Ambulatory Health Care Standards Saudi

Central Board for Accreditation of

Healthcare Institution
Effective 2020
1st edition

www.medicalkpis.com
 CONTENTS

CHAPTERS SUMMARY...................................................................................................................................... ii
1. Leadership of the Organization (LD) .................................................................................................... 1
2. Provision of Care (PC)......................................................................................................................... 14
3. Laboratory Service (LB) ...................................................................................................................... 19
4. Radiology Services (RD) ...................................................................................................................... 25
5. Dental Services (DN) .......................................................................................................................... 27
6. Medication Management (MM) ........................................................................................................ 30
7. Management of Information (MOI) ................................................................................................... 35
8. Infection Prevention and Control (IPC) .............................................................................................. 38
9. Facility Management and Safety (FMS) ............................................................................................. 43
10. Day Procedure Unit (DPU).................................................................................................................. 47
11. Dermatology & Aesthetics Medicine (DA) ......................................................................................... 53

i
 CHAPTERS SUMMARY

Chapter No. of Standards No. of Sub Standards

1 LD Leadership of the Organization 36 152

2 PC Provision of Care 15 58

3 LB Laboratory Services 12 82

4 RD Radiology Services 3 13

5 DN Dental Services 5 21

6 MM Medication Management 14 49

7 MOI Management of Information 7 28

8 IPC Infection Prevention and Control 14 49

9 FMS Facility Management and Safety 9 52

10 DPU Day Procedure Unit 12 66

11 DA Dermatology & Aesthetics Medicine 6 23

Total 133 593

ii
1. Leadership of the Organization (LD)

No. of
Sub Standards Sub Sub
Standard
The governing body defines its structure and operational responsibilities in a written
LD 1.1 6
document
The governing body approves and evaluates the center’s quality and patient safety
LD 1.2 3
program and risk management program

LD 1.3 The center has a current organizational chart. 3

LD 1.4 The center is managed effectively by a qualified director. 6

The leaders together with governance develop the center’s scope of services based
LD 1.5 4
on community needs.

LD 1.6 The leaders work collaboratively to develop the center’s strategic plan. 5

LD 1.7 The leaders transform the approved strategic plan into an operational plan. 5

LD 1.8 The leaders work collaboratively to develop the operational budget. 2

LD 1.9 The leaders work collaboratively to fulfill the mission and provide quality care. 4

LD 1.10 The leaders develop a staffing plan for the center. 3

LD 1.11 The leaders develop a policy and procedure for staff recruitment. 2

LD 1.12 All categories of staff have clearly written job descriptions. 4

The leaders develop an effective process for credentialing and recredentialing all
LD 1.13 6
healthcare providers.

LD 1.14 All medical staff members have current delineated clinical privileges. 4

LD 1.15 All new employees attend a mandatory orientation program. 3

The leaders develop and implement a policy that ensures nurses and other allied
LD 1.16 4
healthcare staff are competent in specific procedures.
The leaders ensure staff are trained and test competent in the safe operation of
LD 1.17 3
equipment including medical devices.

LD 1.18 The leaders support continuing education and training for all categories of staff. 3

LD 1.19 Staff are trained and kept up to date with cardiopulmonary resuscitation. 3

1
 No. of
Sub Standards Sub Sub
Standard
The leaders develop an effective process to evaluate staff performance at least
LD 1.20 5
annually.
The leaders implement a comprehensive program to protect the health and safety
LD 1.21 4
of staff.

LD 1.22 The leaders support and protect the patient and family rights. 4

The leaders ensure that patients/families have the right to be involved in their own
LD 1.23 5
care and treatment.
The leaders develop and implement a policy and procedure to describe the patients’
LD 1.24 4
right to voice their complaints and concerns.
The leaders ensure that patients/families have the right to accurate billing for
LD 1.25 3
provided services.
The leaders develop ethical standards to guide patients’ care and employees’ code
LD 1.26 4
of conduct.

