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LD.1. A qualified hospital director is responsible for managing the hospital.
LD.1.1 The hospital director has a good command of the Arabic and English language.
LD.1.2 The hospital director ensures the hospital's compliance with Saudi mental health acts, other relevant laws and regulations.
LD.1.3 The hospital director participates actively in supporting the safety of patients, staff and visitors.
LD.1.4 The hospital director ensures the hospital's compliance with scope of services approved by the governing body.
LD.1.5 Hospital director ensures availability of hospital's set of values and the code of conduct describes the hospital's expectations of the staff regarding their behavior and communication with each other and with their patients and other external customers.
LD.1.6 The hospital director ensures availability of qualified duty manager with a job description to coordinate the care during off duty hours
LD.2 Hospital leaders work collaboratively to establish medical and nonmedical hospital committees that support integration of services and communication amongst staff.
LD.2.1 Hospital director in charge of establishing hospital committees.
LD.2.2 Medical committees provide oversight on specific areas of responsibilities that include:
LD.2.2.1 Psychiatric patients' rights committee.
LD.2.2.2 Technical medical committee.
LD.2.2.3 Forensic psychiatry committee (for forensic service)
LD.2.2.4 Pharmacy and therapeutics.
LD.2.2.5 Morbidity and mortality.
LD.2.2.6 Infection control.
LD.2.2.7 Cardio pulmonary resuscitation.
LD.2.2.8 Credentialing and privileging.
LD.2.2.9 Quality and patient safety.
LD.2.2.10 Medical records review.
LD.2.2.11 Utilization review.
LD.2.3 Hospital director ensures annual review of each committee's accomplishments and non-resolved issues submitted by the committee chair to the executive management.
LD.3 Hospital director ensures there is a system for the safe management of medical supplies and devices.
LD.3.1 Medical supplies and devices are stored safely and in accordance with manufacturer's recommendations.
LD.3.2 Medical supplies and devices are protected against theft, damage, contamination, or deterioration.
LD.3.3 Hospital leaders ensure the reporting of adverse effects resulting from the use of medical supplies and devices to the relevant regulatory authorities.
LD.3.4 The hospital has a process for safe segregation and disposal of expired, damaged, or contaminated medical supplies and devices.
LD.4 Each clinical and administrative department is directed by a qualified individual.
LD.4.1 Each department has an assigned department head.
LD.4.2 Qualifications, experience, and training of the appointed department head match the services provided by the department.
LD.5 The department head ensures the work of the department is guided by a set of departmental policies and procedures.
LD.5.1 Each department maintains a manual for all relevant policies and procedures.
LD.5.2 The department work collaboratively to develop multidisciplinary policies and procedures.
LD.6 The department head ensures sufficient resources and staffing are available for the delivery of safe and quality service.
LD.6.1 The department head defines and requests the resources required by the department for a safe and quality service.
LD.6.2 The department head ensures the provision of orientation, training, and continuing education for the staff working in the department.
LD.6.3 The department head monitors the performance of the staff.
LD.7 The department head ensures performance measurement and improvement of the outcomes of the department.
LD.7.1 Performance measurement and improvement are consistent with the hospital wide quality improvement, patient safety, and risk management plans.
LD.7.2 Performance measurement and improvement are based on the important processes and priorities of the department.
LD.7.3 The department head selects and monitors the appropriate performance indicators.
LD.7.4 Performance measurement and improvement involve regular data collection and analysis and appropriate improvement actions/projects.
LD.7.5 Results of performance measurement and improvement are reported periodically to the hospital leadership and shared with staff, departments, and committees as applicable.
HR.1 Human resources department in collaboration with heads of departments develop, implement, and monitor departmental staffing plans
HR.1.1 The staffing plan defines the number, type, and qualifications of staff required and their job responsibilities.
HR.2 The hospital maintains personnel files for all employees.
HR.2.1 The hospital has a policy guiding the initiation, management, content update, and retention time and disposal of personnel files.
HR.2.2 Personnel files are kept confidential and only those who are authorized can access them.
HR.2.3 Personnel files contain the following:
HR.2.3.1 Qualifications; including current licensure, certification, or registration, if applicable.
HR.2.3.2 Job description defines the roles and responsibilities signed by the staff member.
HR.2.3.3 References.
HR.2.3.4 Orientation, continuing education, and training records.
HR.2.3.5 Performance evaluations.
HR.2.3.6 Records of leave and sickness.
HR.2.3.7 Disciplinary actions, if any.
HR.2.3.8 Other documents as required by relevant laws and regulations.
HR.3 The hospital has a process for proper credentialing of staff members licensed to provide patient care.
HR.3.1 The hospital has a written policy describing the process used for the verification of credentials.
HR.3.2 The hospital gathers, verifies, and evaluates the credentials (license, education, training, certification and experience) of health professionals licensed to provide patient care.
HR.3.3 Credentials are verified from the original source.
HR.3.4 The hospital ensures the registration of all healthcare professionals with the Saudi Commission for Health Specialties.
HR.3.5 Staff licensed to provide patient care must always have and maintain a valid license to practice only within their profession.
HR.3.6 When verification of credentials is conducted through a third party, the hospital must request for a confirmatory documentation.
HR.3.7 Verification process applies to all clinical staff categories (full time, part time, visitor, and locum).
HR.4 New employees go through a general hospital orientation program before allowed to work independently.
HR.4.1 New employees, contract workers, students, and volunteers go through a general orientation program that provides the relevant initial training and information on the following:
HR.4.1.1 Hospital mission, vision, values, and organizational chart.
HR.4.1.2 Role of staff members in all programs related to facility management and safety.
HR.4.1.3 General information on infection control.
HR.4.1.4 General information on the paging and telephone system.
HR.4.1.5 General information on staff evaluation process.
HR.4.1.6 Definition of adverse and sentinel events along with the process of reporting.
HR.4.1.7 Hospital policy on abuse and neglect of children and adults.
HR.4.1.8 Hospital policy on credentialing and privileging.
HR.4.1.9 General information about staff health program.
HR.4.1.10 General information about important local cultural and social themes.
HR.4.1.11 General information about the hospital-wide quality, patient safety, and risk management plans.
HR.4.1.12. General information about Saudi mental health care act.
HR.4.1.13 Ethical conduct and expected professional communication with patients and
colleagues.
HR.4.1.14 Patient rights.
HR.5 New employees go through a departmental and job orientation program before allowed to work independently
HR.5.1 The departmental and job orientation program is defined in a departmental policy and includes the following:
HR.5.1.1 Departmental policies and procedures.
HR.5.1.2 Specific job responsibilities within the department as outlined in the job description.
HR.5.1.3 Safe operation of equipment and medical devices including troubleshooting and malfunctions reporting.
HR.5.1.4 Clarification on all topics provided in the general orientation as needed.
HR.5.2 Additional orientation is provided upon changing the job description or introducing a new technology or equipment.
HR.6 The hospital has a process for initial/ regular evaluation and competency of the staff.
HR.6.1 All new employees go through a probationary period for competency evaluation. During this period, clinical staff can only work under direct supervision.
HR.6.2 The competency evaluation is documented in the personnel file.
HR.6.3 There is a policy describing the process used in the regular evaluation of staff performance.
HR.6.4 The performance evaluation is based on objective criteria and is linked with the job description.
HR.6.5 The performance evaluation is a two-way process conducted at least annually.
HR.6.6 The outcome of the performance evaluation is used to set objectives for performance improvement and professional development.
HR.6.7 The performance evaluation is signed by both the employee and the supervisor and is documented in the personnel file.
HR.7 The hospital supports continuing education for all staff members.
HR.7.1 The hospital grants financial support and time off for staff to attend educational activities.
HR.7.2 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.8 The hospital has a program that addresses staff health and safety.
HR.8.1 The hospital has a staff health and safety program covering all staff members.
HR.8.2 The program is based on assessment and where necessary, reduction of occupational health and safety risks.
HR.8.3 The program is coordinated with the hospital's quality, safety, risk management, and infection control programs.
HR.8.4 The program includes, but is not limited to, the following:
HR.8.4.1 Pre-employment medical evaluation of new employees.
HR.8.4.2 Response to the health problems of the employees through direct treatment or referral.
HR.8.4.3 Response to the safety issues such as aggression, and homicidal behaviors of patients through immediate preventions, assessment, management and/or reporting & referral.
HR.8.4.4 Periodic medical evaluation of staff members.
HR.8.4.5 Screening for exposure and/or immunity to infectious diseases.
HR.8.4.6 Staff preventive immunizations.
HR.8.4.7 Management of exposure to blood borne pathogens and other work-related conditions.
HR.8.4.8 Measures to reduce occupational exposures and hazards, including the use of protective equipment and clothing, stress management, and ergonomics.
HR.8.4.9 Staff education on the risks within the hospital environment as well as on their specific job-related hazards.
HR.8.4.10 Documentation and management of staff incidents, injuries or illnesses, taking corrective actions, and setting measures in place to prevent recurrences.
HR.8.4.11 There is appropriate record keeping and management (e.g., employee health records that are filed separately).
HR.9 The hospital has a process for handling staff complaints and dissatisfaction.
HR.9.1 The hospital has a policy for handling staff complaints and dissatisfaction.
HR.9.2 Staff members are aware of the procedure to be followed to bring forward a complaint or a dissatisfaction issue.
QM.1 The hospital has an incident (occurrence/variance) management mechanism that supports improvements of care processes.
QM.1.1 There is a policy and form that are utilized for reporting incidents including adverse events and near misses.
QM.1.2 The hospital defines reportable incidents such as assault.
QM.1.3 Incidents are reported and investigated in a timely manner.
QM.1.4 Immediate remedial actions are taken as well as actions to prevent recurrence of similar incidents.
QM.1.5 Incidents are monitored over time and the resulting information is used for improvement.
QM.1.6 Staff are educated on the incident reporting process.
QM.2 The hospital has a process to handle sentinel events.
QM.2.1 There is a policy for management of sentinel events
QM.2.2 The policy must include the updated list of sentinel events by national regulations.
QM.2.3 Reportable sentinel events are reported to CBAHI within three working days of the internal notification of the event.
QM.2.4 The hospital forms a team to complete the root cause analysis along with an action plan for all sentinel events. The team should bring together those who have an intimate knowledge of the normal process.
QM.2.5 The root cause analysis and risk reduction plan are sent to CBAHI within thirty working days from the date of the internal notification of the event.
QM.2.6 Reportable sentinel events are reported as required to other relevant authorities.
QM.3 The hospital develops and maintains a patient safety program
QM.3.1 Hospital leaders provide direction and resources to support the patient safety program.
QM.3.2 The hospital assigns a qualified individual to provide coordination and supervision of the organization-wide patient safety program.
QM.3.3 Hospital leaders establish a multidisciplinary patient safety committee (can be integrated with quality improvement committee) to provide direction and oversight of the patient safety program.
QM.3.4 Hospital leaders conduct regular leadership patient safety rounds in patient care services to encourage reporting of incidents/near misses and to identify potential risks and hazards.
QM.3.5 The hospital adopts safe practices that have been proven to improve patient safety and reduce harm to patients.
QM.3.5.1 The hospital develops and implements policies, procedures, protocols, and guidelines for implementation of the patient safety practices.
QM.3.5.2 The hospital provides equipment/devices with technological features proven to reduce errors and improve safety.
QM.3.6 Relevant information developed from patient safety activities is integrated into quality improvement and risk management activities.
QM.3.7 Patient safety activities and their results are communicated to the staff and other relevant groups and used as the base for improving the hospital's processes.
QM.4 The hospital has a process to ensure correct identification of patients.
QM.4.1 At least two patient identifiers (e.g., patient full name and medical record number) are required whenever taking blood samples, administering medications, or performing procedures.
QM.4.2 The hospital has a standardized approach to patient identification (e.g., use of ID bands with standardized information).
QM.4.3 Patients are actively involved in the process of patient identification.
QM.5 The hospital ensures availability and safety of infusion pumps.
QM.5.1 Infusion pumps are available with adequate numbers throughout patient care areas.
QM.5.2 Infusion pumps have "free-flow" protection.
QM.5.3 Infusion pumps have documented preventative maintenance, inspection and testing on a regular basis.
QM.6 The hospital ensures the safety of the alarm systems of patient care equipment.
QM.6.1 All alarm systems for patient care equipment (such as infusion pumps and monitors) have documented preventative maintenance, inspection and testing on a regular basis.
QM.6.2 All staff are trained on the safe use of alarm systems for patient care equipment and the use of appropriate settings for sound.
QM.7 The hospital ensures appropriate communication of patient care information during patient handovers.
QM.7.1 Patient care information is appropriately documented in an understandable form to all care providers within and between care settings.
QM.7.2 The hospital implements a standardized approach to handover communication between staff (e.g., Situation, Background, Assessment, Recommendation-SBAR), change of shift, and between different patient care units in the course of a patient transfer.
QM.8 The hospital has a process for effective identification, assessment, and intervention for patients who are at risk for fall and suicide
QM.8.1 Patients are assessed for the risk of fall and suicide on admission.
QM.8.2 Patients are reassessed for the risk of fall after a change in risk factors (e.g. after receiving sedating medications) and upon transfer from another unit.
QM.8.3 The hospital implements evidence-based interventions for falls and suicide reduction according to the risks identified.
QM.9 The hospital implements evidence-based interventions to prevent catheter and tubing misconnections.
QM.9.1 Patients and families are informed not to connect or disconnect devices or infusions.
QM.9.2 High-risk catheters must be labeled.
QM.9.3 All lines (tubes or catheters) are always traced from the patient to the point of origin before connecting any new device or administering medications or infusion.
QM.9.4 All lines (tubes or catheters) are always traced from the patient to the point of origin upon the patient's arrival to a new setting or service as part of the hand-off process. The hospital standardizes this "line reconciliation" process as part of the hand-over communication.
QM.9.5 The hospital prohibits the use of standard luer-connection syringes for oral medications or enteric feedings.
QM.10 The hospital has a policy on verbal or telephone orders and telephone reporting of critical test results.
QM.10.1The complete verbal or telephone order or critical test result is written down by the receiver of the order or test result.
QM.10.2 The complete verbal or telephone order or critical test result is read back by the receiver of the order or test result.
QM.10.3 The order or test result is confirmed by the individual who gave the order or test result.
PFE.1 The hospital leaders support patient and family education.
PFE.1.1 The hospital develops policies and procedures to ensure effective patient and family education process.
PFE.1.2 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., highly cautious psychotropics and its use).
PFE.1.3 The hospital provides different teaching methods for the health education process such as pamphlets, diagrams, models to practice on, videos, or other teaching methods.
PFE.1.4 The job description of the clinical staff (e.g. nurses, physicians, dietitians) reflects their role in patient/family education.
PFE.2 The hospital leaders ensure proper communication between the health educator and the patient/family.
PFE.2.1 Patient/family education is provided in an easy language understandable by the patient/family.
PFE.2.2 Sufficient time is provided to allow the patient to understand the information provided and interact with the health educator.
PFE.3 Each patient's educational needs are assessed and planned.
PFE.3.1 Staff conduct educational needs assessment for every patient by:
PFE.3.1.1 Assessing learning needs.
PFE.3.1.2 Assessing literacy skills.
PFE.3.1.3 Assessing caregiver/patient's readiness and ability to learn.
PFE.3.1.4 Assessing patient's capability and motivation to provide self-care.
PFE.3.1.5 Assessing caregiver/patient's appropriate educational materials and methods that meet their learning skills.
PFE.3.1.6 Assessing who will provide care after discharge (caregiver and/or patient).
PFE.3.2 Staff use the assessment findings for planning and delivery of education as appropriate to the plan of care.
PFE.3.3 Staff provide the caregiver/patient with educational materials that meet their learning skills (e.g. written and verbal notes, pictures, demonstration).
PFE.3.4 When the patient is unable/unsuitable to learn education is provided to the family or the caregiver.
PFE.4 Patients and their families are given the necessary education and information by clinical staff and health educators as appropriate to their needs.
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.4.4 The hospital provides the patient with the necessary education and information about:
PFE.4.4.1 Primary illness and all possible complications
PFE.4.4.2 Required treatments and procedures.
PFE.4.4.3 Appropriate and safe use of the medical equipment or appliances.
PFE.4.4.4 Rational and benefits of any dietary restrictions.
PFE.4.4.5 Conditions in which the patient needs to seek medical assistance and how to access it if necessary.
PFE.4.4.6 How to carry out activities of daily living.
PFE.4.4.7 Community resources for additional care and how to access emergency services if necessary.
PFE.4.4.8 Psychotropics or controlled medications.
PFE.4.4.9 Any psychiatric interventional procedure and its benefits and potential risks.
PFE.4.4.10 Post-intervention care.
PFE.4.5 The hospital ensures that the patient has his follow up clinic appointments.
PFE.4.6 The hospital ensures that the patient can always state the name of his most responsible physician.
PFE.4.7 Clinical staff and health educators obtain feedback from the patient and/or family to ensure proper understanding (e.g., demonstrates learning, verbalizes understanding).
PFR.1 Hospital leaders support and protect the patient and family rights.
PFR.1.1 Hospital leaders establish and maintain a structure that involves hospital's leaders and others to support and oversee all patient rights activities through psychiatric Patients' Rights Committee.
PFR.1.2 Patients and families have an access to communicate their concerns/inquiries regarding their rights.
PFR.1.3 Hospital leaders develop and maintain patient rights and responsibilities statement that includes all patient and family rights and responsibilities.
PFR.1.4 The hospital develops and implements policies and procedures that protect and support the implementation of patient and family rights.
PFR.1.5 The hospital makes patient rights and responsibilities available to patients and families in a format and language they can understand (e.g., providing patient rights and responsibilities document or posting in the patient's room and public places throughout the hospital).
PFR.1.6 The hospital ensures that patients and substitute decision maker are informed about their rights and responsibilities and accessibility to report their complaint regarding involuntary admission and/or treatment and sign the required form.
PFR.1.7 The hospital educates staff on their responsibilities regarding patient and family rights (e.g., during orientation as well as refresher courses).
PFR.1.8 Staff are aware of their responsibilities in protecting patient and family rights.
PFR.2 Cultural, psychosocial, religious, and spiritual needs of patients are respected and supported.
PFR.2.1 The hospital recognizes and provides staff training on responding to patient's cultural, psychosocial, religious and spiritual beliefs, values and needs.
PFR.2.2 The hospital provides separate facilities for women where appropriate.
PFR.2.3 The hospital provides access to spiritual care or advice that meets the needs of the different populations served.
PFR.2.4 Staff members provide care to patients with respect and dignity.
PFR.3 Privacy of patients is maintained throughout the care process.
PFR.3.1 Patient privacy is respected during all interviews, examinations, and treatments.
PFR.3.2 Patient private parts are not exposed unnecessarily during care process.
PFR.3.3 The hospital mandates a written consent to photograph patients.
PFR.4 The hospital protects patient belongings.
PFR.4.1 There is a process described in a policy for the protection of patient belongings.
PFR.4.2 Patients receive information about the hospital's responsibility for safeguarding and protecting their belongings.
PFR.4.3 When the hospital assumes responsibility for safeguarding patient belongings, the hospital has a process to protect them from theft or loss.
PFR.4.3.1 The hospital defines where the patient belongings are kept.
PFR.4.3.2 The hospital defines who is responsible for obtaining the required signatures on the related form when receiving and handing over the patient's belongings.
PFR.4.4 The hospital addresses how the valuables of those patients unable to make decisions regarding their belongings (e.g., mentally incapable patients, elderly and children) are handled and safeguarded.
PFR.5 The hospital provides protection for patients.
PFR.5.1 Patients are protected from neglect and abuse by physicians, nurses, or any other staff.
PFR.5.2 The hospital provides appropriate security and prevents unauthorized access to remote or sensitive areas (e.g., female wards).
PFR.5.3 The hospital has a process in place to protect vulnerable patients (e.g. children, disabled and elderly patients).
PFR.6 The hospital provides assistance to patients with special needs.
PFR.6.1 The hospital provides the necessary assistance to patients with special needs where and when needed (e.g., providing assistance in case of fire, off-street parking spaces near the entrance for disabled patients, handicapped accessible bathrooms, accessibility for wheelchair users).
PFR.7 The hospital respects and protects patient health information confidentiality throughout the care process.
PFR.7.1 The hospital implements a policy that ensures the confidentiality of information related to the patient's health and how to protect it from loss or misuse.
PFR.7.2 The policy indicates the circumstances under which such information may be released and how to obtain patient's permission if required.
PFR.8 The hospital assists patients and their families to participate in making informed decisions about the care process, treatment and services.
PFR.8.1 Patients/ legal representatives are informed about how they can actively participate in their care decisions.
PFR.8.2 Patients' choices are respected.
PFR.8.3 Staff members provide patients and, when appropriate, their families with honest, accurate and reasonable information in a manner they can understand about their illness, the proposed treatment and other alternatives, potential benefits, potential complications and likelihood of success of treatment.
PFR.8.4 When it is medically inadvisable to provide the patient with such information, the information is provided to a legally authorized body or a person designated by the patient.
PFR.8.5 Patients or substitute decision maker are supported to discuss their plans of care with the responsible staff members and have all their questions answered.
