This document summarizes an orientation program at GAHAR Hospital that covers leadership and workforce requirements. The agenda includes reviewing GAHAR's leadership manual, job descriptions, strategic planning policy, and workforce requirements. For leadership, the manual, job descriptions, strategic planning components, and related policies are presented. Workforce topics include staffing plans, recruitment, credentialing, competencies, privileging, employee manuals, bylaws, health programs, and training needs. The objectives are to identify and implement GAHAR's leadership and workforce requirements and adopt their implementation.

1. Orientation Program
on GAHAR Hospital
Registration
Requirements

2. IT’S A NEW DAY
EXPECT GREAT THINGS

3. GAHAR
Please
Introduce Yourself

4. CODE OF CONDUCT
Effective
interaction
Keep
Smiling

5. Copyright
Reproduction of this material in whole or in part is
totally prohibited without a written permission
from the General Authority for Healthcare
Accreditation & Regulation (GAHAR).

6. GAHAR 6
Day 4

7. GAHAR
3/11/2021
AGENDA
7
GAHAR
Day 4
Session1 Session 2
Leadership Requirements:
 Leadership manual
 Leadership Personnel Job
Description
 Strategic planning policy
 Strategic plan components
Workforce requirements

8. GAHAR 8
OBJECTIVES
Identify & implement GAHAR leadership
requirements
Identify & implement GAHAR workforce
requirements
By the end of this training day each participant will be
able to:
Adopt the implementation of GAHAR
leadership & workforce requirements

9. GAHAR
Session 1
Day 4

10. GAHAR
GAHAR
Leadership Requirements

11. GAHAR
Leadership Manual including
1
a. Administrative:
I. Hospital –Mission, Vision & Values Statement
II. Hospital Organizational Chart
III. Leadership Structure
IV. Leadership Responsibilities
V. Standards of Patient Service
VI. Plan for the provision of Patient Care & Services
VII.Culture of Safety & Quality
VIII.Leadership Support of Quality Initiative
IX. Monitoring & Improvement Activities
X. Administrative Call

12. GAHAR
Leadership Manual including
1
X. Budget Process
XI. Orientation of Top Management & Senior
XII. Medical Staff
XIII. Confidentiality of Information –General Rules
XIV. Community Needs Assessment
XV. Information management plan
XVI. Release of Patient Information to News Media
XVII.Financial Incentives & Clinical Decision Making
XVIII.Dress code
XIX. Disruptive & Inappropriate Behavior

13. GAHAR
Leadership Manual including
1
b. Ethics:
I. Research Conduction Guidelines
II. Conduction of Clinical Research
III. End of Life Issues and Care for Dying Patient
IV. Sexual Harassment
V. Conflict of Interest

14. 2
Code of
conduct
3
Organizational
ethics
4
Departmental
leadership policy
5
Requirements, responsibilities
& appointment of all
hospital leaders

15. 6
Governance
Policy
7
Strategic &
operational
plans
8
Contract
monitoring
9
Quality, patient safety & risk
management plan/s
10
Key performance
indicators:
a. Policy
b. indicators

16. 11
Hospital wide
committees
Structures &
functions
12
Training program of hospital
leaders including not
limited to:
a. Quality concepts, skills and tools.
b. Problem solving
c. Conflict resolution
d. Team management
e. Communication skills
f. Data management (as related)
g. Change management

17. GAHAR
GAHAR
Leadership Personnel
Job Description

18. Medical
Director
Head of
Department
Director Quality
Management Department
Director of Infection
Control Department
Deputy- Chief of Medical
Records
Risk Management &
Safety Manager

19. Chief of Medical
Record Department
Chief of Laboratory &
Pathology Department
Chief of Laboratory
Technician
Chief of Radiology
Department
Chief Radiographer
Chief X-ray Technician

20. Chief of Pharmacy
Department
Assistant Chief of
Pharmacy
Chief of Laboratory
Technician
Chief of Radiology
Department
Chief Radiographer
Chief X-ray Technician

21. Deputy Director of
Nursing
Director of
Nursing
Head Nurse
Nursing
Supervisor
Head Nurse
Head of
Technicians

22. 22
‫العام‬ ‫المدير‬
‫للمستشفى‬
‫المناوب‬ ‫المدير‬
‫للمستشفى‬
‫المالي‬ ‫المساعد‬
‫واالداري‬
‫إدارة‬ ‫رئيس‬
‫الخدمة‬
‫االجتماعية‬
‫قسم‬ ‫رئيس‬
‫االتصاالت‬
‫اإلدارية‬
‫رئيس‬
‫التغذ‬ ‫قسم‬
‫ية‬
‫قسم‬ ‫رئيس‬
‫الصيانة‬
‫قسم‬ ‫رئيس‬
‫العيادات‬