LD 1.27 The center provides assistance to patients with special needs. 5

The center has an implemented policy for controlling the development and
LD 1.28 7
maintenance of key documents.
The center develops a comprehensive quality improvement and patient safety
LD 1.29 5
program.
The leaders prioritize and select a set of indicators that focus on the structure,
LD 1.30 7
process, and outcome of the services provided within the center.

LD 1.31 The leaders develop and implement a comprehensive risk management program. 6

LD 1.32 The leaders develop and implement an incident reporting policy. 5

LD 1.33 The leaders oversee any contracts for clinical or operational services. 5

The leaders ensure the integrity and security of telemedicine, teleradiology and
LD1.34 3
interpretation of other diagnostic remote contracted services.
The leaders implement policies and procedures to guide the efficient procurement
LD 1.35 of equipment either purchased or donated, medications and essential medical 3
consumables in accordance with national laws and regulations.

LD 1.36 The leaders ensure an aesthetic appeal for the center. 4

Total 152

2
 The governing body defines its structure and operational responsibilities in
LD.1.1 Value Percent Evaluation
a written document

The governing body approves and periodically reviews, the center’s mission,
1.1.1 (O,DR)
vision and values and make it public

The governing body approves the center’s scope of services, the center’s
1.1.2 (DR)
plans, programs and all policies and procedures

The governing body approves the center’s operating and capital budgets, as
1.1.3 (DR)
well as other resources required to manage the center efficiently

When the center is part of network, the governing body plans for services
1.1.4 (LI)
and functional relationships among the network components

1.1.5 The governing body defines any approval authority delegation (LI)

The governing body appoints a qualified director responsible for managing

1.1.6 (PF)
the center

Total Score

The governing body approves and evaluates the center’s quality and
LD.1.2 Value Percent Evaluation
patient safety program and risk management program

The governing body annually approves the quality and patient safety
1.2.1 (DR)
program, including risk management.
The governing body receives and evaluates the quality and patient safety
1.2.2 reports, including the corrective actions and outcomes from the center, (DR, LI)
including risk management, at least quarterly.
Recommended corrective actions by the governance are documented and
1.2.3 (DR)
received by the center director for implementation.

Total Score

LD.1.3 The center has a current organizational chart Value Percent Evaluation
An approved and updated organizational chart identifies the relationship
1.3.1 between the center’s governance, leadership, and other directors with (DR)
names and titles
1.3.2 The organizational chart is communicated to all staff. (SI)
The staff are aware of the organizational chart and its intent and can
1.3.3 (SI)
demonstrate their relationship to it.
Total Score

3
LD.1.4 The center is managed effectively by a qualified director Value Percent Evaluation

The center director has a written job description and his/her qualifications
1.4.1 (LI)
match the requirements in the job description
The center director, with other leaders, develops the mission, vision and
1.4.2 (LI)
values statements.
The center director ensures the center’s compliance with all relevant laws
1.4.3 (LI)
and regulations.
The center director recommends to the governing body required new
1.4.4 (LI)
policies for approval and ensures compliance with approved policies.
The center director ensures the availability of adequate and proper
1.4.5 resources for the planned services in accordance with the approved (LI)
operating budget.
The center director ensures a safe and functional facility environment for
1.4.6 (SI)
patients, visitors, and staff.
Total Score

The leaders together with governance develop the center’s scope of

LD.1.5 Value Percent Evaluation
services based on community needs.
The scope of services includes the range of coverage in relation to
1.5.1 preventive medicine, health promotion, curative and rehabilitative (DR, LI)
medicine.
The scope of services includes the specialty services that the center
1.5.2 provides, the number of clinics for each specialty, the level of professional ( LI)
coverage.
The scope of services includes the age group that can be served and the
1.5.3 (SI)
working hours.
Services are displayed in the center, and patients and, when needed,
1.5.4 (O)
families can obtain additional related information from the reception staff.
Total Score