PFR.8.5.1 The patient is provided with the name and the professional status of the physician or other professional who has the primary responsibility for managing the care process.
PFR.8.5.2 Staff members identify themselves by introduction and by displaying the name.
PFR.8.6 Patients are informed of how to contact care providers in case of emergency.
PFR.8.7 Staff members respond appropriately to patients' requests of a second opinion if necessary.
PFR.8.8 The hospital respects patients' demands and needs including their preferences in personal issues such as food, drink, clothing, and self-care.
PFR.9 Informed consent is obtained prior to needed treatments/procedures.
PFR.9.1 The hospital has a policy and form(s) for obtaining the informed consent from the patient or a legal representative prior to starting high risk treatments and procedures.
PFR.9.2 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.9.3 The informed consent is always obtained before any invasive surgery/ procedure, sedation/ anesthesia, and transfusion of blood and blood components.
PFR.9.4 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.10 The hospital has a process to deal with patients who refuse or discontinue the treatment.
PFR.10.1 There is a policy and procedure that addresses the patient's right to refuse or discontinue treatment offered.
PFR.10.2 The consequences of treatment refusal are explained to the patient.
PFR.10.3 Patients are informed about available care and treatment alternatives.
PFR.10.4 Whenever appropriate, family members are involved in the process according to medical consent manual.
PFR.10.5 Patient and family choices are respected.
PFR.11 The hospital informs patients about their responsibilities.
PFR.11.1 Patients are provided with appropriate information regarding their responsibilities.
PFR.11.2 Patient responsibilities require the patient to:
PFR.11.2.1 Provide complete and accurate information about his health, including medications, dietary supplements, and any allergies.
PFR.11.2.2 Follow the plan of care prescribed by his provider.
PFR.11.2.3 Be respectful to all staff as well as other patients.
PFR.11.2.4 Be respectful to the hospital policies and procedures (e.g., visiting hours, no smoking policy, use of electrical appliances, and safety of belongings).
PFR.11.2.5 Be responsible for the safe use of the hospital's facilities and equipment.
PFR.12 The hospital has an effective process to seek feedback and respond to patient complaints.
PFR.12.1 There is a policy and procedure for the fair management of patient complaints in a reasonable timeframe.
PFR.12.2 The hospital assigns a specific unit or person (e.g., patient relations) responsible for managing patients' complaints.
PFR.12.3 The hospital conducts patient satisfaction surveys on a regular basis.
PFR.13 The hospital has an effective system for clinical research activities.
PFR.13.1 The hospital implements policies, procedures, and code of ethics for the selection and participation of patients in research activities.
PFR.13.2 The policies and procedures that guide experimental research activities are in accordance with laws and regulations, professional standards, and codes of conduct.
PFR.13.3 The hospital has a research committee or another structure to oversee all research activities and ensure their appropriateness and safety.
PFR.13.4 Informed consent is obtained before entering in a research protocol.
PFR.13.5 The hospital informs patients of their right to refuse participation in experimental research with no effect on access to care or the quality of care provided and respects their wishes.
PFR.14 Hospital develops and adopts ethical standards in dealing with patients and their supporters and sponsors.
PFR.14.1 Guidance is provided for clinical and non-clinical staff covering patient-care and non-patient care ethical issues.
PFR.14.2 The hospital accurately bills for services.
PFR.14.3 The hospital honestly portrays its services to patients.
PFR.14.4 The hospital maintains ethical marketing.
PFR.14.5 The hospital has a process to provide care for impoverished patients presenting with emergent situations.
PFR.14.6 Outcomes of ethical considerations are reviewed and system improvements are made accordingly.
PFR.15 The hospital has a policy and procedure guides the care of vulnerable dependent patients.
PFR.15.1 The hospital has policies to define and guide the care of vulnerable dependent patients (e.g., immune-compromised, elderly and frail, disabled, terminally ill, and children).
PFR.16 The hospital ensures a uniform standard of care to all patients.
PFR.16.1 All patients receive the same standard of care across all hospital settings and departments in accordance with professional standards and applicable laws and regulations.
PFR.16.2 All patients receive the same standard of care at all times (e.g., during working hours, after working hours, during weekends and holidays).
PFR.16.3 All patients receive the same standard of care regardless of race, gender, or religion.
PFR.16.4 All patients receive the same standard of care regardless of their ability to pay or source of payment.
PFR.17 The hospital ensures easy accessibility to care and services.
PFR.17.1 The hospital has a process to minimize language barriers by communicating with patients in their primary language or have interpreter services provided at all times.
SC.1 Patients identified at psychosocial risk undergo comprehensive psychosocial assessment.
SC.1.1 Psychosocial screening is conducted by qualified hospital staff (e.g., registered nurse) to determine the patient's need for comprehensive psychosocial assessment by a licensed social worker.
SC.1.2 Psychosocial assessment is preferably completed by a qualified social worker within twenty-four hours of referral.
SC.1.3 The psychosocial assessment is described in a policy and procedure that defines factors
facilitating/impeding healthcare progress, including:
SC.1.3.1 Emotional, social, and psychological factors.
SC.1.3.2 Home situation.
SC.1.3.3 Financial factors.
SC.1.3.4 Noncompliance to treatment
SC.1.3.5 Physical/mental disabilities.
SC.2 The hospital ensures the provision of effective social care services for inpatients and outpatients.
SC.2.1 Social worker helps patients subjected to abuse, neglect, or violence.
SC.2.2 Social worker assists patients in job-related and school concerns.
SC.3 The social worker documents all relevant patient information in the medical record.
SC.3.1 The social worker documents relevant information in the patient's medical record, which include:
SC.3.1.1 Reason for referral.
SC.3.1.2 Patient/family assessment and reassessment findings.
SC.3.1.3 Plan of care including goals and interventions such as counseling, education, and facilitation of resources.
SC.3.1.4 Evaluation of the plan of care.
SC.3.1.5 Regular progress notes that include the patient/family understanding, care progress, and needs for different or additional services.
MOI.1 The hospital has a process for ensuring confidentiality, security, and integrity of data and information.
MOI.1.1 The policy defines data and information confidentiality, security, and integrity.
MOI.1.2 The policy is in compliance with Saudi mental health care act and related regulations.
MOI.1.3 The hospital defines appropriate levels of security and confidentiality for data and information and provides appropriate confidentiality measures accordingly.
MOI.1.4 Staff access to different categories of information is restricted on a need to know basis.
MOI.1.5 There is an appropriate mechanism for response to requests for access to information.
MOI.1.6 Data and information are safeguarded against loss, destruction, tampering, damage, and unauthorized access or use.
MOI.1.7 There are measures for protecting data and information in the event of a disaster such as flood, fire, loss of power, and abnormal temperature conditions.
MOI.1.8 Staff responsibilities to maintain confidentiality of data and information are defined (e.g., signing a confidentiality agreement).
MOI. 1.9 Information confidentiality and security incidents are reported and acted upon.
MOI.2 The hospital has a policy on the retention and backup of data and information.
MOI.2.1 There is a policy on the retention of data and information that is consistent with relevant laws and regulations.
MOI.2.2 The policy defines the length of time required to retain the data and information.
MOI.2.3 The policy addresses how confidentiality, integrity, and security of the data and information will be maintained during retention.
MOI.2.4 The hospital has a process in place for regular information system data backup and retrieval.
MOI.3 The hospital maintains sufficient provisions that ensure the operation of the information system during scheduled or unscheduled (unexpected) downtime.
MOI.3.1 End-users are trained on procedures to follow during interruptions of the information system.
MOI.3.2 Patient information are documented and reported during the downtime (e.g., reporting laboratory results).
MOI.4 The hospital uses and contributes to comparative reference databases in accordance with national guidelines.
MOI.4.1 The hospital contributes to external databases in accordance with national laws and regulations.
MR.1 A medical record is initiated for every patient.
MR.1.1 The hospital initiates a medical record for each patient on his first contact with the hospital, whether it is for an admission, emergency department or outpatient clinic visit.
MR.1.2 Each medical record is assigned a unique identification number.
MR.1.3 The hospital keeps only one medical record for each patient.
MR.1.4 There is patient identification on each page of the medical record.
MR.2 The hospital maintains a master patient index (either manual or computerized) of all patients who have ever been admitted to or treated by the hospital.
MR.2.1 The master patient index is used to identify a patient's medical record number.
MR.2.2 The master patient index provides basic patient demographic information (identification information collected during the registration process) as well as patient activity (visit) information:
MR.2.2.1 The patient demographic information (identification information) includes: medical record number, patient's full name, date of birth, gender, marital status, address, national identification number, next of kin (and his contacts) and/or a person that the patient wishes to be contacted in an emergency, or authorized representative/designee.
MR.2.2.2 The patient activity (visit) information includes: admission and discharge/transfer dates for inpatient hospitalizations, date of death when a death occurs, encounter date or date of service for outpatient visits, most responsible physician.
MR.2.3 The patient demographic information (identification information) of the master patient index is recorded on the front sheet of the medical record.
MR.2.4 The master patient index is updated for each new episode of care for any change in information.
MR.2.5 The master patient index is retained permanently to provide historical access to basic patient information and dates of stay in the hospital.
MR.3 Medical records contain sufficient information to promote continuity and coordination of care and communication among care providers.
MR.3.1 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.4 The hospital develops and implements a policy for the release of medical records from the medical records department.
MR.4.1 There is a policy that describes the process for the release of medical records for patient care encounters (inpatient, outpatient, and emergency department).
MR.5 The hospital has a complete and accurate medical record for every patient.
MR.5.1 The hospital identifies in a policy all staff members authorized to make entries in medical records.
MR.5.2 All entries in the medical records must be legible, indelibly verified, dated, and authenticated.
MR.5.3 The author of each entry must be identified and authenticated by official stamp, signature, written initials, or computer entry.
MR.5.4 The hospital has a policy to deal with delinquent medical records.
MR.6 The hospital maintains the medical records in one central place.
MR.6.1 The hospital has processes to manage the different parts of the medical records.
MR.6.1.1 The different parts of multiple records are cross referenced to the patient's unique identifier to enable records linkage.
MR.6.1.2 The different parts can be easily located when not stored together.
MR.6.2 The policy addresses how confidentiality, integrity, and security of the records will be maintained during storage.
MR.6.3 Individual medical records are securely compiled.
MR.7 The hospital uses nationally recognized standardized diagnosis and procedure codes.
MR.7.1 The hospital uses the International Statistical Classification of Diseases and Related Health Problems, Updated edition.
MR.7.2 The hospital uses Australian Classification of Health Interventions (ACHI) for procedure coding.
MR.8 There is a process to ensure availability of the medical records in a timely manner.
MR.8.1 Care providers have access to current and past medical records.
MR.8.2 Medical records are readily retrievable for each patient encounter.
MR.8.3 Medical records can be retrieved any time of the day.
MR.9 The hospital has a system to manage voluminous medical records.
MR.9.1 There is a system that enables medical record linkage.
MR.9.1.1 The hospital develops thinning guidelines that remain consistent for the type of documentation contained.
MR.9.1.2 The hospital retains documentation in the medical record that reflects the current plan of care and services provided.
MR.9.1.3 The hospital removes parts of the medical record older than a certain date and moves them into a secondary record (the overflow record).
MR.10 The hospital has a system for the retention of medical records in accordance with laws and regulations.
MR.10.1 The hospital has a policy on the retention of medical records.
MR.10.2 The policy is consistent with laws and regulations.
MR.10.2.1 The medical records are retained for a minimum of ten years after the patient was last seen unless otherwise specified by laws and regulations. For minors, records shall be kept until he/she is eighteen years of age, and then for a minimum additional ten years.
MR.10.2.2 The policy addresses the retention period of the different types of the medical records as well as the permanent types (e.g., medical records, records of medico-legal cases).
MR.10.2.3 The policy addresses the retention period of the different parts of the medical records as well as the permanent parts (master patient index, admission and discharge dates, name of the most responsible physician, diseases treated and operations performed; and a discharge summary for each admission).
MR.10.3 The method used for medical records destruction, when the retention period is complete, renders the information unreadable.
NR.1 Qualified nursing director is responsible for managing nursing services.
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 participates with the other hospital's leaders in the decision-making processes, including planning and budgeting.
NR.1.5The nursing director participates in the hospital's multi-disciplinary structures (e.g., committees such as quality improvement, infection control and pharmacy and therapeutics).
NR.1.6 The nursing director oversees and assures that committee's recommendations are implemented at the nursing level.
NR.2 The nursing director assumes the authority, responsibility, and accountability for assuring proper and effective nursing services.
NR.2.1 The nursing director together with other relevant staff work to develop essential policies and procedures including:
NR.2.1.1 Admission and discharge procedures. NR.2.1.2 Basic hygiene of patients and skin care. NR.2.1.3 Patient and family rights. NR.2.1.4 How to transcribe physician ordersNR.2.1.5 Patient education. NR.2.1.6 General infection control policies. NR.2.1.7 Calling physicians. NR.2.1.8 Patient transfer (internal and external).
NR.2.1.1 Admission and discharge procedures.
NR.2.1.2 Basic hygiene of patients and skin care.
NR.2.1.3 Patient and family rights.
NR.2.1.4 How to transcribe physician orders
NR.2.1.5 Patient education.
NR.2.1.6 General infection control policies.
NR.2.1.7 Calling physicians.
NR.2.1.8 Patient transfer (internal and external).
NR.2.2 The nursing director implements an effective method for organizing the delivery of patient care (e.g. functional, team, primary care).
NR.2.3 The nursing director ensures the implementation of a policy and procedure that defines patient care delivery method(s).
NR.3 Nursing reference manuals and policies are readily available and accessible to all nursing units.
NR.3.1 There are nursing reference manuals and policies that are available and accessible to all nursing units. This includes:
NR.3.1.1 Nursing policies and procedures manual. NR.3.1.2 Current nursing practice manuals/books. NR.3.1.3 Infection control manual. NR.3.1.4 Safety manual or safety policies. NR.3.1.5 Operating manuals for the safe use of equipment. NR.3.1.6 Laboratory services guide. NR.3.1.7 Dietary manual. NR.3.1.8 Material Safety Data Sheet (MSDS).
NR.3.1.1 Nursing policies and procedures manual.
NR.3.1.2 Current nursing practice manuals/books.
NR.3.1.3 Infection control manual.
NR.3.1.4 Safety manual or safety policies.
NR.3.1.5 Operating manuals for the safe use of equipment.
NR.3.1.6 Laboratory services guide.
NR.3.1.7 Dietary manual.
NR.3.1.8 Material Safety Data Sheet (MSDS).
NR.3.2 Policies and content of manuals are implemented as evidenced by the daily practice and the patients' medical records.
NR.4 The nursing director ensures the competency of the nursing staff.
NR.4.1 The nursing director participates in the recruitment of qualified nurses.
NR.4.2 The nursing director monitors the performance of the nursing staff and assures their ongoing
competency through policies and procedures defining nursing competency assessment program
NR.4.3 Nursing competencies to be assessed include:
NR.4.3.1 Monitoring patients' vital signs and knowledge of acceptable deviations from the norm.NR.4.3.2 Mental health assessment/reassessment of patients according to the scope of services NR.4.3.3 Medications administration. NR.4.3.4 Intravenous therapy (insertion, maintenance, discontinuing). NR.4.3.5 Infection control guidelines. NR.4.3.6 Patient falls (assessment of risk and methods to prevent falls). NR.4.3.7 Use of pulse oximetry. NR.4.3.8 Nursing role in cardiac/respiratory arrest. NR.4.3.9 Feeding tubes. NR.4.3.10 Urinary catheters. NR.4.3.11 Sterile dressings. NR.4.3.12 Skin care and prevention and care of pressure ulcers. NR.4.3.13 Nursing role in disaster or fire.NR.4.3.14 Use of restraints and seclusion room.NR.4.3.15 Dealing with violent aggressive behavior and suicidal patientsNR.4.3.16 Operation of blood sugar testing equipment. NR.4.3.17 Managing chemical spills. NR.4.3.18 Blood extraction.
NR.4.3.1 Monitoring patients' vital signs and knowledge of acceptable deviations from the norm.
NR.4.3.2 Mental health assessment/reassessment of patients according to the scope of services
NR.4.3.3 Medications administration.
NR.4.3.4 Intravenous therapy (insertion, maintenance, discontinuing).
NR.4.3.5 Infection control guidelines.
NR.4.3.6 Patient falls (assessment of risk and methods to prevent falls).
NR.4.3.7 Use of pulse oximetry.
NR.4.3.8 Nursing role in cardiac/respiratory arrest.
NR.4.3.9 Feeding tubes.
NR.4.3.10 Urinary catheters.
NR.4.3.11 Sterile dressings.
NR.4.3.12 Skin care and prevention and care of pressure ulcers.
NR.4.3.13 Nursing role in disaster or fire.
NR.4.3.14 Use of restraints and seclusion room.
NR.4.3.15 Dealing with violent aggressive behavior and suicidal patients
NR.4.3.16 Operation of blood sugar testing equipment.
NR.4.3.17 Managing chemical spills.
NR.4.3.18 Blood extraction.
NR.5 Sufficient nurses are available to meet the needs of patients.
NR.5.1 The nursing director develops a staffing plan that maintains an adequate staffing level in all nursing units.
NR.5.2 The staffing plan identifies an evidence-based estimation of the number of staffs needed per shift, considering all relevant factors (e.g., patient acuity, patient care hours, size of the hospital, scope of services provided).
NR.5.3 Nursing staff are allocated according to the skill level, qualifications, patients' volume and acuity, and in accordance with laws and regulations and nursing licensing boards.
NR.6 The nursing department provides regularly updated work schedule.
NR.6.1 There is a nursing scheduling policy that defines:
NR.6.1.1 Duration of working shiftsNR.6.1.2 Assignment of overtime when needed. NR.6.1.3 On-call requirements. NR.6.1.4 Vacation schedules. NR.6.1.5 Method for approving change of schedule. NR.6.1.6 Participation in education/training activities. NR.6.1.7 Participation in designated committees, departmental meetings, and quality improvement activities.
NR.6.1.1 Duration of working shifts
NR.6.1.2 Assignment of overtime when needed.
NR.6.1.3 On-call requirements.
NR.6.1.4 Vacation schedules.
NR.6.1.5 Method for approving change of schedule.
NR.6.1.6 Participation in education/training activities.
NR.6.1.7 Participation in designated committees, departmental meetings, and quality improvement activities.
NR.6.2 The work schedule provides an adequate number of staffs on every shift.
NR.7 There is a process for assignment of nurses out of their normal working areas.
NR.7.1 The nursing director ensures that nurses assigned out of their normal working area have the competency required for safe and effective patient care.
NR.7.2 The nursing director maintains a list of cross-trained nurses and makes it available for all nursing units.
NR.8 Nursing services are provided by qualified nurses.
NR.8.1 The nursing director ensures the availability of adequate number of licensed registered nurses to provide nursing care for all patients.
NR.8.2 Each unit has a head nurse/charge nurse/ nurse manager with the required nursing and managerial experience.
NR.8.3 Nursing services are provided by registered nurses in accordance with their license and scope of practice.
NR.8.4 Qualified registered nurses are readily available to provide bedside nursing care to all patients twenty-four hours a day, seven days a week.
NR.8.5 Nursing assistants or aides are supervised by a registered nurse at all times.
NR.8.6 Nursing assistants have defined job description and responsibilities.
NR.8.7 There is an education program for nursing assistants performing patient-care services to orient them to their role.
NR.9 There is a comprehensive Mental/ physical health nursing assessment for each patient upon admission
NR.9.1 The nursing assessment is timely completed by a registered nurse.
NR.9.2 The scope and content of the mental/physical nursing assessment is defined in hospital policies that include:
NR.9.2.1 History of the patient's main complaint. NR.9.2.2 Drug allergies. NR.9.2.3 Physical condition. NR.9.2.4 Mental status. NR.9.2.5 Pain assessment. NR.9.2.6 Nutritional Status. NR.9.2.7 Discharge planning. NR.9.2.8 Skin assessment. NR.9.2.9 Fall risk assessment.
NR.9.2.1 History of the patient's main complaint.
NR.9.2.2 Drug allergies.
NR.9.2.3 Physical condition.
NR.9.2.4 Mental status.
NR.9.2.5 Pain assessment.
NR.9.2.6 Nutritional Status.
NR.9.2.7 Discharge planning.
NR.9.2.8 Skin assessment.
NR.9.2.9 Fall risk assessment.
NR.10 The nursing department ensures adequate supplies and equipment for the safe and effective provision of care through:
NR.10.1 Equipment and supplies that includes:
NR.10.1.1 Scales appropriate to the age group and mobility needs of the patient. NR.10.1.2 Stretchers with safety straps. NR.10.1.3 Equipment for taking vital signs. NR.10.1.4 Wheelchairs with safety straps. NR.10.1.5 Sharp boxes. NR.10.1.6 Foot stools. NR.10.1.7 Lifting devices. NR.10.1.8 Soft restraints. NR.10.1.9 Bed rails. NR.10.1.10 Devices for treatment and prevention of skin break down. NR.10.1.11 Patient call bell. NR.10.1.12 Oxygen and suction. NR.10.1.13 Glucometer. NR.10.1.14 Nebulizers. NR.10.1.15 ECG machines.
