,
chemotherapy agents, high-alert, radioactive or investigational, and other specialty medications
MM.20.2 All currently prescribed or ordered medications are written in a uniform location in the patient’s medical record.
MM.20.3 Medication reconciliation is conducted at the time of admission and discharge.
MM.20.4 Patient identification, diagnosis, indication, or clinical condition are made available with each medication order.
MM.20.5 Medications are prescribed by generic name except when brand names are acceptable or required.
MM.20.6 Staff comply with the proper use of approved and prohibited prescribing abbreviations.
MM.20.8
All medications are accurately transcribed into the medication administration record (MAR) after being verified
against the original physician order or prescription.
MM.21.1
The hospital implements a policy and procedure on specific types of medication orders including as needed (PRN),
standing, automatic stop (ASO), titrating, tapering, range, weight-based, body surface area-based medication
orders, and discharge or transfer orders.
MM.21.2 The hospital prohibits blanket orders (e.g., resume pre-op medications).
MM.21.3
Prescribing controlled drugs is according to laws and regulations of the Saudi Food and Drug Authority and other
relevant authorities.
MM.21.4
The transcription of medication order into the medication administration record (MAR) clearly reflects the type
of order.
MM.22.3
There is proper implementation of the approved guidelines for antibiotics prophylaxis before surgery and/or dental
procedures.
MM.22.4 There is proper implementation of the approved guidelines for empiric and therapeutic use of antibiotics.
MM.22.5 There is proper implementation of the approved prescribing privileges for antibiotics.
MM.23.3
Verbal and telephone orders are limited to emergent and urgent situation where immediate written or electronic
medication order is not feasible. Clear definition of emergent and urgent situations should be included.
MM.23.4
Time frame for authentication of verbal (as soon as the emergency is over) and telephone orders (within twenty
four hours) is clearly stated and implemented.
MM.36.4 The hospital has approved, disseminated, and implemented guidelines on standard drug administration time.
MM.36.6 The hospital maintains updated and accurate records of drug administration.
MM.36.7 Independent double check of all high alert medications is performed.
MM.37.2 Medications are verified against the medication administration record (MAR) before administration.
MM.37.3 Medications are administered in the prescribed dose and by the correct route.
MM.37.4 Medications are administered at the correct time (the approved hospital standard administration time).
MM.38.1 The hospital educates patients and families involved in self-administration of medications about:

of 134
MM.38.1.1 Medication name, type, and indication.
MM.38.1.2 Time, frequency, route, and dose of medication.
MM.38.1.3 Expected medication effect and potential side effects.
MM.38.1.4 Monitoring and reporting of medication effects.
MM.39.3
The hospital has a collaborative process, involving physicians, nurses, and pharmacists, to monitor the patient’s
response to medications.
MM.39.4
Monitoring includes the following
MM.39.4.1
The medication’s effect on patient’s clinical condition, as well as blood count, liver and renal
functions and other relevant therapeutic monitoring parameters
MM.39.4.2 The patient’s perception of side effects to the first dose of a new medication.
MM.39.4.3 Unanticipated drug-drug interactions.
MM.39.4.4 Changes in the patient’s equilibrium that may raise the risk of falls
MM.39.4.5 Allergic reactions including documentation and flagging of medical records.
MM.40.4 The patient affected by ADR receives appropriate care at the appropriate time.
MM.40.6 All ADRs are documented in the patient’s medical record.
MM.41.9 Medication errors, near misses, and hazardous situations are documented in the patient’s medical record.

of 134
Annex D
Personnel Files Review Tool

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
Hospital Director
LD2.1 The hospital director is qualified in healthcare management by education, training or experience.
LD2.3 The hospital director ensures the hospital’s compliance with all relevant laws and regulations.
LD2.4 The hospital director ensures the recruitment and selection of competent and skilled From Hospital.
LD2.5 The hospital director is accountable to the governing body for the clinical performance and professional
conduct of the From Hospital.
LD2.6 The hospital director ensures the implementation of the policies set by the governing body.
LD3.2 Hospital leaders ensure compliance with all relevant laws and regulations (e.g., laws and regulations related
to recruitment, professional staff licensure and registration, waste management, food management, infection
control, medications management, patient rights, radiation safety, and physical environment).
LD5.2 Hospital leaders are qualified in healthcare management by education, training, or experience.
LD5.3 Hospital leaders have specific responsibilities as outlined in a current job description.
LD13.1 The hospital has a finance director who is qualified by education and experience.
LD22.1 The hospital has a qualified duty manager with a clear job description to coordinate the care during off duty
hours.
LD25.2 Qualifications, experience, and training of the appointed department head match the services provided by the
department.
LD25.3 When the department head is appointed on a part-time basis (e.g., a small hospital or a hospital that is part of
a corporate chain), the department head:
LD25.3.1 Ensures that work flow and patient safety are not compromised during his absence.
LD.25.3.2 Ensures that the department functions are well managed through regular scheduled visits.
LD.25.3.3 Provides guidance as well as continued assessment of the individual in charge of the
department during his absence.
LD.25.3.4 The frequency and duration of the visits must be documented in the contract.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
LD.30.5 The department head monitors the performance of the staff.
HR.1.2 The head of the human resources department is qualified in managing human resources by education, training,
or experience.
HR.3.3 All job descriptions are revised at least every three years and as needed.
HR.3.4 The job description defines the required knowledge, skills, and attitude to perform the job responsibilities.
HR.3.5 The job description clearly defines the roles and responsibilities.