LD.1.6 The leaders work collaboratively to develop the center’s strategic plan. Value Percent Evaluation
The strategic plan is guided by the mission, vision and inputs from
1.6.1 patients/service users, their families, staff and where possible the wider (DR)
community.
The strategic plan is based on a comprehensive evaluation of the internal
1.6.2 (LI)
and external environmental factors.
The strategic plan addresses all clinical and non-clinical services and
1.6.3 (SI)
programs.
The strategic plan spans a period of three to five years and is reviewed on a
1.6.4 (LI)
regular basis.
The strategic plan includes the broad goals and objectives required to fulfill
1.6.5 (LI)
the center’s mission.
Total Score

4
 The leaders transform the approved strategic plan into an operational
LD.1.7 Value Percent Evaluation
plan.
Goals and objectives are translated into operational plans with defined
1.7.1 projects, clearly delineated responsibilities, required resources and time (DR)
frames.
Governance approves the resources required for executing the operational
1.7.2 (LI)
plans.
Operational plans are implemented and closely monitored for progress by
1.7.3 (DR, LI)
structure and process indicators.

1.7.4 The plans are communicated to department directors and other staff. (SI)

Department directors develop annual departmental plans in alignment with

1.7.5 (DR, LI)
the center’s strategic plan.
Total Score

LD.1.8 The leaders work collaboratively to develop the operational budget. Value Percent Evaluation

The leaders plan and budget for the upgrade or replacement of buildings,
1.8.1 (DR, LI)
equipment, and other resources.
The budget process allocates resources to all patient care units based on the
1.8.2 scope of care and complexity of patient must ensure a safe and effective (O, SI)
facility.
Total Score

The leaders work collaboratively to fulfill the mission and provide quality
LD.1.9 Value Percent Evaluation
care.
The leaders communicate the mission, vision and values to all staff and
1.9.1 (SI)
customers.
The leaders ensure the use of evidence-based and best practice information
1.9.2 (O, SI)
to develop and improve the center’s services.
The leaders work collaboratively to develop and carry out plans, policies,
1.9.3 (SI)
and procedures.
The leaders meet regularly to review the key performance indicators of
1.9.4 services, survey, audits and feedback and use the collected data to improve (SI ,LI)
the center’s operations.
Total Score

LD.1.10 The leaders develop a staffing plan for the center. Value Percent Evaluation

1.10.1 The staffing plan ensures that services meet the needs of safe patient care. (DR)

The staffing plan defines the number, type, and credentials of required
1.10.2 (SI ,DR)
staff, and their roles.
The center recruits and assigns appropriately qualified staff in accordance
1.10.3 (PF)
with the staffing plan.
Total Score

5
LD.1.11 The leaders develop a policy and procedure for staff recruitment. Value Percent Evaluation
The policy and procedure highlight the receiving authority(s) of staff
1.11.1 (DR)
resumes, the short listing process, and the accepted method for interview.
Applicants are informed of their acceptance or refusal within a set time
1.11.2 (DR)
frame.
Total Score

LD.1.12 All categories of staff have clearly written job descriptions. Value Percent Evaluation

The job description outlines the knowledge, skills, and attitude necessary to
1.12.1 (DR)
perform the job responsibilities.
The job description clearly defines roles and responsibilities for the
1.12.2 (DR)
position.
Job responsibilities and clinical work assignments are based on evaluation
1.12.3 (PF)
of staff credentials.
The job description is discussed with and signed by the employee upon
1.12.4 (PF)
his/her hiring and is located in his/her personnel file.
Total Score

The leaders develop an effective process for credentialing and

LD.1.13 Value Percent Evaluation
recredentialing all healthcare providers.
1.13.1 The credentialing process applies to all clinical staff members: medical
(DR)
staff, nursing staff, and other clinical staff licensed to provide patient care.
1.13.2 The credentialing process includes gathering, verifying, and evaluating
credentials including license, education, training, experience and (PF)
competence.
1.13.3 To the extent possible, the credentials are verified from the original source
(PF)
directly or through a third party with documented evidence.
1.13.4 The center ensures the registration of healthcare professionals with the
Saudi Commission for Health Specialties and licensing by the Ministry of (PF)
Health in accordance with laws and regulations.
1.13.5 The credentialing process guides the appointment of healthcare staff to
their appropriate job assignment and is repeated every two (2) years to (SI, PF)
ensure that staff are still capable of performing their job functions.
1.13.6 Information about staff credentials, privileges, competencies, orientation,
training, education, and evaluation are kept securely in an updated (PF)
personnel file.
Total Score