NR.10.1.1 Scales appropriate to the age group and mobility needs of the patient.
NR.10.1.2 Stretchers with safety straps.
NR.10.1.3 Equipment for taking vital signs.
NR.10.1.4 Wheelchairs with safety straps.
NR.10.1.5 Sharp boxes.
NR.10.1.6 Foot stools.
NR.10.1.7 Lifting devices.
NR.10.1.8 Soft restraints.
NR.10.1.9 Bed rails.
NR.10.1.10 Devices for treatment and prevention of skin break down.
NR.10.1.11 Patient call bell.
NR.10.1.12 Oxygen and suction.
NR.10.1.13 Glucometer.
NR.10.1.14 Nebulizers.
NR.10.1.15 ECG machines.
NR.10.2 A process to maintain adequate supplies and linen to meet patient needs.
NR.10.3. Identifying critical levels.
NR.10.4. Emergency backup process when there are issues/delays receiving supplies.
NR.10.5. Method to track issues with supplies and linen so that patterns can be studied for quality improvement.
NR.11 The nursing department assess, report, initiate suicide precaution
NR.11.1 The nurse assesses the patient at risk of suicide utilizing a validated screening tool every shift or as required.
NR.11.2 Suicide precaution must be initiated upon suspicion or confirmed case of serious self-harm due to suicidal ideation or determination by the provider.
NR.11.3 Body search along with security to remove items that can be used to harm themselves.
NR.11.4 Suicide precaution will remain in effect until a physician assess the patient and declare patient no longer high risk.
MS.1 The organization, functions, and responsibilities of the medical staff are documented and communicated to all medical staff members.
MS.1.1 The hospital has medical staff bylaws that govern the organization, functions, and responsibilities of the medical staff.
MS.1.2 Medical staff bylaws are approved by the governing body.
MS.1.3 Medical staff bylaws are consistent with acceptable medical staff practices and laws and regulations.
MS.1.4 Medical staff bylaws describe the organizational structure of the medical staff and the reporting relationships, including all medical departments and committees.
MS.1.5 Medical staff bylaws address:
MS.1.5.1 The medical staff classification and the qualifications required for each level.MS.1.5.2 Categories of the medical staff membership (e.g., full time, part time, and locum).MS.1.5.3 Roles and responsibilities of the medical staff members.MS.1.5.4 Appointment, promotion, and reappointment of medical staff members.MS.1.5.5 The process for verification of the medical staff credentials.MS.1.5.6 Granting and maintaining clinical privileges, including temporary privileges (e.g., for locums and emergency situations).MS.1.5.7 Disciplinary procedures for medical staff members, including corrective actions and appeals.
MS.1.5.1 The medical staff classification and the qualifications required for each level.
MS.1.5.2 Categories of the medical staff membership (e.g., full time, part time, and locum).
MS.1.5.3 Roles and responsibilities of the medical staff members.
MS.1.5.4 Appointment, promotion, and reappointment of medical staff members.
MS.1.5.5 The process for verification of the medical staff credentials.
MS.1.5.6 Granting and maintaining clinical privileges, including temporary privileges (e.g., for locums and emergency situations).
MS.1.5.7 Disciplinary procedures for medical staff members, including corrective actions and appeals.
MS.1.6 Responsibilities of the department head include:
MS.1.6.1 Defining medical staff qualifications required for the provision of effective and safe patient care.MS.1.6.2 Recommending the need for further training/certification of a medical staff member.MS.1.6.3 Monitoring admissions to ensure that the diagnostic and therapeutic interventions are within the staff capabilities and the available hospital resources.MS.1.6.4 Ensuring that medical staff members work within the clinical privileges granted to them.
MS.1.6.1 Defining medical staff qualifications required for the provision of effective and safe patient care.
MS.1.6.2 Recommending the need for further training/certification of a medical staff member.
MS.1.6.3 Monitoring admissions to ensure that the diagnostic and therapeutic interventions are within the staff capabilities and the available hospital resources.
MS.1.6.4 Ensuring that medical staff members work within the clinical privileges granted to them.
MS.2 The credentialing and privileging of the medical staff is based on an informed group decision.
MS.2.1 The hospital has a credentialing and privileging committee chaired by the medical director or a designee.
MS.2.2 The credentialing and privileging committee provides oversight on the credentialing and privileging processes.
MS.2.3 The credentialing and privileging committee ensures that only qualified physicians and dentists are appointed and granted privileges.
MS.2.4 Applicants for initial appointment submit a complete set of documents required for the credentialing and privileging process, including:
MS.2.4.1 Curriculum vitae, detailing the professional history of the applicant.MS.2.4.2 Education, training, certificates, courses, experience, published research, and other relevant credentials.MS.2.4.3 List of references.MS.2.4.4 List of the privileges requested for approval.
MS.2.4.1 Curriculum vitae, detailing the professional history of the applicant.
MS.2.4.2 Education, training, certificates, courses, experience, published research, and other relevant credentials.
MS.2.4.3 List of references.
MS.2.4.4 List of the privileges requested for approval.
MS.3 The hospital has defined and documented processes used to credential, appoint, and grant clinical privileges to medical staff.
MS.3.1 All members of the medical staff must be registered with the Saudi Commission for Health Specialties before allowed to work independently.
MS.3.2 The hospital has a documented process for appointment, reappointment and granting of clinical privileges to all categories of medical staff.
MS.3.3 Medical staff appointment, reappointment and granting of privileges are in accordance with relevant laws and regulations.
MS.3.4 Medical staff appointment, reappointment and granting of privileges are based on:
MS.3.4.1 Evaluation of the verified credentials (license, education, training, and experience).MS.3.4.2 Evaluation of the mental and physical health and capabilities.MS.3.4.3 Competency, actual performance and outcomes of care.MS.3.4.4 Category of the medical staff as stated in the professional registration with the Saudi Commission for Health Specialties (e.g., consultant, specialist).
MS.3.4.1 Evaluation of the verified credentials (license, education, training, and experience).
MS.3.4.2 Evaluation of the mental and physical health and capabilities.
MS.3.4.3 Competency, actual performance and outcomes of care.
MS.3.4.4 Category of the medical staff as stated in the professional registration with the Saudi Commission for Health Specialties (e.g., consultant, specialist).
MS.3.5 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.3.6 The hospital has a process in place for appeals against credentialing or privileging decisions.
MS.4 Medical staff members have current delineated clinical privileges.
MS.4.1 Medical staff members are allowed to practice only within the privileges granted by the credentialing and privileging committee.
MS.4.2 Clinical privileges are reviewed and updated every two years and as needed.
MS.5 Hospital has a process to review mortality and morbidity cases.
MS.5.1 There is a mortality and morbidity committee that is chaired by the medical director or a designee.
MS.5.2 Heads of clinical departments conduct mortality and morbidity meetings on a monthly basis to review all cases of mortality and significant morbidity.
MS.5.3 Mortality and morbidity meetings are documented and attendance is considered essential.
MS.6 The hospital has a cardiopulmonary resuscitation committee.
MS.6.1 There is a cardiopulmonary resuscitation committee with representatives from relevant services such as medical staff, nursing staff, intensive care staff and emergency staff.
MS.6.2 The cardiopulmonary resuscitation committee ensures there is an effective system to handle all cases requiring cardiopulmonary resuscitation at all times.
MS.6.3 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.1 The hospital has a systematic process for the initial assessment of patients.
PC.1.1 The hospital implements a policy and procedure that defines the assessment process and its scope and content for all care settings (inpatients, outpatients, critical care and emergency room).
PC.1.2 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).
PC.1.3 The hospital implements a policy and procedure that defines the assessment process and its scope and content for all disciplines (physicians, nurses, social service and others).
PC.1.4 The policy defines the staff categories qualified by license, certification, and experience to assess patients.
PC.1.5 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.2 Medical assessment is completed and documented for each patient.
PC.2.1 Each patient undergoes an initial mental and medical assessment that includes a health history, and mental status examination (MSE), covering the following:
PC.2.1.1 Main complaint.PC.2.1.2 Details of the present illness.PC.2.1.3 Systems review. PC.2.1.4 Past history including previous admissions and interventions.PC.2.1.5 Allergies and prior adverse drug reactions.PC.2.1.6 Drug history.PC.2.1.7 Family history.PC.2.1.8 Psycho-social history.PC.2.1.9 Economic factors.PC.2.1.10 PainPC.2.1.11 Risk for fallPC.2.1.12 Physical status and functionality including malnutrition.PC.2.1.13 Complete physical examination.PC.2.1.14 Need for additional or specialized assessment as indicated by the patient's condition.PC.2.1.15 Need for discharge planning as indicated by the patient's condition.PC.2.1.16 Provisional diagnosis.PC.2.1.17 Risk assessment (safety on self and others).PC.2.1.18 Risk for suicide and the plan to mitigate the risk PC.2.1.19 Complete mental state examinations including cognitive testing if needed.
PC.2.1.1 Main complaint.
PC.2.1.2 Details of the present illness.
PC.2.1.3 Systems review.
PC.2.1.4 Past history including previous admissions and interventions.
PC.2.1.5 Allergies and prior adverse drug reactions.
PC.2.1.6 Drug history.
PC.2.1.7 Family history.
PC.2.1.8 Psycho-social history.
PC.2.1.9 Economic factors.
PC.2.1.10 Pain
PC.2.1.11 Risk for fall
PC.2.1.12 Physical status and functionality including malnutrition.
PC.2.1.13 Complete physical examination.
PC.2.1.14 Need for additional or specialized assessment as indicated by the patient's condition.
PC.2.1.15 Need for discharge planning as indicated by the patient's condition.
PC.2.1.16 Provisional diagnosis.
PC.2.1.17 Risk assessment (safety on self and others).
PC.2.1.18 Risk for suicide and the plan to mitigate the risk
PC.2.1.19 Complete mental state examinations including cognitive testing if needed.
PC.2.2 Diagnostic tests (e.g., laboratory and radiology) are appropriately and timely ordered to aid in reaching a final diagnosis.
PC.2.3 The medical assessment is documented in the patient's medical record.
PC.3 Additional and specialized assessments are performed for identified patient groups.
PC.3.1 There are criteria implemented to identify patient groups who need additional or specialized assessments.
PC.3.2 Additional assessment includes, but is not limited to, the following categories:
PC.3.2.1 Patients in severe or chronic pain.PC.3.2.2 Children.PC.3.2.3 Frail and elderly.PC.3.2.4 Pregnant woman.
PC.3.2.1 Patients in severe or chronic pain.
PC.3.2.2 Children.
PC.3.2.3 Frail and elderly.
PC.3.2.4 Pregnant woman.
PC.4 The hospital provides safe psychiatric care services in accordance with professional standards and applicable laws and regulations.
PC.4.1 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.4.2 Psychiatric care is provided by qualified physicians.
PC.4.3 There are admission and discharge criteria for psychiatric patients.
PC.4.4 The hospital follows Saudi mental health care act related policies and procedures for voluntary, Involuntary, emergency admission as well as involuntary temporary detention and involuntary therapeutic care.
PC.4.5 The physical layout of the psychiatry service area allows for:
PC.4.5.1 Quiet and separate counseling of patients and families.PC.4.5.2 Access only by authorized staff.PC.4.5.3 Quick assistance from security.PC.4.5.4 A means to separate adults from Child.
PC.4.5.1 Quiet and separate counseling of patients and families.
PC.4.5.2 Access only by authorized staff.
PC.4.5.3 Quick assistance from security.
PC.4.5.4 A means to separate adults from Child.
PC.5 A comprehensive plan of care is developed collaboratively and documented for each patient.
PC.5.1 The plan of care is developed through a collaborative approach between the healthcare team(s),
patient, and family.
PC.5.2 The plan of care is based on the assessment findings and aimed to meet all patients' needs.
PC.5.3 The patient and family are involved in developing the plan of care.
PC.5.4 The plan of care contains the measurable goals/desired outcomes towards discharge.
PC.5.5 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.5.6 The plan of care contains details of risk assessments and management including level of nursing observations and potential use of seclusion room, chemical and physical restraints.
PC.5.7 The plan of care follows the regulations of Saudi mental health care Act. That includes filling up the appropriate forms.
PC.5.8 The plan of care is reviewed by the most responsible physician on a daily basis.
PC.5.9 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.5.10 The plan of care includes a provisional date of discharge set within 24 hours of admission.
PC.5.11 The plan of care is documented in the patient's medical record
PC.6 Patients are reassessed to ensure effectiveness of care plans.
PC.6.1 All patients are reassessed at appropriate intervals to determine:
PC.6.1.1 Response to treatment.PC.6.1.2 Complications and side effects.
PC.6.1.1 Response to treatment.
PC.6.1.2 Complications and side effects.
PC.6.2 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.6.3 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.6.4 Reassessments are documented in the patient's medical record.
PC.6.5 The hospital defines situations where re-assessments are performed less frequently (e.g., long stay patients requiring a nursing care)
PC.6.6 All patients are re-assessed for falling risk, suicidality or risk behavior every twenty-four hours.
PC.7 Clinical practice guidelines, pathways, and protocols are developed or adopted to guide priority clinical care services.
PC.7.1 The hospital implements the national clinical practice guidelines, pathways, and protocols that are consistent with current evidence- based practice.
PC.7.2. The hospital implements application of mental health act to all patient services.
PC.8 The hospital ensures uniform patient care processes during invasive interventions.
PC.8.1 The hospital implements a policy for the assessment and management of patients undergoing invasive procedures.
PC.9 The patient's medical record is available to the authorized care providers to facilitate the exchange of information.
PC.9.1 Continuous specialty coverage by qualified physician according to the hospital scope of service must be granted.
PC.9.2 Medical and other relevant staff who are “on call" are within the hospital premises during the on-call hours.
PC.9.3 Medical and other relevant staff who are on call respond promptly to incoming consultations and care related requests.
PC.10 Patients at risk for developing venous thromboembolism are identified and managed.
PC.10.1 Patients are screened for the risk of developing venous thromboembolism.
PC.10.2 Patients at risk receive prophylaxis according to current evidence-based practice.
PC.11 Restraints are applied safely and in accordance with applicable laws and regulations
PC.11.1 The hospital implements a policy and procedure that defines the indications for restraints.
PC.11.2 Patients are restrained only after an order by the most responsible physician.
PC.11.3 The most responsible physician performs periodic assessment as dictated by the policy and patient's condition including blood circulation assessment to the limbs restrained.
PC.11.4 Use of restraints must be appropriate and safe for patient and staff, used as a last resort.
PC.11.5 Patient's dignity and rights are protected and preserved, including preventing visibility by others and covering the patient when attending to the patient's physical needs.
PC.11.6 Nursing staff provide continuous monitoring of the restrained patient.
PC.11.7 Patients are reassessed on a frequent basis (at least every 15 minutes and as appropriate).
PC.11.8 The restraint order should be renewed at least every 24 hours.
PC.11.9 An alarm system is available in the room and at nursing station for immediate help or assistance.
PC.11.10 Staff members involved in restraint are trained and competent.
PC.11.11 The physician and the nurse at the receiving unit assess the patient at arrival to ensure safe and smooth handover.
PC.12 The hospital has an effective system for the safe provision of care to patients requiring cardio-pulmonary resuscitation.
PC.12.1 The hospital implements a policy and procedure that guides cardio-pulmonary resuscitation across all hospital areas.
PC.12.2 The policy and procedure define the following:
PC.12.2.1 A simple number to dial (such as 999) or other mechanism to call when summoning help for a code.PC.12.2.2 The CPR team composition and the team leader.PC.12.2.3 Roles and responsibilities of the staff who first discover the code, the team leader and the code team members.PC.12.2.4 The team member responsible for documenting events with date and time.PC.12.2.5 How the medications given during the resuscitation are prescribed.PC.12.2.6 How the medications in the emergency cart are timely replenished.PC.12.2.7 The CPR form that is used to standardize documentation of the CPR.
PC.12.2.1 A simple number to dial (such as 999) or other mechanism to call when summoning help for a code.
PC.12.2.2 The CPR team composition and the team leader.
PC.12.2.3 Roles and responsibilities of the staff who first discover the code, the team leader and the code team members.
PC.12.2.4 The team member responsible for documenting events with date and time.
PC.12.2.5 How the medications given during the resuscitation are prescribed.
PC.12.2.6 How the medications in the emergency cart are timely replenished.
PC.12.2.7 The CPR form that is used to standardize documentation of the CPR.
PC.13 The hospital has an effective process for responding to patients with deteriorating conditions
PC.13.1 There are written criteria communicated to the staff to define how and when to call for a rapid response team before the patient “coded".
PC.13.2 Activities of the rapid response teams are documented.
PC.13.3 There is a regular evaluation of the activities and outcomes of the rapid response teams.
PC.14 Policy and procedure guides the transfer of patients between hospital units.
PC.14.1 The most responsible physician assesses the need for transfer and matches the condition of the patient with admission criteria of the unit.
PC.14.2 The physician and the nurse at the receiving unit assess the patient at arrival to ensure safe and smooth handover.
PC.15 The hospital has an efficient discharge process.
PC.15.1 The patient and the family are involved in the discharge process with follow up instructions.
PC.15.2 There is policies and procedures for counseling and follow-up care at discharge for patients identified as at risk for suicide.
PC.16 The hospital has a safe and efficient process for initiating transfer to other organizations.
PC.16.1 Policy and procedure guides the transfer of patients to other organizations.
PC.16.2 The transportation is provided promptly and safely in emergency cases (e.g. trauma, or cardiac emergency).
PC.16.3 The most responsible physician ensures that all patient's health needs during transportation are met.
PC.16.4 Adequate equipment and supplies are available during transportation.
PC.16.5 A qualified staff member accompanies the patient during transportation.
PC.16.6 The patient is monitored as appropriate during transfer.
PC.16.7 Handover is completed to staff at the receiving organization.
PC.17 The receiving organization of a transferred patient receives the necessary information for continuity of care.
PC.17.1 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.17.1.1 Reason for the patient's admission.PC.17.1.2 Patient diagnosis.PC.17.1.3 Brief summary of hospitalization and services provided (therapies, consultations, procedures to date).PC.17.1.4 Medication list and time of last dose(s) given.PC.17.1.5 Patient condition and physical status at the time of transfer.PC.17.1.6 Rationale for transfer.PC.17.1.7 Results of the patient's diagnostic investigations (e.g., laboratory and radiology)
PC.17.1.1 Reason for the patient's admission.
PC.17.1.2 Patient diagnosis.
PC.17.1.3 Brief summary of hospitalization and services provided (therapies, consultations, procedures to date).
PC.17.1.4 Medication list and time of last dose(s) given.
PC.17.1.5 Patient condition and physical status at the time of transfer.
PC.17.1.6 Rationale for transfer.
PC.17.1.7 Results of the patient's diagnostic investigations (e.g., laboratory and radiology)
PC.18 The hospital ensures the continuity of care after discharge or referral.
PC.18.1 The patient receives information on how and when to re-access health and supportive services when required.
PC.19 The hospital has a process for managing psychiatric patients in need for critical care.
PC.19.1 The hospital ensures the availability of resuscitation set up with adequate equipment and supplies including:
PC.19.1.1 Ventilators.PC.19.1.2 Suction apparatus.PC.19.1.3 Airway sets.PC.19.1.4 Crash cart that includes defibrillator and all emergency supplies and medications.PC.19.1.5 ECG monitor, pulse oximetry and vital signs monitoring devices.PC.19.1.6 Automated blood pressure monitoring machine.PC.19.1.7 Intravenous infusionPC.19.1.8 Portable monitoring equipment for patient transfer.PC.19.1.9 The availability and functionality of all tools and equipment are checked daily.PC.19.1.10 Equipment are cleaned and disinfected daily and as needed.
PC.19.1.1 Ventilators.
PC.19.1.2 Suction apparatus.
PC.19.1.3 Airway sets.
PC.19.1.4 Crash cart that includes defibrillator and all emergency supplies and medications.
PC.19.1.5 ECG monitor, pulse oximetry and vital signs monitoring devices.
PC.19.1.6 Automated blood pressure monitoring machine.
PC.19.1.7 Intravenous infusion
PC.19.1.8 Portable monitoring equipment for patient transfer.
PC.19.1.9 The availability and functionality of all tools and equipment are checked daily.
PC.19.1.10 Equipment are cleaned and disinfected daily and as needed.
PC.19.2 The hospital has valid contract/agreement with CBAHI accredited hospital for providing critical care service.
PC.19.3 The hospital must ensure the availability of ambulance vehicle equipped to deal with critically ill patients.
PC.20 the hospital has policy for patients requiring moderate sedation
PC.20.1 The area where moderate sedation is performed must have the necessary equipment and supplies for safe sedation.
PC.20.2 Physicians who perform moderate sedation have competency-based privileges.
PC.21 Electroconvulsive Therapy (ECT) treatment sessions should be performed in a safe environment
PC.21.1 ECT services provided in HCF that offer comprehensive psychiatric, anesthesia, and medical services.
PC.21.2 ECT service provided in well-equipped designated area with essential requirements enable medical team to perform the procedure, recover and resuscitate patients if needed.
PC.21.3 The ECT treatment sessions must be conducted by privileged psychiatrist.
PC.21.4 An assessment for cognitive function must be conducted and documented along with physical and neurological exam before, during and after ECT.