HR.3.6 The job description specifies the reporting relationships.
HR.3.7 The job description is discussed with and signed by the staff member on hiring and is kept in the personnel
file
HR.4.4 Personnel files contain the following minimum items:
HR.4.4.1 Qualifications; including current licensure, certification, or registration, if applicable.
HR.4.4.2 Current job description.
HR.4.4.3 References.
HR.4.4.4 Orientation, continuing education, and training records.
HR.4.4.5 Performance evaluations.
HR.4.4.6 Records of leave and sickness.
HR.4.4.7 Disciplinary actions, if any.
HR.4.4.8 Other documents as required by relevant laws and regulations.
HR.5.2 The hospital gathers, verifies, and evaluates the credentials (license, education, training, certification and
experience) of those medical staff, nursing staff, and other health professionals licensed to provide patient
care.
HR.5.3 Credentials are verified from the original source.
HR.5.4 Job responsibilities and clinical work assignments/ privileges are based on the evaluation of the verified
credentials.
HR.5.5 The hospital ensures the registration of all healthcare professionals with the Saudi Commission for Health
Specialties.
HR.5.6 Staff licensed to provide patient care must always have and maintain a valid license to practice only within
their profession.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
HR.5.7 The hospital maintains an updated record of the current professional license, certificate, or registration, when
required by laws, regulations, or by the hospital for every medical staff, nursing staff and other healthcare
professionals.
HR.5.8 When verification of credentials is conducted through a third party, the hospital must request for a
confirmatory documentation.
HR.5.9 Verification process applies to all clinical staff categories (full time, part time, visitor, and locum).
HR.6.3 The general orientation program is conducted before working independently.
HR.6.4 The general orientation program is documented in the employee’s personnel file.
HR.7.4 An evidence of attending the departmental and job orientation program is signed by the new employee and
documented in the personnel file.
HR.8.3 Competency evaluation during the probationary period is a structured process that aims to assess and review
the employee’s knowledge, performance, capability, conduct, and suitability for the role.
HR.8.4 The competency evaluation is documented in the personnel file.
HR.9.2 The performance evaluation is based on objective criteria and is linked with the job description.
HR.9.5 The performance evaluation is signed by both the employee and the supervisor and is documented in the
personnel file.
HR.11.4 The department head recommends and evaluates the educational and training activities required to maintain
staff competencies to provide care. This process is linked to performance improvement and documented in
the personnel file.
HR.12.1 All staff members who provide direct patient care (medical staff, nursing staff, and other healthcare
professionals) maintain a valid certification in basic cardiac life support (BCLS) and certification is renewed
every two years.
HR.12.2 The hospital identifies and provides training for other staff categories in areas related to advanced cardiac life
support (ACLS), neonatal resuscitation program (NRP), pediatric advanced life support (PALS), and
advanced trauma life support (ATLS). Examples include, but are not limited to:
HR.12.2.1 Physicians and nurses working in critical care areas must maintain additional certification in
ACLS, PALS and NRP as appropriate to the patients’ age groups.
HR.12.2.2 Internal medicine physicians must maintain additional certification in ACLS.
HR.12.2.3 Emergency department physicians must maintain additional certification in ACLS, PALS and
ATLS.
HR.12.2.4 Pediatricians must maintain additional certification in PALS and NRP.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
MS.2.1 The medical director is a board certified physician or equivalent, qualified in healthcare management by
education, training or experience.
MS.2.2 The medical director is responsible and accountable for the clinical performance of the medical staff, the
quality of care they provide, as well as their professional conduct.
MS.2.3 The medical director recommends to the hospital director the appointment of the heads of clinical departments.
MS.2.4 The medical director has a current written job description that clearly describes his managerial roles and
responsibilities.
MS.4.1 The department head is board certified or equivalent in his field and qualified in healthcare management by
education, training or experience.
MS.4.2 The department head has a written job description that clearly describes his role and responsibilities.
MS.4.3 Responsibilities of the department head include:
MS.4.3.1 Defining medical staff qualifications required for the provision of effective and safe patient
care.
MS.4.3.2 Recommending the need for further training/certification of a medical staff member.
MS.4.3.3 Monitoring admissions to ensure that the diagnostic and therapeutic interventions are within
the staff capabilities and the available hospital resources.
MS.4.3.4 Ensuring that medical staff members work within the clinical privileges granted to them.
MS.4.3.5 Developing a written scope of services for the department.
MS.5.3 The credentialing and privileging committee ensures that only qualified physicians and dentists are appointed
and granted privileges.
MS.5.4 Applicants for initial appointment submit a complete set of documents required for the credentialing and
privileging process , including:
MS.5.4.1 Curriculum vitae, detailing the professional history of the applicant.
MS.5.4.2 Education, training, certificates, courses, experience, published research, and other relevant
credentials.
MS.5.4.3 List of references.
MS.5.4.4 List of the privileges requested for approval.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
MS.6.1 All members of the medical staff must be registered with the Saudi Commission for Health Specialties before
allowed to work independently.
MS.6.3 Medical staff appointment, reappointment and granting of privileges are in accordance with relevant laws and
regulations.
MS.6.4 Medical staff appointment, reappointment and granting of privileges are based on
MS.6.4.1 Evaluation of the verified credentials (license, education, training, and experience).
MS.6.4.2 Evaluation of the mental and physical health and capabilities.
MS.6.4.3 Competency, actual performance and outcomes of care.
MS.6.4.4 Category of the medical staff as stated in the professional registration with the Saudi
Commission for Health Specialties (e.g., consultant, specialist).