LD.1.14 All medical staff members have current delineated clinical privileges. Value Percent Evaluation
1.14.1 The center has a policy and procedure for granting privileges to medical
(DR)
staff.
1.14.2 Clinical privileges are determined based on the center’s documented
(SI)
competency and available services.
1.14.3 The medical staff’s clinical privileges are recommended by the medical
director and approved by the governing body, either directly or by (PF)
appropriate delegation.
1.14.4 The clinical privileges are reviewed and updated every two (2) years, and
(SI)
earlier if needed.
Total Score

6
LD.1.15 All new employees attend a mandatory orientation program. Value Percent Evaluation
1.15.1 The new employees’ general orientation program includes information
about the center’s mission, vision, values, and organizational structure;
patient and family rights; safety and security; the basics of infection (DR)
control; and an introduction to the center’s quality and patient safety and
risk management programs.
1.15.2 Each new employee attends a department-specific orientation program,
including specific infection prevention and safety issues, that helps in (SI)
executing the specific job responsibilities as outlined in the job description.
1.15.3 The new employee orientation is documented in the employee’s
(PF)
personnel file.
Total Score

The leaders develop and implement a policy that ensures nurses and
LD.1.16 Value Percent Evaluation
other allied healthcare staff are competent in specific procedures.
The policy contains a list of procedures requiring competency assessment
1.16.1 (DR)
in each and every staff category.
1.16.2 All newly hired staff are initially tested for the required competencies. (SI, PF)

1.16.3 All staff are tested annually for the required competencies. (SI)

1.16.4 All test results are available in staff personal files. (PF)

Total Score

The leaders ensure staff are trained and test competent in the safe
LD.1.17 Value Percent Evaluation
operation of equipment including medical devices.
A policy is in place to ensure staff are trained on the safe operation of the
1.17.1 (DR)
current and newly introduced equipment and medical devices.
The policy addresses the required training and competency testing of staff
1.17.2 (SI, PF)
operating specialized equipment.
Only trained and competent staff handle specialized equipment and
1.17.3 (O, SI)
medical devices.
Total Score

The leaders support continuing education and training for all categories of
LD.1.18 Value Percent Evaluation
staff.
The center has a scheduled educational and training program based on the
1.18.1 center’s needs and person-centred care including quality, patient safety, (SI, DR)
risk management and infection control practices.
The leaders grant financial support and/or time off for staff to attend
1.18.2 educational and training activities relevant to the center’s scope of services (SI)
and in line with labor law.
Employees’ records show documented evidence of training and
1.18.3 (PF)
education.

Total Score

7
LD.1.19 Staff are trained and kept up to date with cardiopulmonary resuscitation. Value Percent Evaluation
All staff members who provide direct patient care receive training on basic
1.19.1 (SI, PF)
life support (BCLS).
The center identifies other staff members to be trained in advanced life
1.19.2 (SI, PF)
support as appropriate to the age groups they serve (ACLS, PALS, NRP).
All staff maintain the validity of their life support certification.
1.19.3 (PF)
50
Total Score

The leaders develop an effective process to evaluate staff performance at

LD.1.20 Value Percent Evaluation
least annually.
The performance evaluation is based on objective criteria and is consistent
with the expected competencies such as knowledge, skills and attitude
1.20.1 (SI, DR)
required to perform the employee’s job responsibilities as outlined in his/
her job description.
The evaluation is done at the end of the initial probationary period and
1.20.2 (PF)
annually thereafter
Staff are involved in the evaluation of their performance by commenting on
1.20.3 (SI)
the required corrective action.
Evaluations include personal goals to achieve for the next year that the
1.20.4 (SI)
employee will carry out.
Both the employee and his/her supervisor sign the performance
1.20.5 (PF)
evaluation, which is kept in the employee’s personnel file.
Total Score

