مشروع المعايير الوطنية المتعلقة بوحدات ومراكز متلازمة الجلطة القلبية

​PR. 1. Program Pre-Certification Requirements 

PR. 1. The hospital is accredited by The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). 

1. The accreditation remains valid for at least 6 months at the time of the certification survey.

2. The hospital has submitted a successful interim assessment report within the preceding year of certification survey, if it has been operational for more than a year.

3. The hospital complies with CBAHI's rules and regulations for accreditation maintenance.

4. Hospitals seeking CBAHI certification shall meets all licensing requirements to provide ACS service and are valid, as indicated by the statutes and regulations of the Ministry of Health and other relevant national regulatory authority.

5. Hospitals seeking CBAHI certification must submit a complete an application form.​

Specific ACS certification requirements 

1. The hospital is part of an ACS network.

2. No refusal policy to accept ACS patients in transfer.

3. 24/7 Cardiac Cath lab operation for both diagnostic and therapeutic coronary procedures.

4. Is part of a national coronary artery disease registry, and periodically submits the required minimum dataset.

PR. 2. Registration Requirements

​PR.2. The ACS program has essential settings to manage ACS patients.

1.The program has an emergency room.

2. The program has access to a comprehensive radiology department.

3.. The program has access to a comprehensive clinical laboratory service.

4. The program has dedicated general cardiology ward. 

5. The program has dedicated cardiac critical unit /intensive care unit and a monitored step-down unit.

6. The program has a cardiac rehabilitation unit/service on-site or outsourced.

7. The program has an outpatient preventive cardiology clinic.

8. A Cath lab service is available.

PR. 3. Certification background services information

PR.3. The hospital is actively participating in ACS care to its community. In the year preceding the certification survey, the number of patients who were:

1. Admitted through the emergency department.

2. Transferred from other facilities.

3. Received through the red crescent or by personal means.

4. Underwent diagnostic Coronary Angiography (CAG) procedures 

5. Underwent percutaneous coronary interventions (PCI) 

6. Underwent primary (PCI).

7. Received rehabilitative services:

8. Referred to higher facilities.

PR. 4. Pre-Requisite- Survey Information

1. The hospital and ACS program organizational chart 

2. The hospital and ACS program scope of service

3. The hospital and ACS program mission and vision

4. The hospital strategic plan and program operational plane.

 ACS center Hub 

1. Has at least two Cardiac catheterization laboratories.

2. Perform a minimum volume of 200 PCIs annually, of which 36 are primary PCIs.

3. Has a minimum of 3 full time consultant interventional cardiologists (IC), all formally certified and credentialed by SCHCS in IC.

4. Has a minimum of five (5) consultant cardiologists in the department. This may inclusive of the three (3) IC consultants.

5. Has at least one cardiology specialist on-call in-house 24/7

6. Availability of onsite cardiac surgery 

7. Is the final destination for essential services for the care of ACS patients.

 ACS center Spoke.

1. Has at least one cardiac catheterization laboratory.

2. Does not fulfil PCI volume requirement of a Hub.

3. Has a minimum of 2 full time consultant interventional cardiologists (IC), all certified by SCHCS in IC.

4. Has at least one cardiology specialist on-call in-house 24/7.

5. Lack of on-site Cardiac surgery but has off-site backup active agreement.

6. Is not required to be a final destination for essential services for the care of ACS patients.

7. Spoke hospitals must have an agreement with a recognized Hub hospital for managing ACS patients, to accept patients in transfer whenever the need arises.

​The program management chapter focuses on the roles and responsibility of the program leaders in the provision of reliable, timely and safe services. The standards are organized as follows:

- Roles and responsibilities of the program director.

- Roles and responsibilities of the program leadership.

- Availability of qualified and competent staff.

- Patients flow throughout the facility; from the time they enter until they are discharged /transfer.

- Supply chain management 

- Role of the leaders in developing and leading the quality improvement and patient safety programs.

- The facilitative role of the appointed quality staff.

- The execution of the quality management and patient safety program 

- The management of safety incidents, adverse events and near misses

- The execution of the risk management program 

- Community and patient-centered care

- The motivation programs.

- The published research.

- Continuous medical training and education program calendar to all the hospitals in its network

- Tele-ACS services

- Registration of ACS population and services provided.

- The participation in national and international ACS data registries.

PM.1. Qualified program director effectively manages the ACS service.

PM.1.1. The program director is a SCFHS-certified interventional cardiologist with a minimum of 3 years' experience in in the care of ACS patients. 

PM.1.2. The program director balances the interrelationships among access, quality, safety, cost, resource allocation, accountability, ACS care setting, community need and professional roles.

PM.1.3. The program director defines, requests, organizes and and monitors all required resources to meet the patient needs.

PM.1.4.  The program director uses data sets to assess performance, establish targets, monitor indicators and trends, and determine if deliverables are met.

PM.1.5. The program director ensures that patient's and family's rights and responsibilities are upheld and mutely respected and to manage violations if any.

PM.1.6. The program director recommends to the hospital director and/or its delegated authority the appointment of qualified individuals, to effectively manage unit's functions. 