PC.21.5 The various parameters of ECT must be documented in each ECT treatment session.
PC.21.6 The following should be monitored and documented: seizure duration, EEG activity, vital signs, and oximetry.
PC.21.7 A bite block must be used to reduce the risks of dental injury during ECT delivery.
PC.21.8 Treating pregnant patients with ECT requires assessment/follow up of Obs/Gyne service.
PC.21.9 A written informed consent for ECT treatment must be obtained.
PC.22 Repetitive Transcranial Magnetic Stimulation (rTMS) treatment sessions should be performed in a safe environment
PC.22.1 rTMS services provided in HCF that offer comprehensive psychiatric and neurological services.
PC.22.2 Facilities where rTMS services are provided, should have instant means to manage seizures.
PC.22.3 rTMS treatment sessions should be conducted in an area with enough space and waiting area.
PC.22.4 The rTMS treatment sessions must be conducted by privileged psychiatrist.
PC.22.5 A written informed consent for rTMS treatment must be obtained.
PC.22.6 An assessment for cognitive function must be conducted and documented along with physical and neurological exam before, during and after rTMS.
PC.22.7 Identifying high-risk patients such as high-risk for seizure, patients with metallic devices, such as ocular, cochlear implants and pacemakers, etc must be included in preprocedural work up.
PC.22.8 The procedure should be performed in monitored bed.
PC.22.9 The measurement of the motor threshold, the coil placement, and the treatment protocol(s) must be documented.
PC.22.10 Disposable earplugs should be used during the treatment session.
PC.23 The hospital should limit seclusion to certain indications to minimize threats to physical safety of the patient, staff, or others
PC.23.1 The hospital has implemented policies and procedures that guide the use of seclusion.
PC.23.2 The hospital does not use seclusion as a means of coercion, discipline, convenience, or staff retaliation.
PC.23.3 The hospital uses seclusion only when less restrictive interventions are ineffective.
PC.23.4 Order of seclusion only be made by MRP.
PC.23.5 The hospital does not use standing orders such as PRN “as needed" orders for seclusion
PC.24 The hospital evaluates and monitor secluded patients.
PC.24.1 MRP evaluates the patient every 30 min of seclusion.
PC.24.2 Evaluation should be Documented for:
PC.24.2.1 Indications for seclusion.
PC.24.2.2 Behavioral condition and injuries to the patient
PC.24.2.3 Rational for seclusion continuation includes Safety risks assessment to the patients, staff and others
PC.24.2.4 Revisions to the plan of care
PC.24.3 The secluded patient should be monitored by registered nurse in person or through the use of video-audio equipment
ER.1 Emergency department staff members have the appropriate qualifications.
ER.1.1 The head of the emergency department is a physician qualified by education, training, and experience in managing emergency services.
ER.1.2 The emergency department is covered twenty-four hours a day, seven days a week by qualified emergency physicians.
ER.1.3 On call rosters for all specialties are available and posted in the emergency department.
ER.1.4 There is an established policy on how to call consultants.
ER.1.5 All staff members are qualified and experienced in emergency care.
ER.1.6 Clinical staff who participate in caring for patients in the emergency department (resuscitation room) are certified in advanced life support as appropriate to the ages of the patients served.
ER.2 The emergency department has adequate resources that support the provision of safe care.
ER.2.1 The emergency department has the necessary equipment, supplies, and medications as appropriate to the scope of services.
ER.2.2 There is a documented process to check equipment and stock refill on a regular basis or when needed.
ER.2.3 Resuscitation rooms have adequate space to perform resuscitation.
ER.2.4 Waiting areas are available and are visually accessible to the medical staff.
ER.3 The hospital maintains effective ambulance services.
ER.3.1 Emergency department has appropriate channels of communication with Red Crescent services upon receiving or transferring patients.
ER.4 There is an effective triage process to prioritize emergency patients.
ER.4.1 There is a process to identify patients with urgent or emergent care needs.
ER.4.2 Patients with urgent or emergent needs are given priority for assessment and appropriate and timely care.
ER.4.3 Re-triage is performed when appropriate (e.g., change of medical condition, long waiting time).
ER.5 Pathways, guidelines, policies and procedures guide the care of patients in the emergency department.
ER.5.1 There are policies and procedures that are consistent with the hospital scope of services include:
ER.5.1.1 Management of medico-legal cases such as alcohol and narcotic abuse and criminal acts.ER.5.1.2 Management of suspected victims of abuse, neglect, and domestic violence.ER.5.1.3 Management of suicidal patients.ER.5.1.4 Management of agitated patients.ER.5.1.5 Care of patients not competent to care for themselves.ER.5.1.6 Care of minors.ER.5.1.7 Patient transfer from emergency department to inpatient areas or to another organization.ER.5.1.8 Patients who leave against medical advice.ER.5.1.9 Patients who leave without being seen.
ER.5.1.1 Management of medico-legal cases such as alcohol and narcotic abuse and criminal acts.
ER.5.1.2 Management of suspected victims of abuse, neglect, and domestic violence.
ER.5.1.3 Management of suicidal patients.
ER.5.1.4 Management of agitated patients.
ER.5.1.5 Care of patients not competent to care for themselves.
ER.5.1.6 Care of minors.
ER.5.1.7 Patient transfer from emergency department to inpatient areas or to another organization.
ER.5.1.8 Patients who leave against medical advice.
ER.5.1.9 Patients who leave without being seen.
ER.5.2 There are clinical practice guidelines developed for the most common emergency diagnoses.
ER.5.3 The policies, procedures, and guidelines are developed by the emergency department head, nurse manager, and staff in collaboration with other relevant department heads.
ER.6 The hospital implements a policy that defines the responsibility for patients in the emergency department.
ER.6.1 The policy defines the physician responsible for the care of patients in the emergency department including patients under observation, patients waiting for admission (boarding patients) or transfer to another organization.
ER.6.2 The policy defines the process to provide all investigations that are essential but not available.
ER.6.3 The policy and procedure regulate consultation requests coming from the emergency department.
ER.6.4 The contact details of the regional drug and poison information center are available and accessible to the staff in the emergency department if needed.
MM.1 Patient specific information is readily accessible to all healthcare professionals involved in the medication management system.
MM.1.1 The hospital has a multidisciplinary policy and procedure on patient specific information to be readily accessible to all healthcare professionals. The information includes, but is not limited to, the following:
MM.1.1.1 Patient's age and gender.MM.1.1.2 Current medications.MM.1.1.3 Diagnoses, co-morbidities.MM.1.1.4 Laboratory values.MM.1.1.5 Allergies.MM.1.1.6 Body weight and height.MM.1.1.7 Pregnancy and lactation status.
MM.1.1.1 Patient's age and gender.
MM.1.1.2 Current medications.
MM.1.1.3 Diagnoses, co-morbidities.
MM.1.1.4 Laboratory values.
MM.1.1.5 Allergies.
MM.1.1.6 Body weight and height.
MM.1.1.7 Pregnancy and lactation status.
MM.2 The pharmaceutical care department has an organizational structure and is directed by a qualified pharmacist.
MM.2.1 The head of pharmaceutical care is a licensed pharmacist, qualified by education, training, and experience
MM.2.2 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.2.3 The pharmaceutical care department has adequate number of qualified staffs
MM.3 The pharmaceutical care and medication use in the hospital are well planned and comply with laws and regulations of relevant authorities and the Saudi Food and Drug Authority (SFDA).
MM.3.1 Appropriate sources of drug information are readily available to all healthcare professionals involved in medication use. (e.g., books, manuals, CDs/DVDs, online subscription to drug information resources).
MM.4 The hospital has a system for the safety of high-alert medications.
MM.4.1 There is a written multidisciplinary plan for managing high-alert medications and hazardous pharmaceutical chemicals. It includes identification, location, labeling, storage, dispensing, and administration of high-alert medications.
MM.4.2 The hospital identifies an annually updated list of high-alert medications and hazardous pharmaceutical chemicals based on its own data and national and international recognized organizations (e.g., Institute of Safe Medication Practice, World Health Organization). The list contains, but is not limited to, the following:
MM.4.2.1 Controlled and narcotics medications.
MM.4.2.2 Concentrated electrolytes (e.g., hypertonic sodium chloride, concentrated potassium salts).
MM.4.2.3 Antithrombotic medications (e.g., heparin, warfarin).
MM.4.2.4 Insulins.
MM.4.2.5 Anesthetic medications (e.g., propofol, ketamine).
MM.4.2.6 Investigational (research) drugs, as applicable.
MM.4.2.7 Other medications as identified by the hospital.
MM.4.3 The hospital plan for managing high-alert medications and hazardous pharmaceutical chemicals is implemented. This includes the following:
MM.4.3.1 Improving access to information about high-alert medications.
MM.4.3.2 Limiting access to high-alert medications.
MM.4.3.3 Using auxiliary labels or computerized alerts if available.
MM.4.3.4 Standardizing the ordering, transcribing, preparation, dispensing, administration, and monitoring of high-alert medications.
MM.4.3.5 Employing independent double checks.
MM.4.4 The hospital develops and implements standard concentrations for all medications administered by intravenous infusion.
MM.5 The hospital has a system for the safety of look-alike and sound-alike (LASA) medications
MM.5.1 There is a multidisciplinary policy and procedure on handling look- alike/sound-alike (LASA) medications.
MM.5.2 The hospital reviews and revises annually its list of confusing drug names, which include LASA medication name pairs that the hospital stores, dispenses, and administers.
MM.5.3 The hospital takes actions to prevent errors involving LASA medications including the following, as applicable:
MM.5.3.1 Providing education on LASA medications to healthcare professionals at orientation and as part of continuing education.
MM.5.3.2 Using both the brand and generic names for prescribing LASA medications.
MM.5.3.3 Writing the diagnosis/ indication of the LASA medication on the prescription.
MM.5.3.4 Changing the appearance of look-alike product package.
MM.5.3.5 Reading carefully the label each time a medication is accessed, and/or prior to administration.
MM.5.3.6 Minimizing the use of verbal and telephone orders.
MM.5.3.7 Checking the purpose/indication of the medication on the prescription prior to dispensing and administering.
MM.5.3.8 Placing LASA medications in locations separate from each other or in non-alphabetical order.
MM.6 The hospital has an updated, structured, and well-organized drug formulary.
MM.6.1 The hospital formulary includes short drug monographs that illustrate the generic drug name, strength, and dosage form(s), indication(s), adverse drug reactions, and prescribing information.
MM.6.2 The hospital formulary provides guidance on antibiotics use (both prophylactic and therapeutic uses).
MM.6.3 The hospital formulary provides a list of approved prescribing abbreviations.
MM.6.4 The hospital formulary provides a list of prohibited prescribing abbreviations.
MM.6.5 The hospital formulary provides appendixes on important policies, therapeutic guidelines, drug safety in pregnancy and lactation, and dose adjustment in organ failure.
MM.7 The hospital has a system for handling out of stock, shortage and disaster needs of medications.
MM.7.1 The hospital implements a policy and procedure on proper communication of medication shortage and outage to prescribers and other healthcare professionals involved in medication management and obtaining medications in the event of a disaster.
MM.7.2 The pharmacy and therapeutics committee develops and approves medication substitution protocols in the event of medication shortage or outage.
MM.7.3 There is implementation of the hospital approved medication substitution protocols and staff awareness.
MM.7.4 There is a plan for emergency preparedness to respond to the special and large demand of medications during internal and external disasters. The plan is tested for effectiveness and integrated with the hospital plan.
MM.8 The hospital has a safe and secure system for the storage of regular medications and nutrition products in stores, pharmacies, and patient care areas.
MM.8.1 There is a policy and procedure on proper storage and control of medications, nutrition products, and free medical samples (from the point of receipt until the point of administration).
MM.8.2 There is a policy and procedure to control the access of pharmaceutical care and non-pharmaceutical care staff to stores, pharmacies, and patient care areas including after hours and in case of emergency (e.g., fire, flood).
MM.8.3 There are measures in place to secure medications storage areas including limited access, proper locking procedures, and door keys handling.
MM.8.4 Only authorized individuals have access to stored medications.
MM.8.5 Medications are stored in a way to avoid mixing with labels showing the drug name and expiry date.
MM.8.6 No medications are stored directly on floor (a minimum of ten centimeters is left to manage spills). Medications are not stacked so high to block sprinklers or come in contact with overhead lights or pipes.
MM.8.7 Medications are stored according to manufacturer's recommendations (temperature, light, humidity, sanitation).
MM.8.8 There is an appropriate storage area for regular medications with controlled temperature (between 18 and 25 degrees centigrade) all the time.
MM.8.9 The room air temperature is checked and documented at least once daily on the temperature log sheet.
MM.8.10 All antiseptics, disinfectants, and medications for external use are stored separately from enteral and injectable medications.
MM.8.11 All medication storage areas are inspected at least monthly by the pharmaceutical care according to the hospital policy to ensure proper storage of medications. Inspection includes, but is not limited to: availability, stock level, expiry date, and storage conditions.
MM.8.12 Expired and damaged medications are labeled and separated from other drugs until its removal and proper destruction.
MM.9 The hospital has a safe and secure system for storage of refrigerated and frozen medications, biologicals, and vaccines in stores, pharmacies, and patient care areas.
MM.9.1 There is a policy and procedure on proper storage and control of refrigerated and frozen medications from the point of receipt until the point of administration.
MM.9.2 There are medication refrigerators and freezers for storing refrigerated and frozen medications, biologicals and vaccines.
MM.9.3 All medication refrigerators and freezers are equipped with appropriate thermometers or equivalent device for temperature recording.
MM.9.4 The refrigerators' temperature is checked and documented at least once daily on the temperature log sheet.
MM.9.5 The refrigerator's temperature is kept between (2-8°C).
MM.9.6 The freezer's temperature is kept between (-10 and -25°C).
MM.9.7 All vaccine refrigerators are connected to emergency power source and electric outlets are marked accordingly.
MM.9.8 Vaccine refrigerator's temperature is continuously recorded around the clock or an equivalent process is in place to monitor temperature around the clock.
MM.9.9 There is defined mechanism to deal with electric power outage or out-of-range temperature of the medication refrigerators and freezers to ensure the integrity of the affected medications before its reuse.
MM.9.10 Food, drinks, biological samples, and culture media are not allowed inside medication refrigerator or freezer.
MM.10 The hospital has a process for detecting, managing and reporting adverse drug reactions.
MM.10.1 The hospital has a multidisciplinary policy and procedure on handling Adverse Drug Reaction (ADR) reports.
MM.10.2 The policy has a definition of ADR and its severity.
MM.10.3 The treating physician is notified at the appropriate time.
MM.10.4 The patient affected by ADR receives appropriate care at the appropriate time.
MM.10.5 The ADR report forms are readily available and in use.
MM.10.6 All ADRs are documented in the patient's medical record.
MM.11 The hospital has a process for monitoring, identifying, and reporting significant medication errors, including near misses, hazardous conditions, and at-risk behaviors that have the potential to cause patient harm.
MM.11.1 There is a multidisciplinary policy and procedure on handling medication errors, near misses, and hazardous situations (e.g., confusion over look-alike/sound-alike drugs or similar packaging).
MM.11.2 The policy has a definition of significant medication error, near misses, and hazardous situations.
MM.11.3 The treating physician is notified of the medication error at the appropriate time.
MM.11.4 The hospital has a standard format for reporting medication errors.
MM.11.5 Staff are educated on the process and importance of medication error reporting.
MM.11.6 There is active reporting of medication errors, near misses, and hazardous situations.
MM.11.7 The hospital conducts intensive root-cause analysis for all significant or potentially significant medication errors.
MM.11.8 Medication errors are documented in the patient's medical record.
MM.11.9 The hospital utilizes reported data to improve the medication use process, prevent medication errors, and improve patient safety.
MM.11.10 The hospital reports sentinel events related to serious medication errors to the relevant authorities.
MM.12 The hospital has a safe and secure system for the storage and safe management of hazardous medications and pharmaceutical chemicals.
MM.12.1 There is a written policy on proper storage and handling of hazardous medications and pharmaceutical chemicals.
MM.12.2 The hospital has a list of hazardous medications and pharmaceutical chemicals in areas where they are stored or used.
MM.12.3 Hazardous medications and pharmaceutical chemicals are stored separately on low shelves and in the original labeled containers.
MM.12.4 Flammables and volatile substances are stored in appropriate safety cabinets in well ventilated areas.
MM.12.5 Spill kits and personal protective equipment are readily available.
MM.12.6 Material safety data sheets (MSDS) for all available hazardous medications and pharmaceutical chemicals are available and accessible to staff.
MM.12.7 Eye wash station and emergency water shower are available where hazardous medications and pharmaceutical chemicals are located.
MM.12.8 The hospital staff are well educated on the proper storage and handling of hazardous medications and pharmaceutical chemicals and spill management.
MM.13 The hospital has a system for ensuring stability of medications available in multi-dose containers.
MM.13.1 The hospital develops and maintains a set of guidelines for ensuring stability of multi-dose vials, vaccines, multi-dose oral liquids, and other multi-dose medications (e.g., eye, ear, and nasal drops, creams, ointments, nebulization solutions).
MM.13.2 The hospital ensures that all open multi-dose containers are labeled with open date, expiry date, initials, and time (if necessary).
MM.13.3 The hospital ensures that no expired open or unlabeled open multi-dose containers are available in-patient care areas.
MM.14 The hospital has a system for ensuring accessibility, availability, monitoring, and security of emergency medications.
MM.14.1 The hospital develops and maintains a standardized set of guidelines for emergency drugs for crash carts and emergency medical bags in accordance with the current Saudi Heart Association recommendations.
MM.14.2 Emergency medications are available in the patient care units and readily accessible to meet emergency needs.
MM.14.3 The emergency medications in the crash carts and emergency medical bags are protected from loss or theft using safety plastic seal.
MM.14.4 Plastic seals of crash carts and emergency bags are stocked in a safe place under supervision of pharmaceutical care or nursing.
MM.14.5 There is a process in place for monitoring emergency medications and replenishing them in a timely manner after use or when expired or damaged.
MM.15 The hospital has a safe and secure system for managing medications in the patient care areas.
MM.15.1 The hospital implements a multidisciplinary policy and procedure on medications assignment as floor stocks in limited quantities according to the needs of each service unit.
MM.15.2 Benzodiazepine and narcotics antagonists are available in all patient care areas where benzodiazepines and narcotics are stocked.
MM.15.3 All medications in the patient care areas are well separated and properly labeled.
MM.16.4 Concentrated electrolytes are not allowed in patient care areas (unless patient safety necessitates their immediate use). All necessary precautions and separate locked cabinet with proper signage are in place to prevent inadvertent administration of concentrated electrolytes.
MM.16 There is a system to identify all medications brought into the hospital by patients or their families.
MM.16.1 The hospital implements a multidisciplinary policy and procedure on handling medications brought into the hospital by patients or their families (patient's own medications).
MM.16.2 Patient's own medications are checked for integrity and properly labeled if permitted for use, by a qualified pharmacist.
MM.16.3 There is proper documentation of patient's own medications in the medical record (ordering, dispensing, and administration records).
MM.17 There is a system for storing narcotics, psychotropic and other controlled medications in accordance with relevant laws and regulations.
MM.17.1 The hospital implements a multidisciplinary policy and procedure on proper storage of narcotics, psychotropic and other controlled medications.
MM.17.2 Controlled and narcotics medications are kept behind steel doors with double locks.
MM.17.3 The hospital allows a limited floor stock supply of controlled and narcotics medications to meet patients' needs.
MM.17.4 The hospital maintains proper documentation of drug count, endorsement, and accountability.
MM.17.5 The hospital maintains proper documentation of empty containers of narcotics and proper disposal of unused portions.
MM.18 The hospital identifies qualified healthcare professionals permitted to prescribe or order controlled and narcotic medications.
MM.18.1 The hospital has a multidisciplinary policy and procedure on identification of those individuals permitted to prescribe or order controlled and narcotic medications and their prescribing privileges.
MM.18.2 Only individuals permitted by the hospital and relevant laws and regulations prescribe or order controlled and narcotic medications.
MM.18.3 Individuals permitted to prescribe or order controlled and narcotic medications are known to pharmaceutical care staff and nursing staff who dispense medications.
MM.18.4 The hospital implements its policy on prescribing privileges such as those for controlled and narcotic substances, high-alert, radioactive or investigational, and other specialty medications.
MM.19 Safe prescribing, ordering, and transcribing of medication orders are guided by a policy and procedure.
MM.19.1 There is a multidisciplinary policy and procedure that defines a complete prescription.
MM.19.2 Medication reconciliation is conducted at the time of admission and discharge.
MM.19.3 Patient identification, diagnosis, indication, or clinical condition are made available with each medication order.
MM.19.4 Medications are prescribed by generic name except when brand names are acceptable or required.
MM.19.5 Staff comply with the proper use of approved and prohibited prescribing abbreviations.
MM.19.6 The pharmaceutical care team conducts corrective actions when medication order is incomplete, illegible, or unclear.
MM.19.7 All medications are accurately transcribed into the medication administration record (MAR) after being verified against the original physician order or prescription.
MM.20 The hospital ensures safe prescribing, ordering and transcribing of specific types of medication orders.