The leaders implement a comprehensive program to protect the health

LD.1.21 Value Percent Evaluation
and safety of staff.
The program covers all employees and is consistent with laws and
1.21.1 (DR)
regulations.
The program is based on the protection of staff from occupational health
1.21.2 (SI)
and safety hazards and violence in the workplace.
The program is coordinated with the center’s quality, safety, risk
1.21.3 management, and infection control programs, including health screening, (O, SI)
immunization, and post exposure management.
Staff have confidential and secure medical records that reflect their health
1.21.4 (MR)
status.
Total Score

LD.1.22 The leaders support and protect the patient and family rights. Value Percent Evaluation
The leaders develop and maintain a patient rights and responsibilities
1.22.1 (O)
statement and develop processes that support their implementation.
The leaders ensure that patient rights and responsibilities are available to
1.22.2 patients and families and ensure patients are informed about their rights (SI)
and responsibilities in a manner they can understand.
The leaders ensure that patients’ dignity, privacy and confidentiality are
1.22.3 (O)
respected.
The leaders ensure that staff are provided training and education on
1.22.4 (SI, PF)
patient and family rights and responsibilities.
Total Score

8
 The leaders ensure that patients/families have the right to be involved in
LD.1.23 Value Percent Evaluation
their own care and treatment.
Patients/families have the right to be informed of their illness, the
1.23.1 (DR)
proposed treatment and its prognosis.
Patients/families have the right to be involved in the decision making of
1.23.2 (MR)
their care plans.
Patients/families have the right to professional assessment and
1.23.3 (MR)
management of pain.
Patients/families have the right to refuse or discontinue treatment or ask
1.23.4 (MR)
for a second opinion.
Patients/families have the right to request a detailed medical report and
1.23.5 (MR)
sick leave notification.
Total Score

The leaders develop and implement a policy and procedure to describe

LD.1.24 Value Percent Evaluation
the patients’ right to voice their complaints and concerns.
1.24.1 Patients’ complaints are resolved in a time frame described in the policy. (DR, SI)
1.24.2 The center assigns a staff member responsible for managing complaints (SI)
1.24.3 Patient satisfaction surveys are conducted at least quarterly (DR, SI)
Data collected from surveys and complaints are analyzed and trended, and
1.24.4 the information collected is used for improvement and integrated into the (SI)
quality and safety program.
Total Score

The leaders ensure that patients/families have the right to accurate

LD.1.25 Value Percent Evaluation
billing for provided services.
The leaders ensure the availability of the price list for services provided to
1.25.1 (DR)
patients and their sponsors.
The patients and families have the right to receive an initial estimated cost
1.25.2 (O)
of required services.
The patients and families have the right to obtain an invoice for services
1.25.3 (O)
rendered.
Total Score

The leaders develop ethical standards to guide patients’ care and

LD.1.26 Value Percent Evaluation
employees’ code of conduct.
Marketing for staff and services, if performed, is carried out ethically as per
1.26.1 (SI)
laws and regulations.
The leaders develop a set of values and a professional code of conduct for
1.26.2 (SI, DR)
all employees.
The leaders ensure that patients and their families are fully informed and
1.26.3 (DR)
protected when they are involved in clinical research projects.
The leaders develop a process to receive and resolve ethical dilemmas,
1.26.4 patient and non-patient related in a reasonable timeframe as determined (DR)
by the center.
Total Score

9
LD.1.27 The center provides assistance to patients with special needs. Value Percent Evaluation

1.27.1 Dedicated street parking and drop-off points are available. (O)

1.27.2 Handrails for staircases are constructed. (O)

1.27.3 Ramps for elevated areas are available. (O)

The center’s entrance allows wheelchair access and elevators have
1.27.4 (O)
wheelchair access doors.
1.27.5 Wheelchair-accessible toilets are available. (O)