PM.2. The ACS program director ensures availability of qualified and competent staff for the delivery of reliable timely and safe care.

PM.2.1. The program director ensures total number, type, level, skill mix and credentials of required staff, based on professional practice recommendations if available, to match patient needs.

PM.2.2. The program director assures ACS staff development., and ensures qualified staff have relevant and current licensure. competencies, experience, orientation, training, and education.

PM.2.3. The program director ensures all medical independent practitioners' practice only within their approved current assigned clinical privileges.

PM.2.4. The program director encourages and facilitates the use of research, evidence, and best practices information. 

PM.2.5. The program director evaluates the competency, performance, professional conduct of all his staff, and the quality and safety of the service they provide, in line with their job descriptions and privileges and manages the underperformance.

PM.3. The ACS program steering committee ensure the provision of reliable, timely and safe ACS service.

PM.3.1. The ACS program director forms and leads an ACS program steering committee.

PM.3.2 The steering committee meets at least monthly.

PM.3.3. The steering committee fosters alignment and synchronization between different ACS services and integrate all organizational services involved in the management of ACS care.

PM.3.4. The ACS program steering committee ensures that protocols, clinical practice guidelines, standards that govern program's clinical operations and planning of individual care are shared as part of ACS network cooperated alliances.

PM.3.4.  The ACS program steering committee receives and resolves, patient and non-patient related ethical dilemmas, within identified timeframe.

PM.3.5. The meeting minutes reflect the overall services' performance and highlights the progress in the operational plan's execution and clinical and non-clinical issues related to the work.

PM.3.6. Discussions, decisions, and actions taken are documented in a formal meeting minute.

PM.3.7. The ACS program director summarizes the ongoing discussions on the program's resources and plans to the hospital director and/or its delegated authority.​

PM.4. The ACS program optimizes patients flow throughout the hospital from the time they arrive until they leave.

PM.4.1. The ACS program director works collaboratively with hospital leadership to develop a map addresses all parts of patient's journey. 

PM.4.2. The ACS program director selects representatives from relevant clinical services as liaison officers based on staff knowledge and experience and/or contribution to facilitate the agility of ACS patients' journey.

PM.4.3. The ACS program director analyzes function, volume, movement pattern, resource distance travelled, patient demands and throughput time to drive size, space and units' adjacencies and layouts. 

PM.4.4. The ACS program identifies and overcomes all obstacles, in the patients' journey. 

PM.4.5. The ACS program matches capacity in line with demand and responds dynamically to changes in demand.

PM.4.6. The ACS program director works collaboratively with hospital leadership to reduces waiting time, backlogs, avoidable admissions, length of stay, improves the net response time, as well as the patient planning process for transfer or discharge.

PM.5.0. The ACS program manages the supply chain in a cost-effective manner.

PM.5.1 The ACS program director works collaboratively with hospital leadership to effectively manage the down -up sided supply chain, to achieve timelines and efficiency of inputs, warehousing, and distribution. 

PM.5.2. The ACS program director works collaboratively with hospital leadership to adhere supply to procurement regulations in terms of contract management and tendering guidelines.

PM.5.3. The ACS program director works collaboratively with hospital leadership to manage the interface between links and logistics of supply chain services within the organization and the program as well.

PM.5.4. The program director ensures optimal use of the supply within the program by the end operators out of over, under and misuses.

PM .5.6. The ACS program has contingency plans, to manage failures or interruptions if any.

​

PM.6, The ACS program enhances social and community participation in ACS healthcare services.

PM. 6.1. The ACS program considers the perspective of the community as partners in healthcare decision-making processes, respecting expectations.

PM. 6.2. The ACS program identifies the relevant community key stakeholders, including transport authorities and local governments to undertake accessibility planning and how they meet the current and future of ACS health care needs.

PM. 6.3. The ACS program with relevant stakeholders ensure a range of services is available locally for people to choose from as possible as they can. 

PM.6.4. The ACS program coordinates with the community key stakeholders to improve the public awareness of the ACS risk factors and early symptoms of ACS.

PM.6.5. The ACS program evaluates and utilizes stakeholders' inputs to guide decision making and the provision of health services.

PM.7. The ACS program provides the community with information on its services and its accessibility.

PM.7.1. The ACS program provides the community through different means with an appropriate format and understandable information on its scope of services and when and how to access including after hour or in an emergency.

PM.7.3. The ACS program supplies the healthcare community providers with information on how to refer its ACS patients, and types of patient conditions that can appropriately treated.

PM.7.3. Patients and their families/care givers and the general community have a user-friendly access to information about health and healthcare services using different communication means. 

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PM.8.The ACS program provides on going community education to improve the public awareness of the risk factors and early symptoms of ACS. 

PM.8.1. Appropriate education resources are made available and accessible. Patients and family/ and general community as well can friendly access different means.

PM.8.2. All relevant departments participating in the care of the ACS patient are prepared and participate in providing community education. 

PM.8.3. The ACS program ensures the community members receive education to maintain and improve their own health and wellbeing.

PM.8.4. Education focuses on prevention, early presentation, and risk reduction.

PM.8.5. The ACS program conducts training for wider range of organizations that encounter ACS patients.