MS.6.5 Appointment, reappointment and granting of privileges are recommended by the medical staff leaders
(medical director, heads of clinical departments, credentialing and privileging committee, and senior medical
staff members) and approved by the governing body, either directly or by appropriate delegation.
MS.7.2 Clinical privileges are reviewed and updated every two years and as needed.
MS.7.3 The hospital identifies the circumstances under which temporary or emergency privileges are granted.
MS.7.5 When a new privilege is requested by a medical staff member, the relevant credentials are verified and
evaluated prior to approval.
MS.8.1 The department head together with the medical director evaluate the performance and competency of medical
staff members at least annually and when indicated by the findings of performance improvement activities.
MS.8.2 The hospital identifies the circumstances under which an unplanned review of the performance of a medical
staff member may be initiated.
MS.8.3 The performance evaluation includes, but is not limited to, the following:
MS.8.3.1 Assessment of patients.
MS.8.3.2 Adverse events.
MS.8.3.3 Moderate and deep sedation.
MS.8.3.4 Quality of medical records.
MS.8.3.5 Medication errors.
MS.8.3.6 Sentinel events.
MS.8.3.7 Outcome of high-risk procedures and surgeries.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
MS.8.3.8 Morbidities and mortalities.
MS.8.3.9 Blood and blood product usage.
MS.8.3.10 Discrepancies between pre and post-operative pathological diagnoses.
MS.8.3.11 Appropriateness of admissions from the emergency room and outpatient department.
MS.9.1 The data and information resulting from the medical staff performance review are used to :
MS.9.1.1 Provide feedback and counseling to the medical staff regarding their performance.
MS.9.1.2 Recommend plans for improvement.
MS.9.1.3 Amend clinical privileges as necessary, by expansion or limitation, a period of counseling
and oversight, or other appropriate action.
MS.9.1.4 Make informed decisions regarding reappointment.
MS.9.1.5 Recommend training and continuous education as needed.
MS.9.2 The outcomes of the medical staff performance evaluation and actions taken are documented in the physician’s
credentials file.
MS.18.3 The cardiopulmonary resuscitation committee ensures that the cardiopulmonary resuscitation team members
have cardiac life support training as appropriate to the patient population served by the hospital.
PC.27.1 Psychiatric care is provided by qualified physicians.
PC.30.12 Staff members involved in restraint are trained and competent.
PC.32.5 CPR team members have the proper training on cardio-pulmonary life support.
PC.32.6 CPR team is led by:
PC.32.6.1 A physician or an anesthesiologist who is certified in ACLS for adult codes.
PC.32.6.2 A physician who is certified in PALS for pediatric codes.
PC.32.6.3 A physician who is certified in NRP for neonatal codes.
NR.1.1 The hospital has a full time nursing director.
NR.1.2 The nursing director is licensed and registered with the Saudi Commission for Health Specialties.
NR.1.3 The nursing director is qualified by appropriate education, training, and experience (minimum bachelor degree
of science in nursing and five years of managerial experience).
NR.1.4 The nursing director is responsible for the direction, provision, and quality of nursing services provided to
patients
NR.1.6 The hospital designates a deputy director of nursing to coordinate nursing activities and handle administrative
and clinical issues during the absence of the nursing director.
NR.9.1 The nursing director ensures the availability of adequate number of licensed registered nurses to provide
nursing care for all patients.
NR.9.2 Each unit has a head nurse/nurse manager with the required nursing and managerial experience.
NR.9.3 Nursing services are provided by registered nurses in accordance with their license and scope of practice.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
NR.9.4 Qualified registered nurses are readily available to provide bedside nursing care to all patients twenty four
hours a day, seven days a week.
NR.9.6 Nursing assistants have clearly defined job description and responsibilities.
NR.9.7 There is an education program for nursing assistants performing patient-care services to orient them to their
role.
QM.2.3 Staff are trained (formally or through orientation and mentoring) on continuous quality improvement in
accordance with their roles and responsibilities in the quality improvement program.
QM.3.1 The hospital has a quality management director responsible for directing all aspects of the quality management
department.
QM.3.2 The quality management director is qualified by education, training, and experience in healthcare quality.
QM.16.3 The hospital assigns a qualified individual to provide coordination and supervision of the organization-wide
patient safety program.
PFE.1.3 According to the size of the hospital and its scope of services, the hospital assigns adequate health educators
to cover the needs of patient/family education (e.g., diabetic educator, nurse educator).
PFE.1.5 The job description of the clinical staff (e.g. nurses, physicians, dietitians) reflects their role in patient/family
education.
AN.1.1 The head of the department of anesthesia is a qualified anesthesiologist by education, training, and experience.
AN.2.1 Qualified anesthesiologists provide anesthesia services.
AN.2.4 Anesthesia staff are certified in advanced life support as appropriate to the patient’s age.
AN.10.2 Qualified staff members provide post-anesthesia care in the recovery room.
AN.15.1 Physicians who perform moderate and deep sedation/analgesia have competency-based privileges granted to
perform moderate and deep sedation/analgesia.
AN.15.2 Clinical staff who participate in caring for patients receiving moderate or deep sedation are certified in
advanced life support as appropriate to the age of the patients served.
AN.15.3 Clinical staff who participate in conducting sedation must successfully complete a proper education/training
on moderate and deep sedation.
OR.1.1 The operating room is directed by a qualified medical staff (e.g., surgical or anesthesia staff).
OR.2.1 The nurse manager in charge of the operating room is a qualified registered nurse with training, education,
and experience in operative care.