Total Score

The center has an implemented policy for controlling the development

LD.1.28 Value Percent Evaluation
and maintenance of key documents.
The center has a unique identification for each key document, with title,
1.28.1 (DR)
number, date of issue, and date of revision.
Key documents are developed, approved, revised, and terminated by an
1.28.2 (DR)
authorized individual.
1.28.3 Key documents are dated and current. (DR)

1.28.4 Key documents are revised according to a defined revision due date. (DR)

Key documents are communicated to relevant staff and are always

1.28.5 (SI)
accessible.
A process is in place to ensure that key documents are always
1.28.6 (O)
implemented.
A process is in place to ensure that only the last updated versions of key
1.28.7 (O)
documents are available for use in the center.
Total Score

The center develops a comprehensive quality improvement and patient

LD.1.29 Value Percent Evaluation
safety program.
1.29.1 The leaders develop the program collaboratively. (LI)
The program utilizes key performance indicators, and patient and staff
1.29.2 surveys to measure performance and improve clinical and managerial (SI, LI )
areas.
The information generated is readily accessible on a timely basis to those
responsible for and/or involved in the delivery of the services, and is
1.29.3 (PF)
utilized for making improvements and supporting the leaders’ decision
making.
The program utilizes an evidence-based quality improvement method such
1.29.4 (SI)
as “FOCUS – PDCA.”
1.29.5 The center implements at least one improvement project per year. (O, SI)

Total Score

10
 The leaders prioritize and select a set of indicators that focus on the
LD.1.30 structure, process, and outcome of the services provided within the Value Percent Evaluation
center.
The selection process is based on the center’s important processes and
1.30.1 (L)
priorities.
Each indicator has an operational definition, data collection method,
frequency for collection, analysis by qualified staff, mathematical
1.30.2 (SI, DR)
expression such as a ratio, with a defined numerator and denominator or a
percentage and a desirable target.
Structure indicators may include, but not be limited to the following:
availability of essential supplies and equipment, availability of medical
1.30.3 (O, DR)
records, availability of emergency medications, surgical volume, and staff
ratios.
Process indicators may include, but not be limited to the following: waiting
1.30.4 time, documentation in medical records, site marking, and time out (O, DR)
processes.
Outcome indicators may include, but not be limited to the following:
1.30.5 Patient and staff satisfaction, patient’s complaints, health-care-associated (O, DR)
infections, medication errors, sentinel events and various adverse events.
The performance monitoring results are discussed with staff, utilized in
1.30.6 their evaluation, and reported quarterly to the governance together with (SI)
action plans taken for improvement.
The indicators are compared internally by historical trends and externally
1.30.7 (SI, DR)
by benchmarking to other similar centers when available.
Total Score

The leaders develop and implement a comprehensive risk management

LD.1.31 Value Percent Evaluation
program.

1.31.1 The program addresses clinical, managerial and financial risk. (DR)

The reporting of incidents and variances, patients’ morbidities, and clinical

1.31.2 (DR)
and financial claims constitute the program’s essential reactive arm.
The center develops and implements at least one proactive risk
1.31.3 (SI)
management approach per year.
The center develops and periodically updates a risk register for all potential
1.31.4 (O)
clinical, managerial, and financial processes in the center.
The center utilizes an evidence-based process for grading risks based on
1.31.5 (O)
severity, frequency, and/or likelihood of occurrence.
Information from the risk management program, including incidents,
1.31.6 analysis, and improvement projects, is communicated to staff and the (SI, DR)
governing body at least quarterly.
Total Score

11
LD.1.32 The leaders develop and implement an incident reporting policy. Value Percent Evaluation
The policy outlines the types of incidents to be reported internally and to
1.32.1 relevant regulatory authorities and the time frame and mechanism for (SI, DR)
reporting.
The center utilizes a risk scoring matrix to categorize the severity of
1.32.2 (O)
incidences.
Incidences, including near misses, involving patients are documented in the
1.32.3 medical record and patient and family are informed by the physician of any (MR)
investigation results.
The center compiles a report on incidences according to type and severity,
1.32.4 and an action plan to prevent its recurrence is distributed to staff and (SI, DR)
governance at least quarterly
Sentinel events and severe near miss incidents are reported and
1.32.5 (DR)
investigated and findings utilized to prevent recurrence.
Total Score