23. 23
‫إدارة‬ ‫مدير‬
‫المرضى‬ ‫عالقات‬
‫نظم‬ ‫إدارة‬ ‫مدير‬
‫المعلومات‬
‫الخدمات‬ ‫مدير‬
‫المساندة‬
‫الشئون‬ ‫مدير‬
‫والمتاب‬ ‫القانونية‬
‫عة‬
‫أمن‬ ‫مدير‬
‫شئون‬ ‫مدير‬
‫الموظفين‬
‫العام‬ ‫المدير‬ ‫نائب‬
‫للمستشفى‬

24. GAHAR
Activity

27. GAHAR 27
Session 2
Day 4

28. GAHAR
GAHAR
Strategic Planning Policy

29. GAHAR
Policy
The hospital will carry out a strategic planning
every three to five years to gather data &
intelligence for future planning &
implementation activities
The organization will develop and/or revise its
strategic plan at least every three to five years to
define its direction & identify specific strategic
goals to achieve the plan

30. Departments:
All hospital disciplines & functions

31. Definitions
To guide the development of the hospital’s
strategic planning cycle and strategic plan

32. Strategic goals
The specific goals to be achieved. These are few
in number, high level, & represent significant
achievements

33. GAHAR 33
Responsibilities
 The Board of Directors will consult
with stakeholders, scan the
environment, & develop & approve
the strategic plan with support from
the general manager & senior
management. The Board of Directors
will also monitor achievement of the
strategic plan
 The general director supports the
development of the strategic plan by
directly assisting the Board of
Directors in the strategic planning
process

34. GAHAR 34
Responsibilities
 Staff will support the general
director
 External stakeholders will be invited
to provide input into the
environmental scan & strategic
plan

35. GAHAR 35
Procedures
 The Board will identify & document
actions and resources required to
achieve the strategic goals
 The Board will monitor achievement
of the strategic plan
 The strategic plan may be adjusted
or fine-tuned based on changes in
the external environment and
corresponding strategic goals

36. GAHAR 36
Procedures
 The Board will review the current
situation and how it came about
 The Board will scan the external and
internal environments to determine
strengths and weakness internally
and potential opportunities and
threats externally
 The Board will identify a limited
number of strategic goals, and these
will form the basis of the written
strategic plan

37. GAHAR
Strategic Plan & its Components

38. Strategic Plan Preparation Team
Hospital Vision
Hospital Mission
Hospital Values
SWOT Analysis
Goals
Objectives

39. GAHAR
Action Plan

40. GAHAR
Polices &
Procedures
 Governance Policy
 Guidelines For Review Approval of
Organizational Chart
 Leadership Manual – Update
 Organization Ethics
 Quality management & safety
patient plan
 Risk program
 Staffing plan

41. GAHAR 41
Polices &
Procedures
 Code of Conduct
 Committee structure & function
 Contract monitoring
 Department leadership policy
 Departmental chart of radiology
department
 Development of Key Performance
Indicators

42. GAHAR
Workforce Requirements

43. Staffing plans
(Departmental &
hospital wide )
1
Process of
Recruitment
2
Credentialing process
3
Competency assessments
a. initial and ongoing
b. specialized services
competency assessments
4
Privileging process
5

44. Employee Manual including not limited to
the following processes :
a. assignment & reassignment
b. staff appraisal
c. Staff complaints
d. Staff satisfaction (staff retention)
e. Code of conduct
f. Disciplinary actions
g. Termination
6

45. Medical Staff Bylaws
7
Nursing Staff Bylaws
8
Staff health program
9
Job descriptions
a. policy
b. forms
10
New employee
orientation program:
a. policy
b. forms
11

46. Personnel file:
a. Initiation
b. Management
c. Contents
d. Update
e. Retention time
f. Disposal
12
Identification of staff
training &
educational needs.
13
Ongoing scheduled
educational program.
14
Basic and advanced
life support
certification
(as related)
15

47. GAHAR
Activity

48. 48

49. Wrapping Up
Learning Moments

50. GAHAR
Wrapping up of the
Training Program

51. GAHAR
Evaluation

52. THANK YOU
HAVE A NICE DAY