OR.3.1 The nursing staff receive ongoing training on the following general and operating room- related needs:
OR.3.1.1 Use of equipment.
OR.3.1.2 Use of defibrillator.
OR.3.1.3 Use of pulse oximetry.
OR.3.1.4 Infection control.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
OR.3.1.5 Blood transfusion.
OR.3.1.6 Central sterilization policy.
OR.3.1.7 Maintenance of a sterile field.
OR.3.1.8 Draping and gowning.
OR.3.1.9 Surgical table operation and safe positioning of patients.
OR.3.1.10 Assistance in operations of their specialty surgical area.
OR.3.1.11 Pre and post-procedural handling and disposing of surgical equipment.
OR.3.1.12 Safe operation of variable surgical equipment according to specialty.
OR.3.2 Nursing staff competencies are assessed by using different methods (e.g. written test, return demonstration).
ICU.1.1 The adult intensive care unit is directed by a physician qualified in critical care medicine by education,
training, and experience.
ICU.1.2 The unit head takes the overall responsibility for the operation of the unit.
ICU.2.1 The nurse manager is a registered nurse qualified by education, training and, experience in managing
critically-ill patients.
ICU.3.1 The intensive care unit is covered by physicians qualified in managing critically ill patients twenty four hours
a day, seven days a week.
ICU.3.2 Medical staff working in the adult intensive care unit are certified in advanced cardiac life support (ACLS)
and are trained on fundamental critical care support.
ICU.3.3 Nursing staff working in the adult intensive care unit are certified in advanced cardiac life support (ACLS).
ICU.9.1 Nursing staff in the adult intensive care unit receive training and education on the following general and
intensive care related needs:
ICU.9.1.1 Fundamental critical care support.
ICU.9.1.2 Infection control principles.
ICU.9.1.3 Blood transfusion.
ICU.9.1.4 Use of the defibrillator.
ICU.9.1.5 Care of patients with tracheostomies.
ICU.9.1.6 IV therapy.
ICU.9.1.7 Pressure ulcer prevention and care.
ICU.9.1.8 Knowledge of dosage range, side effects and complications of commonly used high alert
medications in critical care including vasopressors, narcotics and controlled medications.
ICU.9.1.9 Recognizing critical ECG changes including arrhythmias.
ICU.9.1.10 Using pulse oximetry.
ICU.9.1.11 Assisting physician in placing central lines or arterial lines.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
ICU.9.1.12 Assessing Glasgow Coma Scale (GCS).
ICU.9.1.13 Obtaining arterial blood gas samples.
ICU.9.1.14 Care of patients on ventilators.
ICU.9.1.15 Reading central venous pressure (CVP) and swan Ganz monitoring.
ICU.9.1.16 Care of endo-tracheal tube (ETT).
ICU.9.3 The competency assessment of the nursing staff is documented.
PICU.1.1 The pediatric intensive care unit is directed by a physician qualified in pediatric critical care by education,
training and, experience.
PICU.1.2 The unit head takes the overall responsibility for the operation of the unit.
PICU.2.1 The nurse manager is a registered nurse qualified by education, training, and experience in pediatric critical
care.
PICU.3.1 Medical staff working in pediatric intensive care unit are certified in pediatric advanced life support (PALS).
PICU.3.2 Nursing staff working in pediatric intensive care unit are certified in pediatric advanced life support (PALS).
PICU.4.1 The pediatric intensive care unit is covered twenty four hours a day, seven days a week by qualified pediatric
intensive care physicians.
PICU.10.1 Nursing staff in the pediatric intensive care unit receive training and education on the following general and
intensive care related needs:
PICU.10.1.1 Pediatric fundamental critical care support.
PICU.10.1.2 Infection control principles.
PICU.10.1.3 Blood transfusion.
PICU.10.1.4 Use of the defibrillator.
PICU.10.1.5 Care of patients with tracheostomies.
PICU.10.1.6 Knowledge of dosage range, side effects and complications of commonly used high alert
medications in pediatric critical care including vasopressors, narcotics, and controlled
medications.
PICU.10.1.7 Recognizing critical ECG changes including arrhythmias.
PICU.10.1.8 Using pulse oximetry.
PICU.10.1.9 Assisting physician in placing central lines or arterial lines.
PICU.10.1.1
0
Assessing Glasgow Coma Scale (GCS).
PICU.10.1.1
1
Obtaining arterial blood gas samples.
PICU.10.1.1
2
Care of patients on ventilators.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
PICU.10.1.1
3
Reading central venous pressure (CVP) and swan Ganz monitoring.
PICU.10.1.1
4
Care of endo-tracheal tube (ETT).
PICU.10.1.1
5
Pressure ulcer prevention and care
PICU.10.1.1
6
Guidelines for Monitoring & Management of IV Infiltration, Phlebitis & Extravasations
PICU.10.1.1
7
Pain assessment and management based on patient’s age and condition (e.g., ventilated &
non-ventilated patients).
PICU.10.3 The competency assessment of the nursing staff is documented.
NICU.1.1 The department head is a qualified Pediatrician with experience in neonatology (for level 1 and 2 NICU) and
certified neonatologist (for level3 NICU).
NICU.1.2 The department head takes the overall responsibility for the operation of the unit.
NICU.2.1 The nurse manager is qualified by education, training, and experience in neonatal intensive care.
NICU.3.1 Medical staff working in neonatal intensive care unit are certified in Neonatal Resuscitation Program (NRP).
NICU.3.2 Nursing staff working in the neonatal intensive care unit are certified in Neonatal Resuscitation Program
(NRP).