LD.1.33 The leaders oversee any contracts for clinical or operational services. Value Percent Evaluation

Contracted entities are selected based on evidence-based criteria that the

1.33.1 (DR)
relevant department develops
The center director ensures relevant leaders’ recommendations and
1.33.2 (DR)
approvals on contracts
The leaders ensure that the contracted entity and services provided meet
1.33.3 (LI)
applicable laws and regulations
The leaders ensure that the services provided are integrated into the
1.33.4 (LI)
overall quality and patient safety program
The leaders regularly monitor and document the compliance of contract
1.33.5 services with the appropriate standards and take documented corrective (DR, LI)
actions for improvement when standards are not met
Total Score

The leaders ensure the integrity and security of telemedicine,

LD.1.34 teleradiology and interpretation of other diagnostic remote contracted Value Percent Evaluation
services.

Telemedicine, teleradiology and interpretation of other diagnostic remote

1.34.1 (DR)
contracted services are registered with Ministry of Health.

The leaders ensure the credentialing and privileging of the physicians

1.34.2 (PF)
involved before starting the service.

The leaders ensure the security and confidentiality of patient information

1.34.3 (O)
that may be exposed as a result of the telecommunication process.

Total Score

12
 The leaders implement policies and procedures to guide the efficient
procurement of equipment either purchased or donated, medications and
LD.1.35 Value Percent Evaluation
essential medical consumables in accordance with national laws and
regulations.
Leaders ensure that all medical devices and supplies contractors and
1.35.1 (DR)
suppliers have a Medical Device Establishment License (MDEL).

Leaders ensure that all newly purchased medical devices have a Medical
1.35.2 (DR)
Device Marketing Authorization (MDMA) certificate.

Leaders approve newly introduced consumables based on a formal testing

1.35.3 (DR)
and feedback process from end users.

Total Score

LD.1.36 The leaders ensure an aesthetic appeal for the center. Value Percent Evaluation

1.36.1 The center is clean and tidy at all times. (O)

1.36.2 The center is free of broken furniture, scratched and distorted walls. (O)

1.36.3 The ambient temperature is maintained between 20 - 24.4 Celsius. (O)

1.36.4 Nonirritant air freshener is used to control unwanted odor in the center. (O)

Total Score

13
2. Provision of Care (PC)

No. of Sub
Sub Standards Sub
Standard
Patients have access to services based on their health needs and available
PC 2.1 5
services and are registered with the center for providing such services.

PC 2.2 The center has a process to ensure the correct identification of patients. 3

Patients are clinically assessed through an established assessment policy and

PC 2.3 4
procedure.
Physicians are provided with the results of requested investigations according
PC 2.4 2
to a time frame.
The center develops and implements a process for reporting critical test results
PC 2.5 4
whether on-site or outsourced.
A care plan is developed by the attending physician to meet the patient’s
PC 2.6 3
needs considering patient and family’s cultural and spiritual matters.
Consultations are available to meet the healthcare provider’s request and
PC 2.7 3
patient’s needs in a timely manner.
Staff members assist patients and, when appropriate, their families in fully
PC 2.8 participating in making informed decisions about their care, treatment and 4
procedures.
Patients and, when applicable, their families are educated about their
PC 2.9 3
healthcare needs.

PC 2.10 Informed consent is obtained from the patient or guardian. 4

Patients planned for a surgery/procedure give their informed consent to the

PC 2.11 4
surgery/procedure and the anesthesia/sedation.
The center has an effective process to safely provide care to patients who
PC 2.12 4
require Cardio Pulmonary Resuscitation (CPR).
Policies and procedures guide the transfer of patients in need of urgent
PC 2.13 5
admission to hospitals.