MM.20.1 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.20.2 The hospital prohibits blanket orders (e.g., resume pre-op medications).
MM.20.3 Prescribing controlled drugs is according to laws and regulations of the Saudi Food and Drug Authority and other relevant authorities.
MM.20.4 The transcription of medication order into the medication administration record (MAR) reflects the type of order.
MM.21 The hospital has a system for prescribing antibiotics.
MM.21.1 The hospital implements updated and approved multidisciplinary guidelines on the proper prescribing of antibiotics.
MM.21.2 The antibiotics guidelines are updated as recommended by the pharmacy and therapeutics committee.
MM.21.3 There is proper implementation of the approved guidelines for antibiotics prophylaxis before dental procedures.
MM.21.4 There is proper implementation of the approved guidelines for empiric and therapeutic use of antibiotics.
MM.21.5 There is proper implementation of the approved prescribing privileges for antibiotics.
MM.22 The hospital has a system for managing the use of verbal and telephone orders of medications.
MM.22.1 The hospital has a multidisciplinary policy and procedure that control ordering, verifying, authenticating and limiting the use of verbal and telephone orders of medications. The policy includes a list of medications not allowed to be prescribed by verbal and telephone order.
MM.22.2 The hospital staff understand the proper use of verbal and telephone orders (accepting, documenting, verifying, authenticating, and executing orders).
MM.22.3 Verbal and telephone orders are limited to emergent and urgent situation where immediate written or electronic medication order is not feasible. Definition of emergent and urgent situations should be included.
MM.22.4 Time frame for authentication of verbal (as soon as the emergency is over) and telephone orders (within twenty-four hours) is stated and implemented.
MM.22.5 The hospital has a multidisciplinary policy and procedure on prescribing formulary medications for off-label (unapproved) indications.
MM.22.6 The department head approves every single case where non-formulary medication is used or where a formulary medication is used for unapproved indication or investigation.
MM.23 The hospital has a system to monitor the patient response to medications.
MM.23.1 There is a multidisciplinary policy and procedure on monitoring the patient response to medications.
MM.23.2 There is an annually updated list of all formulary medications that cause changes in the patient's equilibrium and may raise the risk of falls.
MM.23.3 The hospital has a collaborative process, involving physicians, nurses, and pharmacists, to monitor the patient's response to medications.
MM.23.4 Monitoring includes the following:
MM.23.4.1 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.23.4.2 The patient's perception of side effects to the first dose of a new medication.
MM.23.4.3 Unanticipated drug-drug interactions.
MM.23.4.4 Changes in the patient's equilibrium that may raise the risk of falls
MM.23.4.5 Allergic reactions including documentation and flagging of medical records.
MM.24 The hospital has a system for reviewing the appropriateness of medication orders before medication is dispensed.
MM.24.1 The hospital maintains an updated and complete medication profile (electronic or paper record) for each patient in the pharmaceutical care department.
MM.24.2 A trained pharmacist reviews all medication orders or prescriptions before dispensing (except in emergencies, lifesaving situations, or diagnostic imaging where the prescriber is physically present).
MM.24.3 All medication orders are reviewed for:
MM.24.3.1 Patient's allergies or sensitivities.
MM.24.3.2 Approved indications for use.
MM.24.3.3 Therapeutic duplications.
MM.24.3.4 Existing or potential interactions (drug-drug and drug-food interactions).
MM.24.3.5 Appropriateness of the medication dose, frequency, and route of administration.
MM.24.3.6 Contraindications.
MM.24.4 All issues, concerns, or questions regarding medication order or prescription are clarified with the prescriber and documented before medication dispensing.
MM.25 The hospital has a safe system for self-administration of medications.
MM.25.1 The hospital educates patients and families involved in self-administration of medications about:
MM.25.1.1 Medication name, type, and indication.
MM.25.1.2 Time, frequency, route, and dose of medication.
MM.25.1.3 Expected medication effect and potential side effects.
MM.25.1.4 Monitoring and reporting of medication effects.
MM.25.2 The hospital does not allow administration of any medication brought from outside the hospital unless prescribed by the treating physician.
MM.25.3 The hospital does not allow administration of free medical samples.
MM.26 The hospital has a system for safe preparation of non-sterile compounded preparations (extemporaneous compounds).
MM.26.1 There is a multidisciplinary policy and procedure on non-sterile compounding of oral and topical preparations not readily available from manufacturers.
MM.26.2 The pharmaceutical care has proper facilities for non-sterile compounding that include clean work bench with smooth surface, stainless steel sink with water supply, and storage cabinets.
MM.26.3 The pharmaceutical care has essential equipment and glass wares that include sensitive balance, electric heater, mortar and pestle, beakers, flasks, and measuring cylinders.
MM.26.4 The pharmaceutical care has a preparation manual (formulation book) that is properly referenced.
MM.26.5 A log book is maintained for preparation name, strength, prepared quantity, batch number, preparation date and expiration date, prepared by and checked by.
MM.26.6 When non-sterile compounded preparations are compounded by an outside vendor, the pharmaceutical care team maintains a copy of the contract and ensures compliance of the vendor with quality and safety standards. Contract monitoring is conducted at least annually with corrective actions accordingly.
MM.27 The pharmaceutical care enforces the hospital guidelines for infection prevention and control.
MM.27.1 All areas where medications are stored, compounded, prepared, dispensed, and /or administered are clean, neat and well organized.
MM.27.2 The pharmaceutical care has a separate housekeeping material dedicated for the clean room.
MM.27.3 A sink, antiseptic soap, and/or antiseptic hand rub are available in the pharmaceutical care department and all other areas where medications are stored, compounded, prepared, dispensed, and /or administered.
MM.27.4 Hand washing technique, and antiseptic soap are in accordance with the hospital's policy and procedures.
MM.27.5 Pharmaceutical care staff observe the hospital approved standard precautions and understand the hospital's isolation policy and procedure to reduce the risk of transmission of infection.
MM.27.6 Food and drinks are not allowed in the pharmaceutical care department and all other areas where medications are stored, compounded, prepared, dispensed, and /or administered.
MM.27.7 Laminar air flow hood certification for operational efficiency and maintenance such as checking, cleaning and/or replacing filter are performed regularly and according to the manufacturer's specifications.
MM.28 The hospital has a system for safe dispensing of medications.
MM.28.1 The hospital dispenses medications in the most ready-to-administer form possible (such as repackaged unit-doses) to minimize chance of error during distribution or administration.
MM.28.2 The hospital dispenses quantities of medications consistent with patient needs.
MM.28.3 The hospital dispenses no more than twenty-four hours supply of medications for inpatient at a time except for bulk oral liquids and topical preparations.
MM.28.4 The hospital dispenses medications with time frames defined by the hospital (such as STAT, now, routine).
MM.28.5 The hospital maintains records for all dispensed medications.
MM.28.6 There is implementation of the independent double check during preparation and before dispensing of all high-alert medications.
MM.29 The hospital has a system for labeling medications
MM.29.1 Medications prepared but not intended for immediate administration are labeled. This includes all injectable medications drawn into syringes or mixed with intravenous fluids for use inside the procedure areas.
MM.29.2 Multiple medications for a single patient, such as those in the emergency room, must be labeled for drug name and dose/concentration.
MM.29.3 All individualized medications prepared for multiple patients are labeled with all necessary information in a standardized format.
MM.29.4 All individualized medications prepared for multiple patients are labeled with:
MM.29.4.1 Patient name and medical record number.
MM.29.4.2 Patient location (ward, unit, room, bed number).
MM.29.4.3 Medication name, dosage form, strength, and amount.
MM.29.4.4 Directions for use.
MM.29.4.5 Relevant cautionary instructions (e.g., refrigerate, shake before use, may cause drowsiness).
MM.29.4.6 Date of preparation, beyond use date, and time (when beyond use date occurs in less than twenty-four hours).
MM.29.5 All compounded parenteral nutrition solutions are labeled with individual components quantities, and total volume.
MM.29.6 All outpatient medications are labeled with patient name, medical record number, medication name, dosage form, strength, direction and duration for use, and cautions in a language and form the patient can understand.
MM.30 The hospital has a system for handling recalled, discontinued, and damaged medications.
MM.30.1 There is a multidisciplinary policy and procedure on retrieval and handling of recalled, discontinued, and damaged medications within specified time frame for patient safety.
MM.30.2 The hospital recognizes and maintains on file all drug recall memorandums from the Saudi Food and Drug Administration, manufacturer, and/ or other relevant legal bodies.
MM.30.3 The hospital notifies prescribers and individuals involved in prescribing, dispensing and administration of recalled, damaged, and discontinued medications.
MM.30.4 The hospital informs patients that their medication has been recalled or discontinued for safety reasons.
MM.30.5 The hospital complies with handling recalled, discontinued, and damaged medications guidelines.
MM.31 The pharmaceutical care department has a system for provision of outpatient education and counseling.
MM.31.1 The pharmaceutical care department has a system for provision of outpatient education and counseling that includes verbal explanation and instructions by a pharmacist to patients and their families on the safe and effective use, administration, and storage condition of medications.
MM.31.2 Written educational information is given in a language and form the patient can understand.
MM.31.3 Patient privacy is maintained during education and counseling.
MM.32 The hospital has a safe system for drug administration.
MM.32.1 The hospital defines nurses and other clinical staff authorized to administer medications with or without supervision.
MM.32.2 The hospital guidelines for safe administration of intravenous push medications are available, disseminated and implemented in all patient care units. The guidelines include medication name, infusion time, nurse qualification and patient care unit.
MM.32.3 The hospital has approved, disseminated, and implemented guidelines on standard drug administration time.
MM.32.4 The hospital maintains accurate records of the disposal of the unused portion of narcotic drugs and controlled substances.
MM.32.5 The hospital maintains updated and accurate records of drug administration.
MM.32.6 Independent double check of high alert medications is performed.
MM.33 The hospital has a system to review and verify medications before administration
MM.33.1 The hospital implements a multidisciplinary policy and procedure on proper verification of dispensed medications before administration (right patient, right medicine, right dose, right frequency, right route, and right time).
MM.33.2 Medications are verified against the medication administration record (MAR) before administration.
MM.33.3 Medications are administered in the prescribed dose and by the correct route.
MM.33.4 Medications are administered at the correct time (the approved hospital standard administration time).
MM.33.5 Medications are administered after verifying the expiry date.
MM.33.6 Medications are administered after visual inspection for discoloration, particulate, or other clues of loss of integrity or instability.
MM.33.7 Medications are administered after verifying that there are no contraindication
LB.1 Laboratory services are available to meet patient needs and are in accordance with applicable national standards.
LB.1.1 Basic laboratory services (e.g., hematology and biochemistry) are available twenty-four hours a day, seven days a week.
LB.1.2 When laboratory services are provided through a contract, the hospital provides oversight and management of the contract through the process described in the “Leadership" chapter in this manual.
LB.2 The laboratory has adequate and functional space and facilities that maintain safe and proper working conditions.
LB.2.1 The laboratory management ensures the availability of the following facilities:
LB.2.1.1 Adequate water taps and sinks.LB.2.1.2 Adequate electrical outlets and emergency power.LB.2.1.3 Adequate temperature and humidity control.LB.2.1.4 Adequate ventilation.LB.2.1.5 Adequate lighting.LB.2.1.6 Adequate emergency exits, access control, and all ways are not obstructed.LB.2.1.7 Adequate safety signs.LB.2.1.8 Clean and well-maintained floors, walls, ceilings, bench tops, and sinks.LB.2.1.9 Conveniently located telephones.
LB.2.1.1 Adequate water taps and sinks.
LB.2.1.2 Adequate electrical outlets and emergency power.
LB.2.1.3 Adequate temperature and humidity control.
LB.2.1.4 Adequate ventilation.
LB.2.1.5 Adequate lighting.
LB.2.1.6 Adequate emergency exits, access control, and all ways are not obstructed.
LB.2.1.7 Adequate safety signs.
LB.2.1.8 Clean and well-maintained floors, walls, ceilings, bench tops, and sinks.
LB.2.1.9 Conveniently located telephones.
LB.2.2 Personnel safety, quality of work, patient care, and donor care are not compromised by the allocated laboratory space.
LB.3 The laboratory services are carried out by qualified staff.
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 laboratories a licensed laboratory specialist.LB.3.2.2 Sections' heads/supervisors are qualified in the discipline of their assigned sections.LB.3.2.3 The laboratory staff participate in relevant hospital committees.
LB.3.2.1 The laboratory director of laboratories a licensed laboratory specialist.
LB.3.2.2 Sections' heads/supervisors are qualified in the discipline of their assigned sections.
LB.3.2.3 The laboratory staff participate in relevant hospital committees.
LB.4 The laboratory has a comprehensive training and competency assessment program.
LB.4.1 The laboratory implements an orientation, training and competency assessment program that
ensures:
LB.4.1.1 Satisfactory completion of training program for all lab personnel in their assigned area.LB.4.1.2 Training on new equipment or method.LB.4.1.3 Competency assessment of all laboratory personnel before working independently and annually thereafter.LB.4.1.4 Corrective action plan and reassessment in the event of unsatisfactory performance.LB.4.1.5 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.4.1.6 Laboratory personnel performing tests or tasks requiring color discrimination undergo a color discrimination test.
LB.4.1.1 Satisfactory completion of training program for all lab personnel in their assigned area.
LB.4.1.2 Training on new equipment or method.
LB.4.1.3 Competency assessment of all laboratory personnel before working independently and annually thereafter.
LB.4.1.4 Corrective action plan and reassessment in the event of unsatisfactory performance.
LB.4.1.5 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.4.1.6 Laboratory personnel performing tests or tasks requiring color discrimination undergo a color discrimination test.
LB.5 The laboratory has a system for the receipt of incoming supplies and services, inventory management, and tracking of critical materials.
LB.5.1 The laboratory implements policies and procedures on documenting the receipt, inspection, and testing (as applicable) of incoming critical material or service.
LB.5.2 The laboratory implements policies and procedures on inventory management and tracking the use of critical materials, supplies, and reagents to ensure the following:
LB.5.2.1 Materials are used within their expiration dates.LB.5.2.2 New reagents lot numbers are tested against old lots or suitable reference materials before use.LB.5.2.3 Kit components are used within the kit lot number.
LB.5.2.1 Materials are used within their expiration dates.
LB.5.2.2 New reagents lot numbers are tested against old lots or suitable reference materials before use.
LB.5.2.3 Kit components are used within the kit lot number.
LB.6 The laboratory has reagents and solutions management system.
LB.6.1 The laboratory implements policies and procedures to ensure that prepared/reconstituted reagents and solutions are labeled, as applicable, with:
LB.6.1.1 Content.LB.6.1.2 Concentration/titer.LB.6.1.3 Preparation/reconstitution date.LB.6.1.4 Expiration Date.LB.6.1.5 Storage requirements.
LB.6.1.1 Content.
LB.6.1.2 Concentration/titer.
LB.6.1.3 Preparation/reconstitution date.
LB.6.1.4 Expiration Date.
LB.6.1.5 Storage requirements.
LB.6.2 Laboratory supplies and reagents are stored under appropriate conditions.
LB.6.2.1 Critical laboratory supplies and reagents are stored according to the manufacturer's recommendations under controlled conditions or in an appropriate storage device.LB.6.2.2 Critical supplies and reagents storage conditions are continuously monitored using appropriate temperature monitoring/recording system.LB.6.2.3 In the event of monitoring systems failure, the storage temperature is monitored and recorded every eight hours using a standardized thermometric device.
LB.6.2.1 Critical laboratory supplies and reagents are stored according to the manufacturer's recommendations under controlled conditions or in an appropriate storage device.
LB.6.2.2 Critical supplies and reagents storage conditions are continuously monitored using appropriate temperature monitoring/recording system.
LB.6.2.3 In the event of monitoring systems failure, the storage temperature is monitored and recorded every eight hours using a standardized thermometric device.
LB.6.3 The laboratory defines and specifies water types.
LB.6.3.1 There is definition of the specific type of water required for each of its testing procedures.
LB.6.3.2 Water quality is tested at least annually.
LB.7 The laboratory has a process for equipment validation.
LB.7.1 The laboratory implements policies and procedures describing the validation of critical laboratory equipment for its intended use, including:
LB.7.1.1 Installation Qualification.
LB.7.1.2 Operational Qualification.
LB.7.1.3 Detailed functional validation study with predefined acceptance criteria.
LB.7.1.4 Critical laboratory equipment are not used before completing the validation studies.
LB.8 The laboratory develops a process for test method validation.
LB.8.1 The laboratory implements policies and procedures on test method validation including:
LB.8.1.1 Verification of accuracy/precision.
LB.8.1.2 Verification of sensitivity (lower detection limit).
LB.8.1.3 Verification of carryover acceptability.
LB.8.1.4 Verification of the Analytic Measurement Range (AMR).
LB.8.1.5 Approval of the method for clinical use.
LB.9 The laboratory develops a process for establishing or verifying and evaluating reference ranges/intervals and cut off values for each analyte and specimen source.
LB.9.1 The laboratory implements policies and procedures that define:
LB.9.1.1 Circumstances and method for establishing reference ranges.
LB.9.1.2 Circumstances and method for verifying published reference ranges.
LB.9.1.3 Circumstances and method for the re-evaluation of reference ranges.
LB.10 The laboratory has a process for standardizing critical laboratory instruments.
LB.10.1 The laboratory implements policies and procedures defining the calibration, adjustment and/or standardization of critical laboratory instruments. This includes:
LB.10.1.1 Calibrations and adjustment are performed before use, after activities that may alter the calibration and at predefined intervals.
LB.10.1.2 All thermometers used in the laboratory are checked against certified standardized thermometric device before being placed in use and annually thereafter.
LB.10.1.3 All stopwatches and instrument timers are checked against standardized stopwatch before the initial use and every six months thereafter.
LB.10.1.4 All pipettes (fixed volume and/or adjustable) are checked for accuracy and reproducibility before being placed in use and semi-annually thereafter.
LB.10.1.5 Balances are placed on vibration resistance surface and checked against standardized weights before being placed in use and every six months thereafter.
LB.10.1.6 Actions are taken in the event of unsatisfactory results.
LB.11 The laboratory has a process for instruments/methods correlation.
LB.11.1 When the laboratory uses more than one method and/or instruments to test for a given analyte,
the laboratory develops and implements policies and procedures on correlation to ensure the
following:
LB.11.1.1 The correlation studies are conducted every six months.
LB.11.1.2 There is description of the correlation study.
LB.11.1.3 There are defined acceptance criteria.
LB.11.1.4 There is a process for review and approval of the correlation results.
LB.12 The laboratory has a process for controlling the quality of test methods.
LB.12.1 The laboratory implements policies and procedures on quality control of test methods to satisfy the following:
LB.12.1.1 Assignment of performance and review responsibility (control specimens are handled and tested in the same manner and by the same laboratory personnel testing patient samples).
LB.12.1.2 Number and frequency of running controls.
LB.12.1.3 Tolerance limits of controls results.
LB.12.1.4 Corrective action to be taken in the event of unacceptable results.
LB.13 The laboratory has comprehensive work instructions and procedures manuals.
LB.13.1 The laboratory develops work instructions and procedures manuals that fulfill the following:
LB.13.1.1 Conform to the hospital document control/management system.
LB.13.1.2 Readily available at the work areas.
LB.13.1.3 Prepared in accordance with the instrument operating manual, reagent inserts and/or manufacturer's instructions.
LB.14 The laboratory has a comprehensive safety and infection control programs
LB. 14.1 The laboratory implements safety and infection control policies and procedures that are in compliance with the national and international laboratory safety standards as well as the hospital safety and infection control plan. Policies define the following:
LB.14.1.1 Chemical hygiene plan.
LB.14.1.2 Mercury reduction/elimination plan.
LB.14.1.3 Mechanism of fumes and vapors monitoring.
LB.14.1.4 Mechanism of compressed and flammable gases control.
LB.14.1.5 Radiation safety plan.
LB.14.1.6 Biological safety procedures and use of standard precautions.
LB.14.1.7 Tuberculosis and other biological hazards exposure plan.
LB.14.1.8 Electrical safety plan.
LB.14.1.9 Fire prevention and control plan.
LB.14.1.10 Provision and use of Personal Protective Equipment (PPE).
LB.14.1.11 Provision and control of negative pressure in sections dealing with highly infectious materials.
LB.14.1.12 Provision, use, and control of fume hoods.
LB.14.1.13 Provision, use, and control of biological safety cabinets.
LB.14.1.14 Provision of safety equipment (eye wash, emergency shower, fire extinguisher, fire blanket, biological and chemical spill kits).
LB.14.1.15 Waste disposal/control plan (chemical, biological and sharps) using prick proof containers and leak proof bags.
LB.14.1.16 Provision and use of first aid kits.
LB.14.1.17 Reporting of infection and safety incidents.
LB.14.2 The laboratory has safety and infection control training program that includes:
LB.14.2.1 Initial training and competency assessment.
LB.14.2.2 Annual training, recertification and competency assessment.
LB.14.3 The laboratory has a system for monitoring the laboratory safety and infection control program.
LB.14.3.1 Documented safety and infection control audits are conducted at regular predefined-intervals (at least twice yearly).
LB.14.3.2 Findings of the audits are reported to the laboratory director, the facility safety officer, the infection control department, and other concerned parties.