NICU.4.1 The neonatal intensive care unit is covered twenty four hours a day, seven days a week by qualified neonatal
intensive care physicians.
NICU.4.2 For a Level 3 unit, there is certified neonatologist to cover the unit during the on call hours.
NICU.10.1 Nursing staff in the NICU intensive care unit receive training and education on the following general and
NICU intensive care related needs:
NICU.10.1.1 Assisting physicians in the different procedures performed in the neonatal intensive care unit
including securing central lines access.
NICU.10.1.2 Using pulse oximetry.
NICU.10.1.3 Recognizing critical ECG changes including arrhythmias.
NICU.10.1.4 Assisting physician in placing central lines or arterial lines and /or umbilical arterial/venous
lines.
NICU.10.1.5 Obtaining arterial blood gas samples and blood drawing from umbilical catheters.
NICU.10.1.6 Knowledge of dosage range, side effects and complications of commonly used medications
such as surfactant and high alert medications used in neonatal care including vasopressors,
narcotics, and controlled medications.
NICU.10.1.7 Infection control principles.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
NICU.10.1.8 Blood transfusion and exchange transfusion.
NICU.10.1.9 Sarnat and Thompson Scoring.
NICU.10.1.1
0
Use of the defibrillator.
NICU.10.1.1
1
Care of patients on ventilators.
NICU.10.1.1
2
Care of endo-tracheal tube (ETT).
NICU.10.1.1
3
Care of patients with tracheostomies.
NICU.10.1.1
4
Care of the terminally ill and end of life patients.
NICU.10.1.1
5
Care of patient in incubator.
NICU.10.2 There is ongoing competency assessment for the nursing staff (e.g., written test, return demonstration).
NICU.10.3 The competency assessment of the nursing staff is documented.
CCU.1.1 The department head is a physician qualified by appropriate education, training, and experience in managing
intensive cardiac care patients/units.
CCU.1.2 The department head takes overall responsibility for the operation of the unit.
CCU.2.1 The nurse manager is qualified by education, training, and experience in coronary care units.
CCU.3.1 Medical staff working in coronary care unit are ACLS-certified.
CCU.3.2 Nursing staff working in the coronary care unit are ACLS-certified.
CCU.4.1 The coronary care unit is covered twenty four hours a day, seven days a week by physicians qualified in
managing cardiac patients requiring intensive care.
CCU.10.1 Nursing staff in the coronary care unit receive training and education on the following general and intensive
care related needs:
CCU.10.1.1 Assisting physicians in the different procedures performed in the coronary care unit including
securing central line access.
CCU.10.1.2 Using pulse oximetry.
CCU.10.1.3 Recognizing critical ECG changes including arrhythmias.
CCU.10.1.4 Obtaining arterial blood gas samples and blood drawing from umbilical catheters.
CCU.10.1.5 Reading central venous pressure (CVP) and swan Ganz monitoring.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
CCU.10.1.6 Knowledge of dosage range, side effects and complications of commonly used medications
such as high alert medications used in coronary care including vasopressors, narcotics, and
controlled medications.
CCU.10.1.7 Infection control principles.
CCU.10.1.8 Blood transfusions.
CCU.10.1.9 Assessing Glasgow Coma Scale (GSC).
CCU.10.1.10 Use of defibrillator.
CCU.10.1.11 Care of patients on ventilators.
CCU.10.1.12 Care of Endo-tracheal tube (ETT).
CCU.10.1.13 Care of patients with tracheostomies.
CCU.10.1.14 Care of the terminally ill and end of life patients.
CCU.10.3 The competency assessment of the nursing staff is documented.
L&D.1.1 The head of the obstetrics department is an obstetrician qualified by education, training, and experience.
L&D.1.2 The head of the obstetrics department supervises the development and implementation of policies and
procedures related to gynecology and obstetrics practices.
L&D.2.2 Obstetricians are certified in advanced life support in obstetrics (ALSO) or at least one certified obstetrician
is assigned on every shift.
L&D.2.5 Pediatricians are certified in neonatal resuscitation program (NRP).
L&D.3.1 The nurse manager in charge of the obstetrics department is a qualified registered nurse with education,
training and experience in obstetrics.
L&D.3.2 The nurse manager ensures the competency of the midwives and nursing staff.
L&D.4.2 Nurses working in the obstetrics department have adequate experience in obstetrics.
L&D.4.3 Nurses working in the obstetrics department are certified in neonatal resuscitation program or at least one
certified nurse is assigned on every shift.
L&D.4.4 Midwives are registered and are qualified by education, training, and experience in labor and delivery.
L&D.8.1 There is a qualified and competent nurse to receive the newborn during delivery.
L&D.8.2 The attending nurse is qualified to perform the following for each newborn:
L&D.8.2.1 Suction.
L&D.8.2.2 Placing an identity band with the medical record number and other identifier(s) according to
the hospital policy.
L&D.8.2.3 Finding and documenting the APGAR score.
L&D.8.2.4 Obtaining the footprint of the newborn and the thumbprint of the mother.
HM.1.1 Clinical services in the hemodialysis unit are led by a qualified nephrologist with experience in managing end
stage renal disease (ESRD) patients.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
HM.2.1 The nurse in charge of the hemodialysis unit is a qualified registered nurse with training, education or
experience in hemodialysis.
HM.2.2 Nursing staff members are registered nurses qualified to care for ESRD patients by education, training or
experience.