PM.8.6. The ACS program conducts onsite / offsite educational activities / workshops targeting its objectives. Biannually by Hub and yearly by Spoke.

PM.8.7. The on-going community education is evaluated for its effectiveness and improvements are planned accordingly. ​

PM.9. The ACS program develops an effective policy and procedure to guide the management of patients /service users' complaints, concerns, and suggestions, 

PM.9.1. The policy and procedure clarify mechanism for receiving patients/service users' complaints, concerns and suggestions and making them publicly available.

PM.9.2. The ACS program assigns a specific unit or person responsible for recording and managing patients /service users' complaints, concerns, and suggestions.

PM.9.3. The ACS program ensures that quality improvement initiatives are patient centric and are guided by analyzed data.

PM.9.4. Patients /service users receive feedback about their complaints concerns and suggestions within a defined timeframe.​

PM.10. The ACS program seeks feedback from patients and service users regarding the services provided.

PM.10.1 The ACS program conducts direct patients/service users interviews at the provision point, focus group, ‎telephone calls and the appropriated social media.

PM.10.2. The ACS program conducts patients/service user's satisfaction surveys on a regular basis.

PM.10.3. The ACS program evaluates the patient's/service users' feedback and make improvements based on the feedback trended results.

​PM.11. The ACS program director appoints qualified quality staff to support the quality of provided services.

PM.11.1. The quality staff support implementation of relevant hospital-wide quality management and patient safety plan, including risk management program.

PM.11.2. The quality staff support and facilitate the design and execution of staff educational calendar on quality improvement methodologies, tools, performance measurement and risk management.

PM.11.3. The quality staff support the ACS program in designing a balanced set of measures that cover all essential aspect of ACS care. 

PM.11.4. The quality staff support the ACS program in integrated data collection, aggregation, validation, analysis, and interpretation of data.

PM.10.5. The quality staff support the ACS program in prioritizing performance improvement activities including projects.

PM.11.6. The staff functions as the liaison officer with the hospital’s quality improvement and patient safety program.

PM.12. A multidisciplinary quality and risk management committee oversees the quality of service.

PM.12.1. Committee members are selected from clinical and non-clinical ACS program staff and support services.

PM.12.2. The committee chairman is one of the program consultants knowledgeable in quality and risk management tools by education and training.

PM.12.3. The committee meets at least quarterly and as needed to oversee quality improvement.

PM.12.4. The committee is responsible for developing and evaluating the quality and risk management and any corrective actions taken to address any deficiencies.

PM.12.5. The committee designs a tracking tool to monitor the implementation of the quality improvement plans.

PM.12.6. Discussions, and actions taken are documented in a formal meeting minute.

PM.12.7. The committee chairman report to the program ’s director discussions, decisions and actions taken.​

PM.15. The ACS program prioritizes and selects a set of indicators that focus on the essential structures, processes and outcomes of the services provided.

PM.15.1. The selection and prioritization indicators are based on standardized criteria.

PM.15.2. The ACS program develops a set of indicators cover the essential structures, processes and outcomes of the services provided.

PM.15.3. The indicators’ data are collected, aggregated, validated, analyzed following the hospital wide framework.

PM.15.4. The indicators’ results are discussed with staff and reported monthly to hospital leadership along with action plans taken for improvement.

PM.15.5. The indicators are benchmarked internally by historical trends to identify deficiencies and opportunities for improvement.

PM.15.6. The indicators are benchmarked externally with recognized national and international program. and make it public.

PM.16. The ACS program implements and monitors a comprehensive quality management and patient safety program in line with hospital quality and patient safety program. 

PM.16.1. The ACS program leaders develop quality management and patient safety program collaboratively and allocate responsibilities and resources.

PM.16.2. The ACS program covers all services provided and focuses on essential safety requirements in alignment with the 2030 kingdom’s vision and national safety initiatives. 

PM.16.3. The ACS program utilizes key performance indicators, surveys, audits, peer reviews, feedback, risk assessment, safety incidence, complaints, and suggestions for prioritizing quality improvement projects.

PM.16.4. The ACS program utilizes an evidence-based quality improvement methods and tools. 

PM.16.5. Quality and patient safety information is readily accessible in a timely manner to those responsible ‎for and/or involved in the delivery of the services and is utilized for making improvements and supporting the leaders’ decision making.

PM.16.6. The ACS program implements at least two improvement projects for hub center and at least one project for spoke center per year, based on prioritization. 

PM.17. The ACS hub designs and executes a continuous medical training and education calendar and disseminates it to all the hospitals in its network.

PM.17.1. The hub center designs training and education calendar based on training and educational needs assessment.

PM.17.2. The Training and the education include on-site or remote training, workshops, lectures, cases study, morbidity & mortality rounds and journal clubs.

PM.17.3. The hub center uses direct physical and virtual means.

PM.17.4. The hub center assesses training and education quality and needs continuously through direct and indirect feedbacks and takes actions accordingly.

PM.18. The ACS Hub provides secure tele-ACS services to other hospitals in its network to ensure integrated ACS care, whenever the need arises.

PM.18.1. The tele-ACS services cover hospitals in its network and EMS as well.