LB.14.3.3 Corrective actions, whenever needed, are taken and documented.
LB.15 The laboratory has a services/specimen collection manual.
LB.15.1 The laboratory develops a services/specimen collection manual that includes the following:
LB.15.1.1 Available tests and services on and off-site (reference laboratory) and their Turn Around Times (TAT).
LB.15.1.2 Methods of patient preparation.
LB.15.1.3 Procedures for positive patient identification.
LB.15.1.4 Quality and quantity of sample.
LB.15.1.5 Phlebotomy and sample collection procedures.
LB.15.1.6 Recognizing and handling adverse reactions to phlebotomy.
LB.15.1.7 Specimen labeling.
LB.15.1.8 Requisition and required clinical data.
LB.15.1.9 Specimen handling and transportation.
LB.15.1.10 Specimen rejection criteria
LB.15.2 Laboratory services/specimen collection manual is available to all relevant departments.
LB.16 Requests for laboratory tests or services are complete and legible.
LB.16.1 Requests for laboratory tests or services bear sufficient information, including:
LB.16.1.1 Two patient's identifiers (patient's full name and medical record number).
LB.16.1.2 Patient Age and gender.
LB.16.1.3 Patient location.
LB.16.1.4 Identification of the authorized ordering physician.
LB.16.1.5 Type of specimen and required test.
LB.16.1.6 Date and time of specimen collection.
LB.16.1.7 Identification of the phlebotomist or the person who collected the specimen.
LB.16.1.8 Additional clinical information, as required.
LB.17 The laboratory ensures correct specimen labeling.
LB.17.1 The laboratory implements policies and procedures to ensure correct specimen labeling, including:
LB.17.1.1 Labeling of the specimen containers is conducted immediately after sample collection at the patient side.
LB.17.1.2 Two Patient's identifiers (patient's full name and medical record number).
LB.17.1.3 Date and time of sample collection.
LB.17.1.4 Identification of the person collecting the specimen.
LB.18 The laboratory develops a process for sample handling after collection.
LB.18.1 The laboratory has policies and procedures on proper sample handling, transporting, and tracking. This covers:
LB.18.1.1 Packing instructions (use of biohazard leak-proof containers).
LB.18.1.2 Personnel training (including safety and proper packaging).
LB.18.1.3 Specimen tracking system.
LB.18.2 The laboratory has a system to maintain the identity of laboratory specimen during receipt, processing, examination, and archiving.
LB.19 The laboratory develops a process for specimen receipt.
LB.19.1 The laboratory implements policies and procedures for the receipt and inspection of laboratory specimen to ensure the performance and documentation of:
LB.19.1.1 Date and time of specimen reception.
LB.19.1.2 Check for proper packaging.
LB.19.1.3 Check for quality and quantity of specimen.
LB.19.1.4 Check for adequacy of specimen labeling.
LB.19.1.5 Check for request completion.
LB.19.1.6 Check for label/request discrepancies.
LB.19.1.7 The use of suboptimal specimen is highlighted in the reported results.
LB.19.1.8 Final decision (accept/reject).
LB.20 The laboratory has a written description for the format and contents of its reports.
LB.20.1 The laboratory has a written description for the format and contents of its reports which
include:
LB.20.1.1 Identification of the testing laboratory.
LB.20.1.2 Patient identification (full name and medical record number, age and gender).
LB.20.1.3 Identification of the ordering physician.
LB.20.1.4 Date and time of specimen collection and the source of specimen.
LB.20.1.5 Reporting date and time.
LB.20.1.6 Test results and reference intervals.
LB.20.1.7 Identification of the authorized person releasing the report.
LB.20.2 The laboratory implements policies, procedures and records on report the drug of abuse result according to the national regulation and law.
LB.21 The laboratory develops a process for critical results reporting.
LB.21.1 The laboratory implements policies, procedures and records in consultation with clinical departments to address the following:
LB.21.1.1 Identification of results that should be reported as critical.
LB.21.1.2 Identification of the notified party.
LB.21.1.3 Identification of the means of communicating critical results.
LB.21.1.4 Description of the sequence of conveying the result and read-back.
LB.21.2 Documentation of critical results notification event includes:
LB.21.2.1 Date and time of notification.
LB.21.2.2 Patient identification.
LB.21.2.3 Test results.
LB.21.2.4 Documentation of read-back.
LB.21.2.5 Identification of the notifying person.
LB.21.2.6 Identification of the notified person.
LB.22 The laboratory develops a process for amending reported laboratory results.
LB.22.1 The laboratory implements policies and procedures for amending/correcting reported results. This includes:
LB.22.1.1 Definitions of report corrections and amendments.
LB.22.1.2 Format of the corrected report.
LB.22.1.3 Requirement to include the previous result in the corrected report.
LB.22.1.4 Notification of clinical departments.
LB.22.1.5 Application of general reporting requirements.
LB.23 The laboratory has a process for reference laboratory services.
LB.23.1 There is a defined and implemented process describing the laboratory role in selecting
and evaluating providers of reference laboratory service, including:
LB.23.1.1 Selection criteria (including accreditation status) for the provider of reference
laboratory services.
LB.23.1.2 Detailed procedure for specimen transportation and results reporting.
LB.24 The laboratory develops a comprehensive system for Point-of Care-Testing (POCT).
LB.24.1 The laboratory implements policies and procedures to address the following:
LB.24.1.1 Definition of POCT.
LB.24.1.2 Assignment of the responsibility of managing the POCT to the laboratory.
LB.24.1.3 Guidelines describing the process of acquiring POCT devices/methods.
LB.24.1.4 Training and competency testing requirements.
LB.24.1.5 Maintenance, quality control, and quality management of the POCT devices/methods.
LB.25 Laboratory records are retained for defined periods.
LB.25.1 The laboratory implements a general laboratory records retention system that ensures the following:
LB.25.1.1 Laboratory test request forms, specimen accessioning logs, instrument printouts, reported results, records of quality control, proficiency testing records, and quality management reports (quality indicators, audits, process improvement projects) are retained for three years.
LB.25.1.2 Method/instrument validation records are retained for the entire period of using the method/instrument and three years after discontinued.
LB.25.1.3 Maintenance records are retained for the life time of the instrument and three years after retirement.
LB.25.1.4 Employee identification records (signature, initials, identification code, and inclusive dates of hiring) are retained for the entire period of hiring and three years after departure.
LB.25.2 Discontinued (retired) general laboratory-controlled documents are retained for three years after the retirement date.
LB.26 The laboratory has a system for sample retention.
LB.26.1 There is a sample retention policy to ensure that general laboratory specimens are retained under appropriate conditions for no less than the periods specified below:
LB.26.1.1 Whole blood specimens and urine specimens are retained for twenty-four hours.
LB.26.1.2 Serum, plasma, cerebrospinal fluid and other body fluids specimens are retained for forty-eight hours.
LB.26.1.3 Permanently fixed and stained blood films are retained for seven days.
LB.26.1.4 Permanently fixed and stained microbiology slides are retained for seven days.
LB.27 The laboratory develops a process for internal (self) and external assessment of operations and quality management system.
LB.27.1 Selected general laboratory indicators may include, but are not limited to, the following:
LB.27.1.1 Patient identification errors.
LB.27.1.2 Turnaround Time (TAT) of routine, STAT and urgent requests.
LB.27.1.3 Critical value reporting failures.
LB.27.1.4 Corrected laboratory reports.
LB.27.1.5 Blood culture contamination.
LB.27.1.6 Rejected specimens.
LB.27.2 The laboratory has a system for process improvement that covers the following activities:
LB. 27.2.1 Identification of opportunities for improvement.
LB. 27.2.2 Corrective and preventive actions.
LB. 27.2.3 Description of the selected quality improvement tool used in the laboratory.
LB. 27.3 The laboratory is involved in hospital-wide/multidisciplinary improvement projects. During the current accreditation cycle, the laboratory was engaged in at least two quality improvement projects.
LB.28 The laboratory has a comprehensive system for Proficiency Testing (PT) sufficient for the extent and complexity of the laboratory scope of services.
LB.28.1 The laboratory implements policies, processes and procedures on Proficiency Testing to ensure the following:
LB.28.1.1 All laboratory analytes are covered with Proficiency Testing.
LB.28.1.2 Alternative Proficiency Testing is performed when appropriate.
LB.28.1.3 Instruction for the receipt, processing and reporting of Proficiency Testing results.
LB.28.1.4 Proficiency Testing samples are tested by the same personnel handling patient/donor samples.
LB.28.1.5 Proficiency Testing sample are tested by the same method used for testing patient/donor samples.
LB.28.1.6 Proficiency Testing samples are not referred to other laboratory for testing.
LB.28.1.7 Proficiency Testing results are not shared with other laboratories.
LB.28.1.8 Proficiency Testing results are evaluated and compared to the acceptable performance.
LB.28.1.9 Whenever appropriate, unacceptable performance is investigated and appropriate corrective actions are taken.
LB.28.1.10 Proficiency Testing records are reviewed and approved by laboratory management.
LB.28.1.11 Corrective actions are implemented and monitored (if applicable).
LB.29 The laboratory has a system for personnel audit trail.
LB.29.1 The system allows for the identification of who performed a critical task/step.
LB.29.2 The system allows for the identification of when, where, and why the task/step is performed
IPC.1 Hospital leaders support an infection prevention and control program.
IPC.1.1 Hospital leaders allocate adequate resources such as equipment and supplies for the support of the infection prevention and control program.
IPC.1.2 When some infection prevention and control functions are outsourced (e.g., sterilization or laundry), the hospital provides oversight and management of the contract.
IPC.1.3 The hospital has an infection prevention and control structure (e.g., department, team) with adequate qualified staff, based on its size, level of risks, and program scope and complexity.
IPC.2 The hospital designs and implements a coordinated program to reduce the risk of healthcare-associated infections (HAIs) in patients, visitors, and healthcare workers.
IPC.2.1 There is a program to reduce the risk of healthcare-associated infections which involves patients, families, staff, volunteers, trainees and visitors.
IPC.2.2 The program applies to all areas of the hospital.
IPC.2.3 The program is guided by an annual infection prevention and control plan.
IPC.2.4 The program addresses the unique situations of the hospital and its community such as patient populations, complexity of care provided, climate, and location.
IPC.2.5 The infection prevention and control program is based on:
IPC.2.5.1 Risk assessment.IPC.2.5.2 Current scientific knowledge.IPC.2.5.3 Applicable laws and regulations.
IPC.2.5.1 Risk assessment.
IPC.2.5.2 Current scientific knowledge.
IPC.2.5.3 Applicable laws and regulations.
IPC.3 The hospital has an infection prevention and control annual plan.
IPC.3.1 The hospital has infection prevention and control annual plan that addresses the epidemiologically important infections, processes, and devices that are associated with risk of healthcare-associated infections as identified by the hospital.
IPC.3.2 The plan includes measures for patient safety (standard precautions, transmission-based isolation, different care bundles).
IPC.3.3 The plan includes measures for staff safety (e.g., staff immunization and post exposure management).
IPC.4 The hospital provides continuing education on infection prevention and control practices to staff, patients, families, and other caregivers as indicated by their involvement in the care process.
IPC.4.1 The hospital provides education on infection prevention and control to patients, families, and other caregivers as appropriate.
IPC.5 There is a continuous surveillance of healthcare-associated infections integrated into the hospital's quality improvement program.
IPC.5.1 There are written standardized definitions for identification of healthcare-associated infections.
IPC.5.1 The hospital uses risk, rate, and trend information to design or modify processes to reduce healthcare-associated infections to the lowest possible level.
IPC.6 The hospital designs and implements a comprehensive system for investigation and management of outbreaks of infectious diseases.
IPC.6.1 There is a policy and procedure that guides staff for investigation and control of outbreaks of infectious diseases.
IPC.6.2 The policy defines how an outbreak is determined.
IPC.6.3 The infection prevention and control team leads the investigation and control of outbreaks of infectious diseases.
IPC.6.4 The results of investigation of an outbreak are used to prevent recurrence.
IPC.7 The hospital implements a comprehensive program for preventing and managing sharp injuries.
IPC.7.1 There is a policy and procedure that addresses handling of sharps.
IPC.7.2 Needles are not bent, broken, or recapped except in special and approved circumstances (if recapping is necessary, the "scoop method" is used).
IPC.8 Sharps are discarded in appropriate containers.
IPC.8 1 Sharp box used are puncture-proof, leak-proof, and present no risk to staff or patients.
IPC.8.2 Sufficient number of sharp boxes is available in-patient care areas (ideally one per patient's room or at least one per procedure trolley).
IPC.8.3 Sharp boxes are available in appropriate size according to the size of sharps used.
IPC.8.4 Sharp boxes are properly used: not overfilled, not opened to transfer sharps into other containers, and mounted at or below eye level.
IPC.8.5 Sharp boxes are disposed in accordance to laws and regulations when their contents are 3/4 of their sizes and/or when an odor arises.
IPC.9 There is a system that separates patients with communicable diseases and those who are colonized or infected with epidemiologically important organisms.
IPC.9.1 There are policies and procedures that address standard and transmission-based precautions.
IPC.9.1.1 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.9.2 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.9.2.1 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.IPC.9.2.2 All patients transferred to the hospital must be kept under contact transmission-based precaution unless proving otherwise.
IPC.9.2.1 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.
IPC.9.2.2 All patients transferred to the hospital must be kept under contact transmission-based precaution unless proving otherwise.
IPC.10 Facility design and available supplies support isolation practices.
IPC.10.1 There is at least one negative pressure airborne isolation room in the emergency room and one in patient care areas (one negative pressure room for every 25-30 beds in general hospitals).
IPC.10.2 The infection prevention and control team decides the need for more airborne isolation rooms depending on the volume of patients in need for airborne isolation admitted to the hospital.
IPC.10.2.1 The risk assessment can include but is not limited to:
IPC.10.2.1.1 The volume of patients in need of negative pressure airborne isolation room admitted to the hospital (inpatient, critical care wards, and others)
IPC.10.2.1.2 The demography of the population being served.
IPC.10.2.1.3 Infection trends in the populations served by the facility.
IPC.10.2.1.4 The number of patient admissions with infections known or suspected to require isolation.
IPC.10.2.1.5 The general duration of isolation required.
IPC.10.2.1.6 Seasonal variation of diseases to determine peak periods of infection.
IPC.10.2.1.7 Specialties of the health care facility.
IPC.10.2.2 Risk assessment must be discussed and approved by the infection control committee. IPC.10.2.3 Availability of valid/formal agreement with other healthcare facilities for transferring patients who need airborne isolation according to the negative pressure isolation room risk assessment if needed. IPC 10.2.4 Evaluation of the risk assessment plan and agreement must be conducted regularly, with corrective actions/improvements implemented when required.
IPC.10.2.2 Risk assessment must be discussed and approved by the infection control committee. IPC.10.2.3 Availability of valid/formal agreement with other healthcare facilities for transferring patients who need airborne isolation according to the negative pressure isolation room risk assessment if needed.
IPC 10.2.4 Evaluation of the risk assessment plan and agreement must be conducted regularly, with corrective actions/improvements implemented when required.
IPC.10.3 The ventilation system serving airborne isolation facilities provides pressure patterns that prevent airborne pathogens from being distributed to other areas of the hospital.
IPC.10.3.1 Rooms designed for airborne isolation patients are under negative pressure.IPC.10.3.2 Air is exhausted to the outside and is not re-circulated unless it is filtered through High-Efficiency Particulate Air (HEPA) Filter.IPC.10.3.3 The negative pressure for the isolation room should be validated on daily basis when patient is isolated (admitted in the room). Weekly validation is done when the room has no patients.
IPC.10.3.1 Rooms designed for airborne isolation patients are under negative pressure.
IPC.10.3.2 Air is exhausted to the outside and is not re-circulated unless it is filtered through High-Efficiency Particulate Air (HEPA) Filter.
IPC.10.3.3 The negative pressure for the isolation room should be validated on daily basis when patient is isolated (admitted in the room). Weekly validation is done when the room has no patients.
IPC.10.4 Toilet, shower, or tub and hand washing facilities are provided for each isolation room.
IPC.10.5 Transmission-based precaution cards (isolation signs) are consistent with the patient diagnosis and are posted in Arabic and English and indicate the type of precautions required.
IPC.10.5.1 Transmission-based precaution cards (isolation signs) are color coded for isolation of different categories (e.g., contact: green, airborne: blue, droplet: pink or red).IPC.10.5.2 Transmission-based precaution cards (isolation signs) should contain short statements and supported with the required figures.IPC.10.5.3 Isolation instructions must highlight the transmission-based precaution cards (isolation signs) needed while transporting the patients under transmission-based precautions to other department (e.g., radiology).
IPC.10.5.1 Transmission-based precaution cards (isolation signs) are color coded for isolation of different categories (e.g., contact: green, airborne: blue, droplet: pink or red).
IPC.10.5.2 Transmission-based precaution cards (isolation signs) should contain short statements and supported with the required figures.
IPC.10.5.3 Isolation instructions must highlight the transmission-based precaution cards (isolation signs) needed while transporting the patients under transmission-based precautions to other department (e.g., radiology).
IPC.10.6 Respirator (high filtration) masks (N-95, N-99) are used by staff during direct care of patients on airborne precautions and are available on all units likely to admit patients on airborne precautions.
IPC.10.7 Respirator (high filtration) masks (N95, N-99) can be reused by the same patient care giver as per the period specified by the manufacturer.
IPC.11 Disinfectants use is supervised by the infection prevention and control team.
IPC.11.1 Antiseptics and disinfectants are used in accordance with current scientific guidelines and recommended practice (e.g., approved by recognized professional organizations such as the Food and Drug Administration and Environmental Protection Agency).
IPC.12 The hospital ensures efficient and quality sterilization service.
IPC.12.1 The hospital provides central sterilization service.
IPC.12.2 There are policies and procedures for the central sterilization service.
IPC.12.2.1 The policies and procedures are consistent with scientific guidelines.
IPC.12.2.2 The policies and procedures are approved by the infection prevention and control committee.
IPC.12.2.3 There are policies and procedures on transportation, cleansing, decontamination, disinfection, sterilization, storage, and recall of sterile items.
IPC.12.3 Contaminated items are transported in safe closed containers with biohazards sign from the outside to prevent spills or aerosolization of infectious fluids.
IPC.13 Central sterilization service staff are qualified by education, certification, or training in the field of sterilization and disinfection.
IPC.13.1 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.13.2 Central sterilization service staff are qualified by education, certification, or training in the field of sterilization and disinfection.
IPC.13.3 Staff are able to explain the sterilizers' operation and to name the main parameters to be followed: sterilization time, temperature, and pressure.
IPC.13.4 Proper sterilization parameters are recorded.
IPC.13.4.1 Records include load list, daily function test, spore test results, lot number, and name of operator.
IPC.13.4.2 Sterilization records are kept for one year to allow inspection.
IPC.13.5 Sterilization time and temperature cycles used are in accordance with the manufacturer's guidelines.
IPC.14 The central sterilization service design supports its functions.
IPC.14.1 There is a unidirectional flow of traffic from dirty to clean areas (i.e. decontamination area, packing, sterilization, storage areas).
IPC.14.2 Traffic control signs are in place.
IPC.14.3 The decontamination area is under negative pressure with exhaust to the outside; the clean area is under positive pressure with at least ten air cycles/hour.
IPC.14.4 There is complete physical separation between the decontamination area, the area where clean items are packaged and sterilized, and the area were sterilized items are stored.
IPC.15 The central sterilization service has measures to ensure staff safety and proper function.
IPC.15.1 Personal protective equipment is available and used during decontamination (heavy-duty gloves, waterproof aprons, facemask, plastic durable boots and goggles or face shield).
IPC.15.2 If manual cleaning is performed, at least two sinks are used, one for soaking and cleaning and one for rinsing before the final wash.
IPC.15.3 The cleansing brushes are disposable. When the cleansing brushes are auto-cleavable, the manufacturer's instructions are followed and the brushes are replaced when needed.
IPC.15.4 Staff inspect instrument after cleansing to ensure that they are in good practical condition and fit to be used.
IPC.15.5 Preventive maintenance records for sterilizers are available show the maintenance history of the sterilizers.
IPC.15.6 Use of flash steam sterilizer is limited to urgent situations which preclude use of other sterilizer methods. This use is closely monitored and recorded. Policies in this regard are reviewed by central sterilization service staff.
IPC.15.7 Where ethylene oxide is used, safety and health hazards are addressed.
IPC.16 The hospital ensures safe reprocessing of single use items.
IPC.16.1 The hospital implements a policy and procedure regarding reprocessing of single use items. The policy defines the following:
IPC.16.1.1 The items that can be reused.
IPC.16.1.2 Patients and conditions for reuse of single-use items.
IPC.16.1.3 Measures taken to ensure safety and integrity including testing and maintenance by biomedical engineering.
IPC.16.1.4 Manufacturer approval as a prerequisite, whenever applicable.
IPC.16.2 The policy is approved by the infection prevention and control committee and hospital director.
IPC.17 The hospital has policies and procedures for housekeeping.
IPC.17.1 The housekeeping has policies and procedures that describe the areas to be cleaned, the schedule for cleaning, and the procedures to be used for cleaning different environmental surfaces.