HM.3.10 Clinical staff who participate in caring for patients on dialysis are certified in advanced life support as
appropriate to the different age groups of patients, or at least one certified individual is assigned on every shift.
HM.6.3 The preventive maintenance program is performed by qualified staff/entities.
HM.10.1 The nursing staff receive ongoing training and education on all relevant policies including, but are not limited
to, the following:
HM.10.1.1 Care of patients with AV fistula/AV graft.
HM.10.1.2 Dialysis procedures.
HM.10.1.3 Care of tunneled/non-tunneled catheters.
HM.10.1.4 Peritoneal dialysis.
HM.10.1.5 Assessment of patient’s volume status.
HM.10.1.6 Anticoagulation.
HM.10.1.7 Management of clotted access.
HM.10.1.8 Hyperkalemia.
HM.10.1.9 Pulse oximetry.
HM.10.1.10 Blood transfusion.
HM.10.1.11 Use of defibrillator.
HM.10.1.12 Infection control.
HM.10.2 The nursing staff competencies are assessed by using different methods (e.g., written test, return
demonstration) and results are documented.
ER.1.1 The head of the emergency department is a physician qualified by education, training, and experience in
managing emergency patients.
ER.1.2 The head of the emergency department supervises the development and implementation of policies and
procedures related to managing emergency patients.
ER.2.1 The emergency department is covered twenty four hours a day, seven days a week by qualified emergency
physicians.
ER.2.4 All staff members are qualified and experienced in emergency care.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
ER.2.5 Clinical staff who participate in caring for patients in the emergency department are certified in advanced life
support as appropriate to the ages of the patients served (including Advanced Trauma Life Support) and are
present on site or at least one certified individual is assigned on every shift.
ER.3.1 The nurse manager in charge of the emergency department is a qualified registered nurse with bachelor degree
in nursing and appropriate education, training, and experience in emergency care.
ER.5.1 Nursing staff in the emergency department receive training and education as relevant to the scope of services.
ER.5.2 There is ongoing competency assessment for the nursing staff.
ER.5.3 The competency assessment of the nursing staff is documented.
ER.15.2 The ambulance services are supervised by emergency department director or emergency department nursing
manager
RD.1.1 The head of the radiology department is a radiologist qualified by education, training, and experience.
RD.2.2 Staff working in the department are trained and qualified in their field.
BC.1.1 The clinical services in the burn care unit are led by a qualified plastic surgeon with interest/experience in
burn care.
BC.3.1 Clinical staff members in the burn care unit are qualified in the care of burn patients.
BC.3.2 Clinical staff who participate in providing care for burn patients are certified in advanced life support for the
different age groups.
BC.4.1 The nurse manager in charge of the burn unit is a qualified registered nurse with training, education, or
experience in burn care.
BC.11.1 Nursing staff in the burn care unit receive training and education that include , but is not limited to the
following:
BC.11.1.1 Use of pulse oximetry.
BC.11.1.2 Principles of infection control.
BC.11.1.3 Use of the defibrillator.
BC.11.1.4 Knowledge of the dosage, side effects, and complications of commonly used high alert
medications.
BC.11.2 There is ongoing competency assessment for the nursing staff (e.g., written test, return demonstration).
BC.11.3 The competency assessment of the nursing staff is documented.
ORT.1.1 The individual(s) responsible for the oncology and radiotherapy services is qualified by education, training,
and experience in the fields of oncology/radiation oncology.
ORT.3.2 Staff are trained and qualified in their fields.
ORT.3.3 Clinical staff maintain registration with the Saudi Commission for Health Specialties.
ORT.4.1 The nurse manager is a registered nurse qualified by education, training, and experience in the field of
oncology/radiotherapy.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
ORT.9.1 The nursing staff receive training and education that are necessary for the provision of effective and safe care
including, but are not limited to:
ORT.9.1.1 Central and peripheral venous access device.
ORT.9.1.2 Care of tracheostomies.
ORT.9.1.3 Chest tube management.
ORT.9.1.4 Advanced medication administration, including targeted therapy, chemotherapy,
immunotherapy, and hormonal therapy.
ORT.9.1.5 Line management including extravasations.
ORT.9.1.6 Radiation side effects management.
ORT.9.1.7 Assisting and preparing for lumber puncture.
ORT.9.1.8 Assisting in intrathecal administration of chemotherapy.
ORT.9.1.9 Infection control, including hazardous material and blood spill.
ORT.9.1.10 Blood transfusion.
ORT.9.1.11 Use of defibrillator.
ORT.9.2 Nursing staff competencies are assessed and are documented.
RS.1.2 A qualified respiratory therapist with a minimum of bachelor's of science in respiratory care directs the work
of the respiratory care therapists and provides the general administration of the respiratory care services
department/unit.
RS.1.3 A qualified physician (e.g., pulmonologist, anesthesiologist, or intensivist) provides the medical supervision
on the clinical activities of the respiratory care services department/unit.
RS.1.4 Personnel providing respiratory services are trained professionals in respiratory care.
RS.1.5 Clinical staff providing respiratory care services are certified in advanced life support as appropriate to the
age of the patients served and are present on site or at least one certified individual is assigned on every shift.
RS.5.1 Staff members receive ongoing training and education, as applicable, on the unit’s protocols, policies and
procedures.
RS.5.2 Competencies are assessed and results are documented.
DT.1.1 A qualified dietitian supervises all aspects of dietary services in the hospital.
DT.1.2 Services provided by the dietitian include, but are not limited to:
DT.1.2.1 Nutritional screening, assessment and reassessment of patients.