PM.18.2 The ACS Hub ensures the privileging of the involved physicians.

PM.18.3. The ACS Hub develops a process for secure storage of data and information.

PM.18.4. The ACS Hub monitors information security, confidentiality and integrity and takes actions on the areas of improvement.

PM.19. The ACS center participates in research activities.

PM.19.1. The ACS center develops or contributes to at least 2 research projects for Hub and at least 1 for spoke per year.

PM.19.2. The hospital research committee or similar structure oversees all research activities.

PM.19.3. The research activities are compliance with regulatory, professional requirements, selection criteria, code of conduct, appropriateness, and safety.

PM.19.4. The ACS center implements the research outcomes to improve its services.

PM.20. The ACS center maintains a register for its population and services provided.

PM.20.1. The register contains patients’ demographics.

PM.20.2. Each patient is registered with the disease specific code and procedure code.

PM.20.3. The register is shared with relevant authorities as per national regulations.

PM.21.The ACS center actively participates in national and international ACS data registries.  

PM.21.1. The ACS center has current report in ACS national data registries.     

 PM.21.2. Hub center has current risk adjusted outcomes comparable to those reported in benchmarked with international data registries. 

PM.21.3. The ACS program continuously evaluates the gap of its reported outcomes in comparison with the national and international benchmarks.

PM.21.4. The ACS program utilizes the result of evaluation to improve ACS services.

​The chapter covers the sequential fashion of the patient's journey. The chapter includes the following:

- Accessibility and obtainability to care

- The referral and the transferal

- The layout, structure and function facilitate delivery of reliable, timely and safe care to patients.

- The emergency rooms. 

- Availability of radiology services and reporting

- The assessment / reassessment of patients

- The plan of care

- The general cardiology wards.

- The cardiac critical /intensive care unit.

- The rehabilitation services.

- Secondary prevention

- The continuity and coordination of patient care services

- Monitoring morbidities and mortalities

- The discharge

​Availability and equity of care

PC.1. The ACS services are accessible and obtainable in an equitable manner, to all patients whose medical needs can be met within the capability of the ACS program.

PC.1.1. The ACS program informs patients about how to access care, treatment, and services, including after hours or in an emergency.

PC.1.2. Timely access to and appropriateness of care and treatment are available to all patient out of any discrimination. 

PC.1.3. The ACS program ensures that all relevant services for its targeted population are available.

PC.1.4. Acuity of the patient's condition determines the resources allocated to meet the patient's needs.

PC.1.5. The ACS program provides care, treatment, and services to patients in a planned and timely manner.

PC.1.6. The level and quality of care provided to patients is consistent throughout the ACS program.

PC.2. The hospital's layout, structure and function facilitate the delivery of reliable, timely and safe care to patients.

PC.2.1. The hospital's layout optimizes flow of patients between cardiac critical unit /intensive care unit, emergency room, radiology department, cardiac and operating room.

PC.2.2. The program dedicated units including the CCL, the diagnostic coronary angiography (CAG) suite has appropriate design, function, and safe facilities in accordance with applicable national and international guidelines. 

PC.2.3. The diagnostic radiology, the laboratory tests, and other required investigations are ease accessible and obtainable in identifiable time, whenever the need arises. 

PC.3. The ACS program's emergency room is designed, equipped, and has qualified and competent staff to manage ACS patients. 

PC.3.1. The emergency room is in an accessible location to its staff.  

PC.3.2. The emergency room has nominal and has a surge capacity management planning to meet any changes in demand, including staff, equipment, medical devices, medications, and consumable materials required to meet the patient demands. 

PC.3.3. The emergency room is covered by a certified consultant ER physician and nurse with knowledge and experience in managing ACS patients.

PC.3.4. The emergency room maintains on-call schedule for consultant cardiologist, consultant interventional cardiologist, cardiology specialist, and catheterization laboratory staff coverage.  

PC.4. The ACS program uses clinical pathways and protocols to guide the process of providing effective emergency car to ACS patients.

PC.4.1. The ACS program implements a standardized protocol in accordance with the national ACS guidelines for the immediate triaging and management of a suspected ACS patient.

PC.4.2. The ACS program utilizes an evidence-based chest pain management pathway.

PC.4.3. The ACS program uses a protocol to rapidly diagnose an ACS patient by performing of a 12-lead ECG with the goal of completion within 10 minutes of first medical contact.

PC.4.4. The ACS program uses a protocol for a STEMI alert/call system for prompt activation of the STEMI/catheterization laboratory team.

PC.4.5 The catheterization laboratory on-call team arrives on site within 30 minutes of STEMI activation.

PC.4.6 The Cath lab is accessible within 15 minutes, whenever the need arises in the emergency room.

PC.4.7. The Hub ACS center ensure that a Spoke center, has access to the on-call schedule of the Hub ACS center and clear communication channels for timely transfer of an ACS patient.

PC.4.8. Pathway performance is monitored by the ACS quality and steering committees on regular basis, and intervention and corrective action plans are documented.

PC.5. The radiology department is fully equipped for a spectrum of diagnostic procedures and has qualified and competent staff to meet the ACS patients' needs.

PC.5.1. The radiology department is fully equipped for a spectrum of diagnostic procedure to match the ACS patients' needs.