IPC.17.2 Policies and procedures, schedules, and agents utilized are reviewed by infection prevention and control staff.
IPC.17.3 All units have a cleaning/ disinfection schedule which lists all environmental surfaces to be cleaned.
IPC.18 The hospital environment is kept clean.
IPC.18.1 Hospital environment, lockers, and cabinets are clean.
IPC.18.2 Food is stored under sanitary conditions and is consumed in designated places.
IPC.18.3 Food refrigerators are clean and are used only for food storage.
IPC.18.4 There are separate clean and dirty utility areas in each patient care area.
IPC.18.5 There are policies and procedures on pest control that address the regular schedule for pest control, chemical list, and time and place of exposure.
IPC.18.6 Routine environmental microbiological cultures are not performed unless recommended by the infection prevention and control team.
IPC.19 There is a system to handle blood/body fluids spills.
IPC.19.1 The hospital implements a policy on blood/body fluids spill kit use.
IPC.19.2 Blood spill kits are available in all patient care units, including all necessary components. IPC.19.3 Hospital staff working in patient care areas are capable of cleaning of blood/body fluids spills.
IPC.20 The hospital implements a program that is consistent with laws and regulations for safe disposal of medical waste.
IPC.20.1 There is a policy and procedure for safe disposal of medical waste.
IPC.20.2 Medical waste is disposed by specialized company and includes all types of medical waste.
IPC.20.3 Medical waste segregation, collection, and storing is conducted as per applicable laws and regulations.
IPC.20.4 Yellow bags are used for all non-sharp disposable materials contaminated with patient's blood and/or body fluids.
IPC.20.5 Yellow bags are distributed in the hospital in sufficient number and location.
IPC.20.6 Red bags are used for tissues, body parts, and amputated parts to be saved and then collected by the municipality to be buried.
IPC.20.7 Medical waste containers are cleaned and maintained regularly.
IPC.20.8 Hazard signs are fixed on all medical waste containers.
IPC.20.9 Medical waste collection points are cleaned and maintained regularly.
IPC.20.10 Labor working in medical disposal are well trained and vaccinated against blood borne pathogens.
IPC.21 The mortuary and postmortem area are supervised by infection prevention and control.
IPC.21.1 There are written policies on how to handle bodies post mortem especially bodies that have multiple open wounds.
IPC.21.2 The temperature of the morgue is kept at 2-4°C and logged daily.
IPC.21.3 For long term preservation of dead bodies, the facility must provide a deep-freezing compartment (temp < -15°C).
IPC.21.4 The morgue is regularly cleaned and disinfected.
IPC.22 Kitchen environment and functions are supervised by infection prevention and control.
IPC.22.1 Kitchen areas are separated based on assigned function. (Separate area for vegetables, meat, desert preparation, etc.).
IPC.22.2 Adequate number of hands washing facilities are present in each area.
IPC.22.3 Food containers are properly labeled and expiry dates noted.
IPC.22.4 Temperature requirements are met during storage, preparation, and transportation.
IPC.22.5 Food is protected from environment during storage, preparation, display, and transportation.
IPC.22.6 Garbage containers or receptacles are adequate in number, insect and rodent proof, and are covered.
IPC.22.7 Refrigerator temperatures are checked daily and documented on log sheets.
IPC.22.8 The kitchen environment and functions are addressed in policies and procedures that are reviewed by the infection prevention and control team.
IPC.22.9 Food delivery to the receiving area must be checked for quality and temperature.
IPC.22.10 Fruits and vegetables are washed and disinfected thoroughly.
IPC.22.11 Food containers are washed immediately after being emptied from food.
IPC.22.12 Boards used to cut meat, poultry, chicken, or vegetables are identifiably separated and immediately washed after use.
IPC.23 Kitchen staff hygiene and health are supervised by infection prevention and control.
IPC.23.1 There are policies and procedures that address staff hygiene and health in the kitchen and are reviewed by infection prevention and control team.
IPC.23.2 While handling food, hands are washed, hair is covered, and gloves are worn.
IPC.23.3 Personnel with respiratory infections or gastroenteritis are restricted from handling food.
IPC.23.4 Stool tests and cultures are performed routinely upon hiring, every six months, and after returning back from vacation.
IPC.23.5 Results of stool analysis and cultures are reviewed by the infection prevention and control practitioner.
IPC.24 Laundry functions are supervised by infection prevention and control team.
IPC.24.1 There are policies and procedures on linen management that cover all steps starting from collecting linen from patients' rooms until completion of the cleaning process.
IPC.24.2 Clean linen is transported, handled, and stored in a way that keeps it protected from contamination and dust.
IPC.24.3 Clean and used linen are separated during storage and transport.
IPC.24.4 Linen carts used for clean and used linen are identified.
IPC.24.5 Loose (un-bagged) linen is not to be put down a laundry chute.
IPC.24.6 Hand washing facilities are located in all areas where un-bagged linen is handled.
IPC.24.7 Soiled linen (contaminated with patient's blood, excreta, or other body fluids) and linen from patients under isolation precautions are contained and transported in accordance with current professional standards:
IPC.24.7.1 Soiled linen must be handled as little as possible and with minimal agitation.
IPC.24.7.2 Appropriate barriers (gloves, gowns, and masks) should be used when handling soiled linen.
IPC.24.7.3 Linen is bagged at the location where it is used and is not stored or pre-rinsed in patient's care areas.
IPC.24.7.4 Linen is put into special color-coded and water-proof laundry bags.
IPC.25 The infection prevention and control team reviews and supervises construction projects in the hospital.
IPC.25.1 There is a mechanism to ensure involvement of infection prevention and control team prior to any demolition, renovation, and construction projects.
IPC.25.2 Accepted infection prevention & control measures are followed during any demolition, renovation & construction projects e.g. infection control risk assessment (ICRA).
IPC.26 Personal protective equipment use is supervised by infection prevention and control team.
IPC.26.1 Personal protective equipment (gown, gloves, masks, and protective eyewear) are readily available in all patient care areas.
IPC.26.2 Policies and procedures are available on the appropriate use of gloves, gowns, facemasks, protective eyewear, and high filtration respirator masks (N-95, N-99).
IPC.26.3 Proper training for the use of personal protective equipment is conducted.
IPC.27 The hospital supports appropriate hand hygiene practices.
IPC.27.1 The hospital develops policies and procedures on the proper hand hygiene practices.
IPC.27.2 Hand hygiene is practiced according to the relevant policies.
IPC.28 The hospital provides sufficient hand hygiene facilities.
IPC.28.1 Toilets, hand washing, and bathing facilities meet the needs of the hospital and are clean and in good repair.
IPC.28.2 Hand washing sinks are available in all patients' rooms (including clinics and emergency rooms) and nursing stations.
IPC.28.3 Hand washing sinks and bathing facilities are supplied with hot and cold water under pressure.
IPC.28.4 Hand washing sinks are conveniently accessible to staff.
IPC.28.5 Antiseptic soap and towels are available for hand washing.
IPC.28.6 Hand disinfectants are available in adequate number (one dispenser per patients' room in general wards and clinics, one per bed in critical care areas and emergency rooms, and one in every nursing station).
IPC.29 The hospital reports communicable diseases to the relevant authorities.
IPC.29.1 Communicable diseases are timely reported internally to the infection prevention and control team by the treating team.
PC.29.2 The hospital reports communicable diseases to the Ministry of Health in accordance with laws and regulations and to other authorities whenever required.
IPC.30 There are policies and procedures that address employees' immunization and post exposure management.
IPC.30.1 There is a structure (e.g., staff health clinic) that provides pre-employment counseling and medical services related to screening, immunization, and post exposure management.
IPC.30.2 Employees' immunization and post exposure management are addressed in written policies and procedures.
IPC.30.3 Employees' immunization and post exposure management are consistent with laws and regulations and recommendations of professional organizations.
IPC.30.4 All employees have baseline screening for hepatitis B, C, HIV, and tuberculosis.
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.30.5 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.30.6 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.30.7 PPD conversion rates are calculated and monitored.
IPC.30.8 There is a system for reporting, follow up and management of exposure to open pulmonary TB and vaccine-preventable viruses: chickenpox, measles, mumps, and rubella.
IPC.30.9 The infection prevention and control team regularly monitors exposure of staff to pathogens and take corrective actions to prevent recurrence.
IPC.31 The hospital develops an anti-biogram that is regularly reviewed.
IPC.31.1 The anti-biogram is prepared at least once yearly.
IPC.32 The hospital adopts safe injection practices that minimize or prevent transmission of infection.
IPC.32.1 Staff use aseptic technique for injections preparation.
IPC.32.2 Staff use sterile syringes and needles.
IPC.32.3 Staff use single-dose vials as appropriate.
IPC.32.4 Staff use mask during injecting a medicine or placing a catheter into a spinal place.
IPC.33 The hospital implements evidence-based interventions to prevent catheter-associated urinary tract infection.
IPC.33.1 The hospital adopts and implements care bundle for prevention of catheter-associated urinary tract infection consistent with recognized professional practices.
IPC.34 The hospital implements evidence-based interventions to reduce the burden of epidemiologically significant organisms.
IPC.34.1 The hospital adopts and implements care bundle for prevention of Multidrug Resistant Organisms (MDROs) consistent with recognized professional practices.
IPC.35 Staff accommodation is healthy.
IPC.35.1 Staff accommodation is clean, well ventilated, not overcrowded, well maintained, and free from pets.
IPC.35.2 Staff accommodation provides facilities for staff isolated or restricted from work due to infection issues.
RD.1 Qualified radiologist is responsible for managing the radiology department.
RD.1.1 The head of the radiology department is a radiologist qualified by education, training, and experience.
RD.1.2 The head of the radiology department supervises the development and implementation of policies and procedures related to radiology services throughout the hospital.
RD.2 The radiology department has adequate qualified staff.
RD.2.1 Staff working in the department are trained and qualified in their field.
RD.2.2 There is twenty-four-hour coverage by a radiologist and a technologist.
RD.3 The radiology department has policies and procedures that guide all radiological activities
RD.3.1 The radiology department has policies and procedures to address all important radiological investigations and procedures, including:
RD.3.1.1 X-rays.RD.3.1.2 Ultrasonography.RD.3.1.3 Computed Tomography.
RD.3.1.1 X-rays.
RD.3.1.2 Ultrasonography.
RD.3.1.3 Computed Tomography.
RD.4 The radiology department implements a policy and procedure for reporting of critical results.
RD.4.1 There is a policy and procedure for reporting of critical results developed in consultation with clinical departments.
RD.4.2 The policy defines the notified party and mean of communication.
RD.4.3 The policy defines the “read- back “sequence of reporting of critical results.
RD.4.4 The policy defines the proper documentation of a notification event, which includes:
RD.4.4.1 Date and time of notification.RD.4.4.2 Patient identification.RD.4.4.3 The critical result.RD.4.4.4 Documentation of read-back.RD.4.4.5 Identification of the notifying person.RD.4.4.6 Identification of the notified person.
RD.4.4.1 Date and time of notification.
RD.4.4.2 Patient identification.
RD.4.4.3 The critical result.
RD.4.4.4 Documentation of read-back.
RD.4.4.5 Identification of the notifying person.
RD.4.4.6 Identification of the notified person.
RD.5 Previous radiological studies can always be accessed.
RD.5.1 There is a master X-ray jacket or an access to all archived previous radiological studies (Picture Archiving and Communication System-PACS) for every patient.
RD.6 The radiology department has a documented and implemented safety plan.
RD.6.1 There is a safety plan that indicates the periodic inspection, maintenance, and calibration of all equipment.
RD.6.2 The safety plan involves the management of radioactive materials used for therapeutic and diagnostic purposes, particularly with regard to handling, storing, and transportation.
RD.6.3 The safety plan involves posting of safety warnings on the doors.
RD.6.4 The safety plan involves checking female patients for pregnancy before exposure.
RD.6.5 The safety plan indicates monitoring of the staff for radiation exposure, at least quarterly.
RD.6.6 The safety plan involves the provision and regular testing of radiation protection aprons and thyroid and gonad shields for staff and patients.
RD.6.7 Records are available indicating the radiation dosimetry tools and staff radiation exposure for the past twelve months.
RD.6.8 The safety plan is implemented as evidenced by the daily practice.
RD.7 The radiology department ensures the safety of diagnostic imaging equipment.
RD.7.1 The radiology department ensures the following tests are conducted at least annually:
RD.7.1.1 Automatic Exposure Control (AEC) test.RD.7.1.2 Kvp reproducibility and repeatability.RD.7.1.3 Half Value Layer test.RD.7.1.4 Alignment of collimator and x-ray field.RD.7.1.5 Mean glandular dose test (for mammography).
RD.7.1.1 Automatic Exposure Control (AEC) test.
RD.7.1.2 Kvp reproducibility and repeatability.
RD.7.1.3 Half Value Layer test.
RD.7.1.4 Alignment of collimator and x-ray field.
RD.7.1.5 Mean glandular dose test (for mammography).
RD.7.2 The radiology department implements corrective actions accordingly.
FMS.1 Hospital Leaders establish and support a facility management and safety program.
FMS.1.1 The facility management and safety program includes the following written and approved plans:
FMS.1.1.1 Safety of the Building.
FMS.1.1.2 Security.
FMS.1.1.3 Hazardous materials and waste disposal.
FMS.1.1.4 External emergency.
FMS.1.1.5 Internal emergency.
FMS.1.1.6 Fire Safety.
FMS.1.1.7 Medical equipment.
FMS.1.1.8 Utility System.
FMS.1.2 Hospital leaders support the facility management and safety program to acquire the necessary equipment.
FMS.1.3 The program includes regular inspection, testing, and maintenance of all the operating components of the program.
FMS.1.4 The program has a budget for the necessary upgrading or replacement as identified by monitoring data or to meet applicable laws and regulations.
FMS.1.5 There is an orientation program conducted for new hires on the facility management and safety plans.
FMS.2 There is a qualified individual(s) responsible for directing and coordinating the facility management and safety program.
FMS.2.1 The hospital has a facility management and safety program director who directs and coordinates all aspects of the facility management and safety program.
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.2.4 The program director provides ongoing consultation to all departments.
FMS.2.5 Each department has an assigned "liaison safety officer" to liaise all safety issues within the department.
FMS.3 There is a multidisciplinary safety committee that provides oversight of the facility management and safety program.
FMS.3.1 The committee's membership consists of representatives from relevant departments such as
safety, security, housekeeping, infection control, risk management, biomedical engineering,
laboratory, medical staff (E.R), nursing, radiation safety, maintenance, and quality management.
FMS.3.2 The safety committee provides oversight of the facility management and safety program.
FMS.3.3 Safety committee meets at least ten times per year on a monthly schedule. Minutes are
documented to be approved by the hospital leadership.
FMS.3.4 The safety committee, through a multidisciplinary team, conducts quarterly and as needed facility safety tours to identify risks and hazards related to the facility.
FMS.3.5 The committee uses the resulting information for corrective and preventive actions, planning,
and budgeting of long-term upgrading and replacement
FMS.4 The hospital is in compliance with applicable laws and regulations.
FMS.4.1 The hospital has a valid Saudi Civil Defense license.
FMS.4.2 The hospital has a valid Saudi Civil Defense report and action plan as applicable.
FMS.4.3 Hospital leaders ensure compliance with applicable building and environmental protection
standards, laws, and regulations (e.g., MOMRA's hospital building requirements, Saudi building
code, discharges to drainage systems, safe disposal of waste).
FMS.5 The hospital ensures safety and security of staff and patients during construction, renovation, or demolition projects.
FMS.5.1. The hospital implements a policy for safety and security of patients, staff and visitors during construction, renovation, or demolition that includes:
FMS.5.1.1 Safety and security instructions.
FMS.5.1.2 Education of contractors.
FMS.5.1.3 Proper isolation of construction and renovation sites.
FMS.5.1.4 How to eliminate the risks of fire and spread of dust.
FMS.5.1.5 Penalties incurred on contractors for violating the policy.
FMS.5.1.6 Safety rounds on construction/renovation sites by facility management and safety and infection control staff.
FMS.5.2. A work permit is signed by the construction team and posted in the construction, renovation, or demolition sites.
FMS.6 Warning and directive signs are posted inside the hospital as appropriate.
FMS.6.1. There are warning signs posted as appropriate in the hospital and include:
FMS.6.1.1 Signs for the radioactive materials including warning signs for pregnant women.
FMS.6.1.2 Signs for wet floors during cleaning.
FMS.6.2 There are directive signs posted as appropriate in the hospital and include:
FMS.6.2.1 Signs indicating the hospital name and main entrances/exits.
FMS.6.2.2 Directional signs.
FMS.6.2.3 Signs to direct staff and patients to the different services in the hospital.
FMS.6.2.4 Fire exit signs.
FMS.6.2.5 Signs to identify floor level at staircases and in front of elevators.
FMS.6.2.6 Signs to instruct staff, patients, and visitors in restricted areas.
FMS.6.2.7 MRI patient safety measures and steel restriction signs.
FMS.6.2.8 Signs for populations with special needs.
FMS.7 The hospital is equipped for vulnerable individuals and others with special needs.
FMS.7.1. The hospital is equipped with special parking spots.
FMS.7.2. The hospital is equipped with wheel chairs and relevant ramps are in all elevated areas.
FMS.7.3. The hospital is equipped with handrails in the corridors and stairs.
FMS.7.4. The hospital is child safe in the public areas (tamper free outlets, no sharp ends).
FMS.8 Safety measures and equipment are applied where needed in the hospital to ensure safety of patients and staff.
FMS.8.1 the hospital takes necessary action to minimize the risk(s) of physical environment that could be used to attempt suicide including anchor points, door hinges and hooks that can be used for hanging.
FMS.8.2. The patient's bathrooms and showers are provided with the following safety measures:
FMS.8.2.1 Non-slipping floors' surfaces.
FMS.8.2.2 Bars to support patients.
FMS.8.2.3 Bell or a system to call for help.
FMS.8.2.4 Lock system that allows opening from outside.
FMS.8.3. The kitchen has safety equipment that include:
FMS.8.3.1 Eye wash stations.
FMS.8.3.2 Fire blankets.
FMS.8.3.3 First aid kit.
FMS.8.3.4 Fire Extinguishers.
FMS.8.3.5 Emergency shower.
FMS.9 The hospital ensures that all its occupants are safe from radiation hazards.
FMS.9.1 The hospital has a radiation safety policy and procedure and it is implemented.
FMS.9.2 The hospital has the relevant valid license(s) from King Abdulaziz City for Science
and Technology.
FMS.9.3 There is a valid shielding certificate of the x-ray room(s) including regular test to
ensure permissible radiation levels.
FMS.9.4 Lead aprons and gonad/thyroid shields are available to cover patients and staff needs
and are annually tested according to a hospital-wide inventory.
FMS.9.5 Personal radiation dosimeters (TLD cards) are available, tested every 3 months, and
actions taken when test results exceed permissible levels.
FMS.10 The hospital environment is secure for patients, visitors, and staff.
FMS.10.1. There are identification badges for the following staff categories:
FMS.10.1.1 Hospital staff.
FMS.10.1.2 Temporary employees.
FMS.10.1.3 Contractor staff.
FMS.10.2. Security personnel or alternative security systems are utilized to restrict access to sensitive areas that include, but are not limited to, the following:
FMS.10.2.1 Female wards.
FMS.10.2.2 Central sterilization service department.
FMS.10.2.3 Morgue.
FMS.10.2.4 Medical records.
FMS.10.2.5 Hospital roof.
FMS.10.2.6 Medical equipment and goods stores including pharmacy narcotic vault.
FMS.10.3. There are policies and procedures for the following:
FMS.10.3.1 Preventing children abduction.
FMS.10.3.2 Lost and found items.
FMS.10.3.3 Safe keeping of patient belongings.
FMS.10.3.4 Involvement of police in cases of trauma, motor vehicle accidents, and medico-legal incidents.
FMS.10.3.5 Incidents of violence (violence code).
FMS.10.3.6 Women and child abuse.
FMS.10.4. Staff are trained on response to all security alerts.
FMS.11 The hospital has a mechanism to deal with a bomb threat.
FMS.11.1. There is a written policy on how to deal with a bomb threat in the hospital which includes:
FMS.11.1.1 Defining the code or alert.
FMS.11.1.2 Defining the role of the person receiving threat alerts.
FMS.11.1.3 Defining the response team including the individual responsible for announcing the emergency status and contacting the local authorities.
FMS.11.1.4 Defining the duties and the responsibilities of all staff involved and their action cards.
FMS.11.1.5 The command center location.
FMS.11.1.6 Defining the steps to be taken during the bomb threat.
FMS.11.2. Staff are trained on response to bomb threat alerts.
FMS.12 The hospital has a program to diffuse any aggressive situation
FMS.12.1 There is policy and procedure for responding and monitoring the use of the panic alarm system.
FMS.12.2 The hospital has a panic alarm system and it is functioning and regularly inspected.
FMS.12.3 The hospital staff are trained to deescalate the violent situations and in the use of the panic system.
FMS.13 The hospital has qualified individuals assigned to maintain security.
FMS.13.1 The number of security personnel is proportional to the size of the hospital, number of entrances,
and the availability of supporting security systems.
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.