DT.1.2.2 Development of nutritional plan of care.
DT.1.2.3 Highlighting “food-drug interaction” to clinical staff.
DT.1.2.4 Making recommendations related to patient dietary needs.
DT.1.2.5 Nil Per Os (NPO) monitoring.
DT.1.2.6 Education of other health staff, patients, and families.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
DT.1.2.7 Reviewing and updating the dietary manual.
DT.5.2 Therapeutic diets are planned, prepared, and served with supervision or consultation from the dietitian.
SC.1.1 A qualified social worker directs social care services provided by the hospital.
PT.1.1 A physiotherapist qualified by education, training, and experience manages the physiotherapy department.
PT.1.1.1 The department head supervises all aspects of physiotherapy services in the hospital.
PT.1.1.2 The department head develops a written scope of services of the physiotherapy department.
PT.1.1.3 The department head recommends space and equipment to meet the scope of services.
PT.1.2 Staff members are qualified by appropriate education, training, and experience in physical rehabilitation.
DN.1.1 The head of the dental department is a dentist qualified by education, training, and experience.
DN.2.1 Dentists perform dental treatments and procedures within their approved privileges.
DN.2.2 Qualified dental technicians are available as needed.
MOI.5.2 The data management education/training is appropriate to the staff roles and responsibilities within the
hospital.
MOI.6.8 Staff responsibilities to maintain confidentiality of data and information are defined (e.g., signing a
confidentiality agreement).
MR.1.1 The health information management (Medical Records) department is directed by individual qualified by
education (bachelor in health information management) and experience.
MR.1.2 The department director is credentialed in health information management through formal training as per the
national/international guidelines.
MR.1.4 Staff working in the department are credentialed in health information management through formal training
as per the national/international guidelines.
MR.1.5 Clinical coding staff working in the department are credentialed/certified in clinical coding through formal
training as per the national/international guidelines.
MR.1.6 The department has one or more staff members who are credentialed in Clinical Documentation Improvement
(CDI) through formal training as per the national/international guidelines.
MR.5.3 Clinical staff authorized to make entries in the medical record receive formal training in clinical
documentation improvement as per the national/international guidelines.
IPC.2.1 The infection prevention and control Program is supervised by a healthcare professional qualified by
education, training and experience.
IPC.2.3 The supervisor of the infection prevention and control program is responsible for managing and strategizing
the infection prevention and control program, including:
IPC.2.3.1 Developing the annual infection prevention and control plan and assuring its implementation.
IPC.2.3.2 Reviewing the daily activities of the structure responsible for infection prevention and control
(e.g., infection prevention and control department or team).

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
IPC.2.3.3 Ensuring coordination of all aspects of the infection prevention and control activities.
IPC.2.3.4 Ensuring effective implementation of infection prevention and control policies.
IPC.2.3.5 Ensuring that healthcare associated infection surveillance is conducted in a systematic
manner.
IPC.2.3.6 Providing ongoing consultation to all hospital departments.
IPC.3.2 The infection prevention and control practitioners are qualified in infection prevention and control practices
by education (physician, registered nurse, or certified professional in infection prevention and control),
training or experience.
IPC.3.3 The infection prevention and control practitioners acquire and maintain current knowledge and skills in the
field of infection prevention and control and epidemiology.
IPC.8.1 The hospital provides continuing education for relevant staff on:
IPC.8.1.1 Hospital wide policies, procedures, and practices of the infection prevention and control
program.
IPC.8.1.2 Departmental policies, procedures, and practices of the infection prevention and control
program based on the service provided.
IPC.8.3 New staff receive an orientation to the hospital's infection prevention and control policies and procedures upon
hiring. Training records are maintained in their files.
IPC.19.1 The supervisor of the central sterilization service has experience, knowledge, and certification in sterilization
practice and is registered with the Saudi Commission for Health Specialties as a central sterilization service
technician.
IPC.19.2 Central sterilization service staff are qualified by education, certification, or training in the field of sterilization
and disinfection.
MM.2.2 The head of pharmaceutical care is a licensed pharmacist, qualified by education, training, and experience.
MM.2.3 The head of pharmaceutical care has a valid professional registration with the Saudi Commission of Health
Specialties and Ministry of Health practice license in Saudi Arabia, as applicable.
MM.2.4 The authorities and accountabilities of the head of the pharmaceutical care is clearly delineated in a job
description and updated every three years.
MM.3.1 The pharmaceutical care department has adequate number of staff qualified by education, training, and
experience.
MM.3.3 The staff responsible for intravenous admixtures, parenteral nutrition, chemotherapy, and drug information
services have appropriate training and competency assessment.
MM.3.4 The quality coordinator has appropriate certification/training.
MM.3.5 There is a structured orientation program where new staff are briefed on pharmaceutical care and relevant
aspects of the facility to prepare them for their roles and responsibilities.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
MM.3.6 There is a process to ensure that the new employee's competency is evaluated before allowed to work
independent
MM.3.7 There are continuing professional development activities for all pharmaceutical care staff.
MM.26.3 Sterile compounded preparations are performed in the clean room by pharmaceutical care staff, qualified in
intravenous admixture and aseptic technique.
MM.26.4 The hospital provides and documents training and competency assessment of non-pharmaceutical care staff
involved in compounding sterile preparations outside the pharmaceutical care department during emergency
or urgency situations.
MM.27.3 The hospital permits only pharmaceutical care staff qualified in aseptic technique and parenteral nutrition to
prepare parenteral nutrition products.