PC.5.2. Qualified and competent staff perform, evaluate, and report the procedure.  

PC.6. The clinical laboratory is fully equipped for a spectrum of tested procedures and has qualified and competent staff to meet the ACS patients' needs.

PC.6.1. The clinical laboratory department is fully equipped with a spectrum of investigated procedure to meet the ACS patients' needs. 

PC.6.2. Qualified and competent staff perform and report the tests.

PC.7. Multidisciplinary team involved in the management of ACS patients, develops a policy and procedure for the assessment / reassessment of patients.

PC.7.1. The policy defines the scope, content of the assessment, frequency of the reassessment process and the time frame for all disciplines in all ACS care settings, to all ACS patients, including special population. 

PC.7.2. The team utilizes validated assessment and reassessment tools.

PC.7.3. The assessment identifies the patient discharge or referral planning based on the patient’s identified ongoing needs.

PC.7.4. The assessment identifies the risk stratification of patients.

PC.8. The ACS team develops a comprehensive multidisciplinary plan of care, based on assessment findings, and directed by clinical practice guidelines. 

PC.8.1. The plan of care is developed through a collaborative approach between the health care team and is agreed upon by the patient and family.

PC.8.2. The plan of care is based on the assessment findings.

PC.8.3. The plan of care sets desired outcomes that can be measured.

PC.8.4 Patients' needs are reassessed when indicated and care plan is revised and modified accordingly.

PC.8.5. The most responsible physician ensures the relevance and integration of other healthcare givers' plans. 

PC.8.6. Patients' education need is identified and documented in parallel with ACS provided services.

PC.8.7. Care plan is documented for each patient.​

​PC.9. General cardiology ward's design, structure and function facilitate the delivery of reliable, timely and safe care to ACS patients.

PC.9.1. The general cardiology ward has appropriate design, functional areas, and safe facilities in accordance with applicable national and international guidelines.

PC.9.2. The general cardiology ward has nominal and has a surge capacity management to meet any changes in demand, this includes beds, equipment, medical devices, medications, and consumable materials required to meet the patients' needs. (Catalogues)

PC.9.3. The general cardiology ward's beds have the capability of continuously and concurrently monitoring and recording patients' rhythm.  

PC.9.4. A policy in a place to define the type, level, skill mix and ratio of required staff that meet patient needs. (Catalogues)

PC.9.5. Patients are admitted and discharged according to standardized criteria, supported by international guidelines.

PC.9.6. A policy is in a place to clarify the content of patient's assessment and frequency of the reassessment.

PC.9.7. The general cardiology ward has protocols within the ACS management pathway that guide management for ACS patients.

​PC.10. The intensive care unit's design, structure and function facilitate the delivery of reliable, timely and safe care to ACS patients.

PC.10.1. The intensive care unit has appropriated design, functional areas and safe facilities in accordance with applicable national and international guidelines.

PC.10.2. The intensive care unit has nominal and has a surge capacity management to meet any changes in demand, this includes, equipment, medical devices, medications, and consumable materials required to meet the patient demands. (Catalogues)

PC.10.3. The intensive care has policy define the type, level, skill mix and ratio of required staff match patient demands (Catalogues)

PC.10.4. Patients are admitted and discharged according to standardized criteria, supported by international guidelines.

PC.10.5. The intensive care has policy define the most responsible physician while the ACS patient is admitted in the unit.

PC.10.6. The The intensive care unit has protocols within the ACS management pathway that guide management for ACS patients.

​PC. 11. Skilled multidisciplinary team develops a policy and procedure to guide the provision of comprehensive cardiac rehabilitation services.

PC.11.1. The policy defines the admission and discharge criteria for the inpatient and outpatient rehabilitation service.

PC.11.2. The policy defines the components of individualized patient assessment.

PC.11.3. The cardiac rehabilitation services are provided in a timely manner based on individualized patient assessment findings and patient's clinical status.

PC.11.4. The cardiac rehabilitation services encompass dietetics, endocrinology, pharmacy, smoking cessation, psychiatry, and other services as required. 

PC.11.5. The cardiac rehabilitation services provide individualized education and counseling to patient. 

PC.11.6. The comprehensive cardiac rehabilitation services recommend timing for the safe return to normal daily activities and lifestyle modifications. 

​PC.12. The ACS program is active in preventing recurrences and supports patients to pursue an independent healthy lifestyle.

PC.12.1. The program has a well-established multidisciplinary secondary outpatient preventive cardiology clinic protocol. 

PC.12.2 All ACS patients have their risk factors identified and documented.

PC.12.3. All ACS patients have a documented ACS secondary prevention plan based on the identified risks.

PC.12.4. All ACS patients are counselled, and effectively educated towards activities, medications, risk factors modifications and followed up for lifestyle modification.

PC.12.5. Patient and family are actively engaged in the secondary prevention plan.​

​PC.13. The ACS program conduct monthly and as needed mortality and morbidity meetings. 

PC.13.1. All mortality and morbidity cases are reviewed on ongoing basis to highlight avoidable and potentially avoidable cases.

PC.13.2. Morbidity cases are captured from program indicators monitoring and from reports from procedural areas.