FMS.13.3.2 Emergency codes.
FMS.13.3.3 Fire safety.
FMS.13.4 The security personnel roles are defined for the following:
FMS.13.4.1 External disaster plan.
FMS.13.4.2 Internal disaster plan.
FMS.13.4.3 No smoking policy.
FMS.13.5 The security personnel have a dress code.
FMS.13.6 The security personnel conduct hospital wide security rounds and significant findings are
documented.
FMS.14 The hospital ensures safe management of hazardous materials.
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.14.2 Each department has a current list of hazardous materials used in the department. The list
covers:
FMS.14.2.1 Purpose of use.
FMS.14.2.2 The responsible person.
FMS.14.2.3 Permitted quantity.
FMS.14.3 Each department dealing with hazardous materials has Material Safety Data Sheets (MSDS)
relevant to its current list of hazardous materials.
FMS.14.4 Each department using hazardous materials has proper personal protective equipment (PPE) and spill kits to handle any spill or exposure.
FMS.14.5 All hazardous materials are labeled and this includes:
FMS.14.5.1 Corrosives, acids, and toxic materials.
FMS.14.5.2 Hazardous gases and vapors.
FMS.14.5.3 Anesthetic gases.
FMS.14.5.4 Flammable liquids.
FMS.14.6 Any leak, spill, or exposure to any hazardous material is reported
FMS.15 The hospital implements a waste management plan.
FMS.15.1 The hospital has a waste management plan that includes handling, storing, transporting, and
disposing all kinds of waste (e.g., clinical waste and hazardous gases).
FMS.15.2 The plan is implemented.
FMS.15.3 Staff (including contractors' staff) are trained on dealing with hazardous waste.
FMS.16 The hospital ensures preparedness for external disasters.
FMS.16.1 The hospital has a plan to deal with potential external disasters. The plan includes:
FMS.16.1.1 Identification of all potential external emergencies and disasters.
FMS.16.1.2 Names and titles of all staff to be called including their contact numbers and action
cards.
FMS.16.1.3 Duties and responsibilities of hospital leaders.
FMS.16.1.4 The triage areas, their locations, and triage action cards.
FMS.16.1.5 The individual responsible for announcing the emergency state and contacting the
local authority.
FMS.16.1.6 The control room location and the person in charge.
FMS.16.1.7 The total number of beds that can be evacuated.
FMS.16.1.8 The role of the security personnel.
FMS.16.1.9 The role of each department in the hospital.
FMS.16.2 The hospital conducts an external disaster drill at least annually.
FMS.16.3 The hospital ensures the availability of ambulances and medical supplies and equipment required in case of external disasters (e.g., medical bags, drugs and mobile monitors).
FMS.16.4 There is an orientation on the external disaster plan for new hires with an annual update for all staff.
FMS.17 The hospital ensures preparedness for internal disasters.
FMS.17.1 The hospital has a plan to deal with potential internal disasters. The plan includes:
FMS.17.1.1 Names and titles of all staff to be called in case of internal disaster, their contact
numbers, and action cards.
FMS.17.1.2 The control room location and the position of the individual in charge.
FMS.17.1.3 The duties and responsibilities of hospital leaders.
FMS.17.1.4 The procedure for relocation of patients.
FMS.17.1.5 The individual responsible for announcing the emergency state and contacting local
authority.
FMS.17.1.6 Individual(s) authorized to deal with the electricity supply and medical gas system
and to shut them off as needed in case of fire or explosions in the hospital.
FMS.17.1.7 The meeting point for the staff in case of horizontal evacuations (assembly points)
inside the building.
FMS.17.1.8 The meeting point for the full evacuation (holding area) outside the building.
FMS.17.1.9 The evacuation procedure for patients, visitors, and employees.
FMS.17.2 Every department has a specific internal disaster plan that addresses departmental actions in
case internal disasters.
FMS.17.3 There are evacuation maps posted hospital wide indicating locations of:
FMS.17.3.1 You are here.
FMS.17.3.2 Fire extinguishers.
FMS.17.3.3 Fire hose reel/cabinets.
FMS.17.3.4 Fire blankets.
FMS.17.3.5 Escape routes.
FMS.17.3.6 Assembly points.
FMS.17.3.7 Fire exits.
FMS.17.3.8 Call points break glass/pull station.
FMS.17.3.9 Medical gas isolation valves.
FMS.18 The hospital has a system for scheduling and conducting fire drills regularly.
FMS.18.1 Fire drills are scheduled and conducted regularly in all departments.
FMS.18.2 Fire drills are conducted during different shifts to test:
FMS.18.2.1 Using Rescue, Alarm, Confine, Extinguish/Evacuate (RACE) procedure.
FMS.18.2.2 Using Pull, Aim, Squeeze, Sweep (PASS) procedure.
FMS.18.2.3 The ability to contain the fire when it starts.
FMS.18.2.4 Staff performance in the event of fire.
FMS.18.2.5 Evacuation procedures.
FMS.18.2.6 Whether the oxygen and electricity supplies were shut off at the right time.
FMS.18.3 All staff participate in the fire drills.
FMS.18.4 All fire drills' results and corrective actions are documented and integrated into the quality
improvement program.
FMS.18.5 A full fire drill is conducted for the internal disaster plan once a year and this drill is evaluated.
FMS.19 The hospital supports fire prevention.
FMS.19.1 The hospital ensures procuring materials like curtains and drapes that are fire retardant.
FMS.19.2 The hospital ensures separating all dangerous materials or flammables from heat generating
areas.
FMS.19.3 The hospital ensures installing fire rated walls as appropriate, especially in high risk areas like
the laboratory, electrical rooms, and kitchen.
FMS.19.4 The hospital ensures installing fire stop materials to seal penetrations as appropriate (especially
in technical rooms, electrical rooms, and escape routes).
FMS.19.5 The hospital ensures developing and scheduling staff training programs on the use of fire
extinguishers.
FMS.20 Fire extinguishers are available in the hospital and are properly distributed.
FMS.20.1 The fire extinguishers are adequate in number as per civil defense guidelines.
FMS.20.2 The fire extinguishers are appropriately distributed throughout the hospital.
FMS.20.3 The fire extinguishers are appropriately positioned as per civil defense guidelines.
FMS.20.4 The fire extinguishers are inspected monthly to assess functionality.
FMS.21 The hospital has an effective fire alarm system.
FMS.21.1 There is a fire alarm system that is functioning and regularly inspected as per
civil defense guidelines.
FMS.21.2 The fire alarm system testing results are documented.
FMS.21.3 The fire alarm system has preventive maintenance.
FMS.21.4 The elevators are connected to the fire alarm system.
FMS.22 The hospital has a fire suppression system available in the required area(s).
FMS.22.1 The hospital has a functional sprinkler system.
FMS.22.2 The hospital has clean agent suppression system.
FMS.22.3 The hospital has wet chemical system.
FMS.22.4 The hospital has stand pipes and hose system.
FMS.23 There are fire exits that are properly located in the hospital.
FMS.23.1 Fire exits are available and are properly located in the hospital.
FMS.23.2 Fire exits are not locked.
FMS.23.3 Fire exits are not obstructed.
FMS.23.4 Fire exits have panic hard ware.
FMS.23.5 Fire exits are marked with illuminated exit sign.
FMS.24 The hospital and its occupants are safe from fire and smoke.
FMS.24.1 The hospital implements a strict “No Smoking" policy.
FMS.24.2 There are no obstructions to exits, fire extinguishers, fire alarm boxes,
emergency blankets, safety showers, and eye wash stations.
FMS.24.3 Emergency lighting is adequate for safe evacuation of the hospital.
FMS.24.4 Storage areas are properly and safely organized:
FMS.24.4.1 Shelves and racks are sturdy and in good condition.
FMS.24.4.2 No items stored directly on the floor (a minimum of ten centimeters is
left to manage spills).
FMS.24.4.3 Items should be stacked on a flat base.
FMS.24.4.4 Heavier objects are close to the floor and lighter/smaller objects are
higher.
FMS.24.4.5 Items are not stacked so high to block sprinklers or come in contact
with overhead lights or pipes (a minimum distance of fifty centimeters from ceiling level).
FMS.24.5 Fire rated doors are available according to the hospital zones with no separation
between walls and ceiling to prevent smoke spread between rooms and areas.
FMS.25 The hospital has a biomedical equipment plan to ensure that the medical equipment are regularly monitored, maintained, and ready for use.
FMS.25.1 The hospital has adequate number of qualified biomedical staff.
FMS.25.2 There is a written biomedical equipment plan that covers the following:
FMS.25.2.1 A comprehensive inventory of medical equipment with their corresponding locations.
FMS.25.2.2 Preventive maintenance program that conforms with the manufacturer's instructions.
FMS.25.2.3 The program specifies, for each equipment, the frequency of checks, methods of
checks, acceptance criteria, and actions to be taken in the event of unsatisfactory
results.
FMS.25.2.4 The program includes the process for investigation and follow-up of equipment failure that addresses reporting of failure, immediate remedial actions, assessment of the
failure effect on reported results and services (needs alignment), and requalification
of the equipment.
FMS.25.2.5 Electrical safety testing for patient related equipment.
FMS.25.2.6 History record for the maintenance schedule, failure incidence, and repairs done.
FMS.25.3 Technical service manuals for all equipment are available at the biomedical workshops.
FMS.25.4 Operator manuals are available at all departments using the equipment.
FMS.25.5 The hospital ensures that all maintenance works are conducted by qualified and trained staff.
FMS.25.6 Equipment maintenance and repairs are documented to help in the decision making for
replacement.
FMS.25.7 Investigation procedures conform to manufacturer's instructions.
FMS.25.8 There is an equipment recall system that is implemented.
FMS.25.9 Each department has a back-up or alternative for each critical equipment to cover for prolonged downtime.
FMS.25.10 Preventative Maintenance data are used for upgrading/replacing of equipment.
FMS.26 The hospital has policies and procedures that support the medical equipment management program.
FMS.26.1 There is a policy to perform inspection on all new equipment for conformity before commissioning including those brought for "demos".
FMS.26.2 There is a written policy for tagging medical equipment as follows:
FMS.26.2.1 Preventive maintenance with testing date and due date.
FMS.26.2.2 Inventory number.
FMS.26.2.3 Removal from service.
FMS.26.2.4 Electrical safety check.
FMS.26.3 There is a policy for removal of equipment from service.
FMS.26.4 There is a policy to address agent or contractor repairs.
FMS.26.5 There is a policy to eliminate the use of extension cords.
FMS.26.6 There is a policy to restrict the use of cellular phones in the intensive care units, and cardiology units, as needed.
FMS.27 The hospital ensures staff are trained and tested competent on the safe operation of equipment including medical devices.
FMS.27.1 A policy is in place to ensure staff are trained on the safe operation of the current and newly
introduced equipment and medical devices.
FMS.27.2 The policy addresses the required training and competency testing of staff operating
specialized equipment.
FMS.27.3 Only trained and competent staff handle specialized equipment and medical devices.
FMS.28 The hospital has a utility system management plan.
FMS.28.1 The hospital has adequate number of qualified staff to manage the utility system.
FMS.28.2 There is a utility system management plan that includes management of failure or interruption of the following utilities:
FMS.28.2.1 Normal power.
FMS.28.2.2 Emergency power, cases of no power at sockets at critical areas, and lamp failure
at critical areas.
FMS.28.2.3 Elevators.
FMS.28.2.4 Water supply.
FMS.28.2.5 Reverse osmosis plant.
FMS.28.2.6 Air-conditioning fan coil unit (FCU) at patient rooms.
FMS.28.2.7 Medical gas system.
FMS.28.2.8 Sewer lines.
FMS.28.2.9 Boiler.
FMS.28.2.10 Telephone service (Public Address Exchange - PABX).
FMS.28.2.11 Intercom, nurse call, and overhead paging.
FMS.28.2.12 Fire alarm.
FMS.28.3 The utility system management plan includes description of necessary hospital programs to:
FMS.28.3.1 Acquire necessary equipment.
FMS.28.3.2 Upgrade equipment.
FMS.28.3.3 Upgrade physical condition of the building.
FMS.28.4 Emergency plans are tested in simulation at least once a year and the test results are evaluated.
FMS.28.5 The utility system plan ensures the availability of the following:
FMS.28.5.1 Technical utility drawings that show the distribution lines for all utilities and how to
control them centrally and peripherally so that lines can be controlled as required in
case of emergency.
FMS.28.5.2 Statistical data produced by the maintenance management system as an indicator
to evaluate performance of the systems, suggest improvements and upgrade as
required.
FMS.29 The hospital implements a preventive maintenance plan.
FMS.29.1 There is a preventive maintenance plan that covers at least the following:
FMS.29.1.1 Electrical system.
FMS.29.1.2 Elevators.
FMS.29.1.3 Refrigerators/Freezers.
FMS.29.1.4 Air conditioning system.
FMS.29.1.5 Medical gas system.
FMS.29.1.6 Medical suction.
FMS.29.1.7 Domestic water system, including water pumps and fire hydrants.
FMS.29.1.8 Fire water system, including fire pumps.
FMS.29.1.9 Boilers.
FMS.29.1.10 Plumbing.
FMS.29.1.11 Low current and communication system.
FMS.29.1.12 Pavement and ground.
FMS.29.1.13 Hospital building and ancillaries.
FMS.29.2 The hospital ensures all maintenance works are conducted by qualified and trained staff.
FMS.30 The hospital ensures electrical safety.
FMS.30.1 The electrical outlets are identified for:
FMS.30.1.1 Voltage (110/220).
FMS.30.1.2 Source (essential/prime).
FMS.30.2 Thermal inspection of circuit breakers is annually conducted for:
FMS.30.2.1 Laboratory.
FMS.30.2.2 Critical care area.
FMS.30.2.3 Alarm system.
FMS.30.2.4 Medical gas system.
FMS.30.3 There is an earthing system in the roof top and sockets used for medical equipment.
FMS.31 The hospital ensures that emergency power covers the critical areas in case of failure.
FMS.31.1 The hospital has an emergency power that covers at least the following critical areas:
FMS.31.1.1 Critical care area.
FMS.31.1.2 Alarm system.
FMS.31.1.3 Fire pumps
FMS.31.1.4 Medical gas system.
FMS.31.1.5 Refrigerators in the pharmacy, laboratory, medical store, and kitchen.
FMS.31.1.6 Elevators.
FMS.31.1.7 Escape routes/corridors.
FMS.31.1.8 Morgue.
FMS.31.1.9 Medications stores.
FMS.31.1.10 Emergency room.
FMS.31.2 The hospital ensures the readiness of its emergency power generator(s).
FMS.31.2.1 The hospital maintains its generator(s) on a periodic basis. The maintenance results
are documented.
FMS.31.2.2 The hospital performs weekly test without load for ten minutes.
FMS.31.2.3 The hospital performs monthly on load test for thirty minutes.
FMS.31.2.4 The hospital performs full load test every three years on external load.
FMS.31.2.5 The hospital generator starts normally without load for ten minutes.
FMS.32 The hospital ensures proper maintenance of the medical gas system.
FMS.31.1 The medical gas system is regularly tested for:
FMS.32.1.1 Pressure.
FMS.32.1.2 Leaks.
FMS.32.1.3 Functionality of valves, alarms, pressure gauge, and switches.
FMS.32.2 There is a policy and procedure that ensures effective use of medical gas system.
Areas covered include, but are not limited to, the following:
FMS.32.2.1 The procedures to follow for taking any part of the system offline.
FMS.32.2.2 Commissioning and testing new branching or modifications.
FMS.32.2.3 The procedure for ordering and filling liquid oxygen.
FMS.32.2.4 Documenting all repairs/alterations/tests/filling logs/consumption.
FMS.32.3 Compressed medical air is regularly tested for humidity and purity.
FMS.32.4 The central medical gas station is in a safe and secure place.
FMS.32.5 The outlets of medical gases in patient care areas are marked with the type
of gas and have different connections according to the gas type.
FMS.32.6 All medical gas pipes are marked and labeled for the contents and direction
of gas flow.
FMS.32.7. The hospital keeps standby oxygen and medical air cylinders enough for forty-eight hours of average consumption.
FMS.32.8. The gas cylinders are regularly tested for gas type, amount, and any leaks.
FMS.32.9. Emergency shut off valves are available in all units and are marked with
areas/rooms affected.
FMS.32.10 The hospital dedicates the responsibility of the closure of shut off valves to well-trained individual(s) available in the unit concerned.
FMS.32.11 The hospital has adequate medical gases outlets in the patient care areas as appropriate and these outlets are to be error proof medical gas outlets- preferred to be in accordance with DIN standards related to gases piping, outlets and valves.
FMS.33 The hospital has a documented system for handling the various types of compressed gasses.
FMS.33.1 There is a policy on how to handle various types of compressed gasses, which includes:
FMS.33.1.1 Storing them in a well-ventilated area.
FMS.33.1.2 Positioning them upright the wall and secured by a chain.
FMS.33.1.3 Separating any flammables from oxidizing gases.
FMS.33.2 Exhausts of the following gases are extended to the roof and identified:
FMS.33.2.1 Laboratory safety cabinet gases of a certain classes.
FMS.33.2.2 Central vacuum gases.
FMS.33.2.3 Scavenger gases of certain types.
FMS.34 There is a periodic preventive maintenance plan for heating, ventilating, and air- conditioning.
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.34.2 The HVAC maintenance records are maintained.
FMS.34.3 The HVAC is maintained to control the air quality by:
FMS.34.3.1 Cleaning /replacement of filters.
FMS.34.3.2 Cleaning of diffuser.
FMS.34.3.3 Cleaning of ducts.
FMS.34.4 HEPA filters are monitored on a monthly basis and the results are documented.
FMS.34.5 Air change per hour is maintained as per national and international guidelines (e.g., American
Society of Heating, Refrigerating & Air-Conditioning Engineers, ASHRAE).
FMS.35 The hospital ensures proper air flows (positive, negative, balanced) in the required locations.
FMS.35.1 Appropriate air flows (positive, negative, balanced) are established and monitored in isolation
room(s).
FMS.35.2 Appropriate air flows (positive, negative, balanced) are established and monitored in critical care unit(s).
FMS.35.3 Appropriate air flows (positive, negative, balanced) are established and monitored in clean and dirty utility.
FMS.35.4 Appropriate air flows (positive, negative, balanced) are established and monitored in janitorial
closet.
FMS.35.5 Appropriate air flows (positive, negative, balanced) are established and monitored in the
laboratory.
FMS.35.6 Appropriate air flows (positive, negative, balanced) are established and monitored in triage areas.
FMS.35.7 Appropriate air flows (positive, negative, balanced) are established and monitored in the central sterilization and supply department.
FMS.36 The hospital provides appropriate control of temperature and humidity in the required locations.
FMS.36.1 Temperature and humidity are controlled and regularly monitored in nursery.
FMS.36.2 Temperature and humidity are controlled and regularly monitored in critical care unit(s).
FMS.36.3 Temperature and humidity are controlled and regularly monitored in sterile storage supply.
FMS.36.4 Temperature and humidity are controlled and regularly monitored inpatient rooms.
FMS.37 The hospital has a periodic preventive maintenance plan for the water system.
FMS.37.1 There is a periodic preventive maintenance plan (PPM) for the water system that is supported by trained and specialized staff/contractor.
FMS.37.2 The PPM records are maintained for the following:
FMS.37.2.1 Water is available twenty-four hours a day, seven days a week.
FMS.37.2.2 The incoming water supply is checked regularly for at least: chemicals (once every
six months) and bacteria (monthly), and results are monitored.
FMS.38 The hospital ensures safe sewage handling and disposal.
FMS.38.1 Sewage handling and disposal is safely conducted in an efficient and sanitary manner according to professional codes of practice.
FMS.39 The hospital maintains the kitchen and laundry equipment in good working condition.
FMS.39.1 Laundry equipment are regularly inspected and tested.
FMS.39.2 Results of inspection and testing of kitchen equipment are documented as follows:
FMS.39.2.1 Hoods' fans are in good operating condition and free from grease.
FMS.39.2.2 Hood filters are cleaned weekly and no cooking is done with missing filters.
FMS.39.2.3 Cold room temperature is monitored.
FMS.39.2.4 Kitchen and pantry microwaves, stoves, and ovens are at least annually tested and
maintained.
FMS.40 The hospital controls the psychiatric violent patient through safe environment.
FMS.40.1 A thorough body search is conducted to remove any items that can be used to harm patient/ staff before admitting any patient into the seclusion room.
FMS.40.2 The hospital Seclusion Rooms must be designed to protect patient against self-harming
(padded walls, no sharp edges or wiring, high celling, fire rated,…).
FMS.40.3 Seclusion Rooms provide continues surveillance with no blind spots through unbreakable
viewing panel/camera with audio communication.
FMS.40.4 Seclusion rooms should be air conditioned with no furniture other than untearable mattress.
FMS.40.5 Seclusion Rooms air conditioning, lights, door opening,… should be controlled from outside.
FMS.40.6 Seclusion toilets (if needed) should be:
FMS.40.6.1 Located outside seclusion room.
FMS.40.6.2 Attended by staff.
FMS.40.6.3 Unlockable door.
FMS.40.6.4 Unbreakable undetachable sanity ware and accessories.
Last update: 30 November 2023
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