MM.28.3 The hospital permits only pharmaceutical care staff qualified in chemotherapy compounding to work in the
chemotherapy compounding area
MM.28.14 Relevant staff are trained on the proper handling of chemotherapy spills.
MM.36.2 Qualifications, experiences, and competency assessments of individuals involved in drug administration are
available in their personnel files.
LB.3.1 The laboratory services are provided by staff qualified by education, training, and experience.
LB.3.2 The laboratory director, sections’ heads and supervisors are appropriately qualified according to the
complexity of laboratory scope of services.
LB.3.2.1 The laboratory director of a high complexity laboratory (laboratories of tertiary care
hospitals/referral facilities or laboratories providing anatomical pathology and/or transfusion
medicine services) is a licensed/registered anatomical or clinical pathology consultant (board
certified or equivalent).
LB.3.2.2 The laboratory director of a moderate or low complexity laboratory (laboratories with no
anatomical pathology and transfusion medicine services) is a licensed/registered clinical
scientist or laboratory specialist.
LB.3.2.3 The sections’ heads/supervisors are qualified (by education, training and experience) in the
discipline of their assigned sections.
LB.3.2.4 The laboratory staff participate in relevant hospital committees.
LB.5.1 The laboratory implements an orientation, training and competency assessment program that ensures:
LB.5.1.1 Satisfactory completion of training program for all lab personnel in their assigned area.
LB.5.1.2 Training on new equipment or method.
LB.5.1.3 Competency assessment of all laboratory personnel before working independently and
annually thereafter.
LB.5.1.4 Corrective action plan and reassessment in the event of unsatisfactory performance.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
LB.5.1.5 Utilization of the appropriate competency assessment tools, including technique observation
for technical competency, assessment of personnel’s knowledge about the contents of the
procedures and instruments operation manuals (written/verbal exam), and assessment of
personnel’s problem solving skills (unknown samples
LB.5.1.6 Laboratory personnel performing tests or tasks requiring color discrimination undergo a color
discrimination test.
LB.17.2 The laboratory has safety and infection control training program that includes:
LB.17.2.1 Initial training and competency assessment.
LB.17.2.2 Annual training, recertification and competency assessment.
LB.22.1 The laboratory has policies and procedures on proper sample handling, transporting, and tracking. This covers:
LB.22.1.1 Packing instructions (use of biohazard leak-proof containers).
LB.22.1.2 Personnel training (including safety and proper packaging).
LB.22.1.3 Specimen tracking system.
LB.28.2 The laboratory assigned a qualified individual as POCT coordinator.
LB.39.1 There is a policy and procedure for venipuncture site preparation to reduce the risk of bacterial contamination
of the collected blood/blood component that includes:
LB.39.1.1 Detailed and appropriate procedure for the collection site preparation.
LB.39.1.2 Regular assessment of personnel competency on proper venipuncture site preparation.
LB.39.3 The blood bank has sufficient provisions for providing appropriate care for blood donors during and after the
procedure
LB.39.3.1 Donors are given proper written post donation instructions.
LB.39.3.2 Supplies and equipment needed for donors’ care are available.
LB.39.3.3 Personnel are trained and competent in recognition and handling of adverse donor reactions.
LB.39.3.4 Personnel have valid basic life support certification.
FMS.1.5 There is an orientation program conducted for new hires on the facility management and safety plans.
FMS.2.2 The program director is qualified by education (e.g., bachelor’s degree in engineering science), training, and
experience in healthcare facility management and safety.
FMS.2.3 The program director is assisted by qualified staff (e.g., safety officer) as required, according to the size and
complexity of the hospital services.
FMS.9.4 Staff handling nuclear materials are qualified and certified by King Abdul-Aziz City for Science and
Technology.
FMS.13.2 The security personnel have written job descriptions.
FMS.13.3 The security personnel receive orientation about:
FMS.13.3.1 Scope of work and job description.

of 134
Sub-Std
No.
Sub-Standard PF
(1)
PF
(2)
PF
(3)
PF
(4)
PF
(5)
PF
(6)
PF
(7)
PF
(8)
PF
(9)
PF
(10)
AVG
FMS.13.3.2 Emergency codes.
FMS.13.3.3 Fire safety.
FMS.14.1 There is a written hazardous materials plan that includes the following:
FMS.14.1.1 Appropriate handling, storing, transporting, and disposing of hazardous materials.
FMS.14.1.2 Education and training on signs and symptoms of exposure to hazardous materials and the
appropriate treatment according to Material Safety Data Sheets (MSDS).
FMS.15.3 Staff (including contractors’ staff) are trained on dealing with hazardous waste.
FMS.16.4 There is an orientation on the external disaster plan for new hires with an annual update for all staff.
FMS.25.5 The hospital ensures that all maintenance works are conducted by qualified and trained staff.
FMS.25.8 There is an equipment recall system that is implemented.
FMS.28.1 The hospital has adequate number of qualified staff to manage the utility system.
FMS.29.2 The hospital ensures all maintenance works are conducted by qualified and trained staff.
FMS.34.1 There is a periodic preventive maintenance (PPM) plan for heating, ventilating, and air-conditioning (HVAC)
that is supported by trained and specialized staff/contractor.
FMS.37.1 There is a periodic preventive maintenance plan (PPM) for the water system that is supported by trained and
specialized staff/contractor.

Cbahi hospital accreditation guide october 2016

More Related Content

What's hot

Similar to Cbahi hospital accreditation guide october 2016

More from Badheeb

Recently uploaded

Cbahi hospital accreditation guide october 2016