PC.13.3. Highlighted cases are distributed among peers before the meeting to identify areas for improvement.

PC.13.4. Shared cases between departments are referred to the medical director to decide on presenting it to the hospital morbidity and mortality committee.

​PC.14. 0. Referral pathway guides patient referral process within the ACS network, based on the patient's health needs.  

PC.14.1. The pathway highlights the patient's acceptance criteria.

PC.14.2. The pathway determines the transfer timeframes as mandated by the nationally approved ACS guidelines.

PC.14.3. The pathway identifies the required essential information communicated and care needed during transfer.

PC.14.4. The pathway defines the operation times of the communication channels to facilitate immediate transfer.

PC.14.5. The pathway determines staff accountability on both ends of the transfer process.

PC.14.6. The pathway addresses the infection prevention and control measures to be followed. 

​PC. 15. indications and criteria initiate transfer process.

PC.15.1. There are capable ambulance services to promptly and safely transfer critical cases guided by the CBAHI standards.

PC.15.2. Patients and their families are involved in the transfer decision and plan of referral.

PC.15.3. The ACS team determines the transportation needs of the patient including the mode of transportation, date, time, and staffing.

PC.15.4. Immediately before the transfer process, the team ensures the availability and functionality of required equipment, communication channel, and availability of medications and readiness of transport staff.

PC.15.5. The patient is monitored during the transfer process and the receiving organization acknowledges the patient's condition upon arrival in the monitoring tool.

PC.15.6. The monitoring tool is kept in the patient's medical record after the transfer.

PC.15.7. The program has a process to provide feedback to concerned emergency medical service agencies and interfacility transport teams within 48 hours.

PC.15.8. The program has a process to provide feedback whenever needed to intra-facility departments and partner hospitals in the ACS network within 24 hours.

PC.15.9. The program has a clear process to Repatriate stable patients who received essential care back to the referring healthcare facility, when deemed safe.

​PC.16. The ACS team discharges patient through an efficient, safe, and timely process.

PC.16.1. The MRP specifies the estimated date and / or time of discharge for each patient preadmission or on their admission and is updated throughout the duration of staying. 

PC.16.2. The MRP decides the identifiable clinical criteria for discharge and ensure the patient's suitability and stability for discharge. 

PC.16.3. Multidisciplinary team assess and revise the actual and potential patient/family needs based on identifiable criteria and develops interventions to meet the needs ahead of the discharge date.

PC.16.4. The team confirms the discharge date for complex cases or bed blocker, period ahead and troubles shoot any challenges the patient may be having and make plans for discharge.

PC.16.5. Follow up plan are arranged to patients and their families prior to discharge and the patient/family are given a copy upon discharge.and educated on it through a patient exit case conference.

PC.16.6 Patients and families could identify and discuss their post- discharge needs.

PC.16.7. All medications and support services necessary for a safe discharge should be organized and documented in the discharge summary.

​PC.17. The ACS program ensures the continuity of care after patient’s discharge or referral. 

PC.17.1. Post-hospital care is coordinated based on the assessment of the patient’s and family’s identified needs.

PC.17.2. The ACS program communicates the patient’s continuing needs including the needed resources bookings to practitioners, who is responsible to continue care of patient.

PC.17.3. When the patient is handed over to the appropriated setting. The ACS program ensures patient is a combined with follow up plan, and early warning signs warranting the patients’ referral back.

 PC.17.4. The patient, family and handed over health care provider are informed about how to obtain help when required.

​The chapter focuses on the availability of qualified and competent staff, and availability of equipment and other essential resources, additional to illustrate how the procedures are performed.

- Management of the activities of a full occupied spectrum of CCL   procedure suite.

-   The diagnostic procedures

- A multi-disciplinary procedure committee oversee the work in the procedure room. 

- The pre -procedure preparation.

- The cardiovascular assessment / reassessment of patients

- Pre- sedation/anesthesia assessment and anesthesia planning

- Monitoring of patients during procedure.

- Post CC procedure assessment and document 

- The recovery and transfer in

- The percutaneous coronary interventional therapeutic procedures 

- The Reporting

- Radiation safety 

Diagnostic and therapeutic coronary procedures 

CCL.1. Qualified staff effectively manages the activities of a cardiac catheterization laboratory (CCL) procedure suite. 

CCL.1.1. An interventional cardiologist/ electrophysiologist with a minimum of   3 years' experience in invasive cardiology direct the CCL procedure suite. 

CCL.1.2. Qualified nurse manager directs the nursing services of cardiac catheterization laboratory (CCL) procedure suite.

CCL.1.3, The procedures are performed and reported by licensed and privileged CCL consultants as primary operators.

CCL.1.4. The procedures are assisted by licensed qualified and competent staff.

CCL.2. The Cardiac Catherization laboratory's   design, structure and function facilitate the delivery of reliable, timely and safe care, to meet patients' needs. 

CCL.2.1. The CCL has appropriate location, design, access control, fittings, fixtures, functional areas, and safe facilities in accordance with applicable national and international guidelines.

CCL.2.2. The angiography is fully equipped for a defined spectrum of diagnostic procedures to meet the ACS patients' needs. (Catalogue)

CCL.2.3. The procedure suite has nominal and has a surge capacity management planning to meet any unusual changes in demand, including equipm​ent, medical devices, medications, and consumable materials required to meet patient needs. (Catalogues). 

CCL.2.4, The CCL has an initial receiving area for patients, and their recovery. 

CCL.2.5. The procedure suite has the essential anesthesia equipment operated by anesthesia consultant. 

CCL.2.6. The procedure suite monitors safety and infection control and prevention standards, as guided by CBAHI.

CCL3. The interventional procedures team develops a manual to guide the care of patients in procedural areas.

CCL3.1. The manual highlights types of the performed procedures.

CCL3.2. The manual describes how patients are safely transported, received, prepared, and monitored inside procedure area, and movement to appropriate bed.

 CCL3.3. The manual describes the peri- procedure routine and special type preparation.

CCL3.4. The manual describes the intra-procedural monitoring of patients with or without anesthesia or sedation.

CCL3.5. The manual highlights the special considerations for procedure involving implantable devices.

CCL 3.6. The manual describes the pathway to verify the correct procedure is performed, for the correct patient, with patient involvement when possible.

CCL4. Multi-disciplinary procedure committee oversees the work in the procedure room.

CCL.4.1. The committee approves all documents required for proper conduct of the work in the procedure room.

CCL.4.2. The Committee reviews the equipment and medical devices maintenances, calibration.

 and quality control. 

CCL.4.3. The committee plans and monitors the implementation of at least two safety improvement projects for Hub center and at least one for spoke center inside procedure room per year.

CCL.4.4. The committee compiles and presents an annual peri-procedure safety report.

​CCL.5. The interventional procedures team develops cardiovascular assessment policy prior to the CC procedure. 

CCL.5.1The policy defines the scope and content of the cardiovascular assessment process to document preprocedural status.

CCL.5.2. The policy clarifies the history and physical examination that obtained within 30 days prior to the procedure and be in the chart and include documentation of relevant laboratory testing, medications, allergies, and bleeding disorders.

CCL.5.3. In emergency situations where a complete medical assessment cannot be documented, a brief note is written by the most responsible physician before performing the procedure.

CCL.6. Pre- sedation/anesthesia assessment and anesthesia planning are conducted by an anesthesiologist, prior to the procedure.

CCL.6.1. The pre-anesthesia assessment results in assigning an anesthesia risk score for the patient as well as the patient's suitability for the type of sedation/anesthesia selected.

CCL.6.2. The pre-sedation/anesthesia assessment is performed within thirty (30) days before the procedure date. 

CCL.6.3. The anesthesia plan is based on the pre-anesthesia assessment findings.

CCL.6.4. The anesthesia plan includes the management of post-operative pain.

CCL.6.5. The anesthesia plan is communicated and agreed upon to both the physician performing the procedure and the patient/family.

CCL.6.6. The anesthesiologist reassesses the patient immediately prior to induction of anesthesia focusing on the physiologic stability and readiness of the patient for anesthesia.

CCL.6.7. The policy describes anesthetic equipment and staffing skills and competency required to manage high risk patient, difficult and failed intubations, malignant hyperthermia, anaphylaxis, local anesthetic toxicity, and massive hemorrhage.

CCL6.8. The policy includes the daily checking of anesthesia equipment.

​CCL7. The interventional procedures team develops a policy to guide appropriated pre- procedure preparation. 

CCL. 7.1. The policy highlights the pre-procedure required investigations, consultations, and patient's preparation.

CCL.7.2. The policy describes specific intra, post procedure and recovery requirements based on exact patient needs.

CCL.7.3 Procedure preparation include appropriate skin preparation for vascular access site and a minimum of one large bore intravenous access.

CCL.7.4 The Procedure preparations includes assessing the readiness of monitoring equipment and emergency cardiovascular surgical backup.

CCL.7.5 The policy designates which procedures require type and crossmatch for the availability of blood products.

CCL.7.6 When applicable, antithrombotic therapy is administered prior to the procedure, during the procedure and after the procedure. 

CCL.7.7. Procedure preparation ensures aavailability of Paddle or self-adhesive external defibrillation pads prior to the onset and for the duration of the procedure.

CCL.7.8. The operator is aware of prior PCI and CABG data and review the associated prior imaging and/or report(s).

CCL.7.9. The operator is aware of all device and lead hardware present, including those in use and previously abandoned.

CCL.8. Protocols guide appropriate peri- procedure of special type preparations. 

CCL.8.1 A protocol clarifies which procedures require special type preparation, 

CCL.8.2.A protocol guides management of anticoagulant patient,

 CCL.8.3. A protocol guides management of patient at high risk of contrast induced nephropathy.

CCL.8.4. A protocol guide management of radiographic contrast allergy, and anaphylaxis.

CCL.9. The CCL team develops an evidence-based policy and procedure for the monitoring of patients during procedure.

CCL.9.1. The level and frequency of monitoring depends on patient's pre-anesthesia status, the type of procedure performed, and the anesthesia / sedation used.

CCL.9.2. Radiation usage monitored during the procedure by the angiographic system and documented in the final procedure report.

CCL.9.3. Adequate anticoagulation should be monitored with activated clotting time (ACT) throughout the procedure whenever unfractionated heparin is used.

CCL.9.4. The monitoring findings and status of the patient at the end of the procedure are documented in the patient's file, before the patient leaves the procedure room.

​CCL.10. The CCL team establishes post cardiac Cath procedure assessment and documentation. 

CCL.10.1 The team perform post-procedure basic cardiovascular evaluation to assess any immediate post-procedure symptoms or complication(s); prior to moving the patient off the table. 

CCL.10.2 A protocol is in place to address and evaluate any post-procedural complication. 

CCL.10.3.  The team assess blood pressure and the status of the puncture site. 

CCL.10.4 The team assess and control heart rate and rhythm.

CCL.10.5. A protocol is in place to address sheath removal and appropriate personnel to manage sheath removal. 

CCL.10.6. Post-procedure note in the patient’s chart is generated summarizing the procedure and addressing any immediate complications and deviation of the patient’s status at the end of the procedure. 

CCL.10.7. Post-procedure cardiovascular assessment report is available within approximately 24 hours and/or prior to discharge.

CCL.11. Post sedation/ anesthesia patients are recovered and discharged to an appropriate setting according to an evidence-based policy and procedure.

CCL.11.1. Patients are continuously monitored during the recovery period according to defined parameters in the policy. 

CCL.11.2. Patients are continually monitored by qualified nursing staff with minimum 1:2 nurse to patient ratio.

CCL.11.3. Time received in the recovery, monitoring findings and the discharge time are recorded in the patient’s file.

CCL.11. 4.. Nursing staff have immediate access to an anesthesiologist in emergency situations.

CCL.11.5. Patients are safely discharged to an appropriate setting based on established discharge checklist criteria with the equipment and trained nursing staff.

CCL.12. Patient’s post- procedure care is planned and documented. 

CCL.12.1. The post-operative plan of care is comprehensive and includes procedure, anesthesia nursing, rehabilitation and other disciplines as required.

CCL.12.2. The post-procedure plan of care is dynamic and may change according to the reassessment findings from the team.

CCL.12.3. Immediate post-procedure instructions are written by the primary operator or designee before the patient leaves the recovery room.

​CCL13.The ACS program performs effective percutaneous coronary interventional therapeutic procedures based on prioritization of needs and identified patient risks.  

CCL.13.1. Performance of PCI is based on patient’s needs and clinical risk of ACS adverse outcomes and is directed by ACS clinical practice guidelines.

CCL.13.2. The procedures are done by a licensed and privileged consultant interventional cardiologist as a primary operator. and assisted by qualified and competent staff. 

CCL.13.3. The ACS program maintains a report showing the total number, types, staff response time, the appropriateness, the outcomes of PCI procedures. and the cancellation with the reasons behind if any.

CCL.13.4. The ACS program ensures meeting the procedure volume requirements in accordance with published standards of ACS care and ACS network.

CCL.13.5. The ACS program establishes improvements based on findings analysis

​CCL.14. The CCL standardizes reporting interpretation and formats, including Pre-procedural, Procedural and Post-procedural data.  

 CCL.14.1. Preliminary reports and/or post-procedural note(s) issued by the performing physician address and communicate any significant changes between the preliminary and final reports.

CCL.14.2. Physician-authored procedure reports contain complete information regarding all components of the procedure and is documented in the patient's file.

CCL.14.3. The anesthesiologist documents all aspects of the procedure relating to anesthesia or sedation, and the patient's response in the patient's file.

CCL.14.4. The nursing or technical record include all technical aspects of the procedure.

CCL.14.5. A summary of the results of the procedure, including any positive and negative findings or adverse outcomes.

CCL.15. The CCL standardizes diagnostic criteria and the content of study report. 

CCL.15.1. The report is free of internal inconsistencies and accurately reflect the content and results of the study.

CCL.15.2. The study report includes any pertinent positive and negative findings particularly those relative to the indication for the exam.

CCL.15.3. The study report includes demographics summary of the technical aspects of the procedure.

CCL.15.4. The study report includes summary of the results of baseline adult diagnostic catheterization testing.

CCL.15.5. The study report clarifies any need for additional studies and/or procedures based on the results of the procedure being reported.

​ACS:    Acute Coronary Syndrome

ACT:     Activated coagulation Time

ARF: Appeal Request Form. 

CABG: Coronary artery bypass graft

CAP: Corrective Action Plan. 

CBAHI: Saudi Central Board for Accreditation of Healthcare Institutions.

CCL:     Cardiac Catheterization Laboratory

DAP:     Dose Area Product

HCF: Health Care Facility.

 IC :     Interventional Cardiologists

(ISQua): International Society for Quality in Healthcare.

MOH:    Ministry of Health.

PCI:       Percutaneous Coronary Intervention

PDA: Preliminary Denial of Accreditation.

PPE:     Personal Protective Equipment

RCA:     Root Cause Analysis.

SAT:     Self-Assessment Tool.

SCAI: Society of Cardiovascular Angiography and Interventions

SERF:    Sentinel Event Reporting Form.