PC 2.14 Ambulance services are available and meet the patient’s needs. 6

PC 2.15 The center has an emergency services to deal with minor emergencies. 4

Total 58

14
 Patients have access to services based on their health needs and available
PC.2.1 Value Percent Evaluation
services and are registered with the center for providing such services.
A standardized process is in place for registering patients for services based
2.1.1 (SI,DR)
on their full name and ID number or passport number for visitors.
Registration creates a medical record number that is unique to every
2.1.2 (MR)
patient.
Appointment staff are aware of the services that the center offers and to
2.1.3 (SI)
direct patients to the appropriate services.
2.1.4 An appointment system is in place to book patients in advance. (O,SI)
Patients who present with emergencies beyond the capacity of the center
2.1.5 (O,SI)
are stabilized before transfer to a higher center.
Total Score

PC.2.2 The center has a process to ensure the correct identification of patients. Value Percent Evaluation
Patients are identified by at least two identifiers, full name as in
2.2.1 (SI,DR)
identification document and unique medical record number.
Patients are identified prior to any blood withdrawal, investigation,
2.2.2 (O, MR)
administration of medications and surgery or procedure.
2.2.3 Patients are actively involved in the process of patient identification (O)

Total Score

Patients are clinically assessed through an established assessment policy

PC.2.3 Value Percent Evaluation
and procedure.
The policy and procedure are developed collaboratively, highlighting the
2.3.1 scope and content of assessment by different specialties and in different (DR)
locations.
The policy and procedure ensure the availability of a comprehensive patient
2.3.2 (PF)
assessment in the first center’s visit.
The policy and procedure highlight required screening for nutritional needs,
2.3.3 functional needs, the presence or absence of pain, the risk of fall, and social (DR)
needs.
The policy and procedure explain the specific assessments when the initial
2.3.4 (DR)
screening labels the patient “at risk” for the screening elements in PC.3.3.
Total Score

Physicians are provided with the results of requested investigations

PC.2.4 Value Percent Evaluation
according to a time frame.
The time frame for routine and stat or urgent investigations is developed
2.4.1 (DR, MR)
collaboratively with the laboratory, radiology and other services.
The Turnaround Time document is available for routine and stat or urgent
2.4.2 (MR)
radiology, laboratory and other services tests.
Total Score

15
 The center develops and implements a process for reporting critical test
PC.2.5 Value Percent Evaluation
results whether on-site or outsourced.
2.5.1 The process defines staff who receive the result. (DR)
The process involves writing down the result by the receiver and reading
2.5.2 (O)
back the findings to the result provider.
The read-back process and the physician’s intervention are documented in
2.5.3 (MR)
the patient’s medical record.
The center develops a process for contacting patients who left the center
2.5.4 (DR)
when critical test results were reported.
Total Score

A care plan is developed by the attending physician to meet the patient’s

PC.2.6 Value Percent Evaluation
needs considering patient and family’s cultural and spiritual matters.
The attending physician develops and documents the care plan by utilizing
2.6.1 the assessment information obtained by the nurse and other disciplines (MR)
participating in the care and the investigation results, as applicable.
The care plan is designed to achieve desired outcomes specified as
2.6.2 (MR)
measurable goals.
The care plan, is reviewed during every visit based on the outcome measures
2.6.3 (MR)
and other significant changes in the patient’s condition.
Total Score

Consultations are available to meet the healthcare provider's request and

PC.2.7 Value Percent Evaluation
patient’s needs in a timely manner.
2.7.1 The consultation clearly states the reason for and urgency of the request. (MR)
Consultation requests provide appropriate answers to the issues that the
2.7.2 (MR)
referring physician raised.
Arrangements are made to ensure that consultations are immediately
2.7.3 available for emergency cases. Urgent consultations are referred to the (O, MR)
emergency room.
Total Score

Staff members assist patients and, when appropriate, their families in fully
PC.2.8 participating in making informed decisions about their care, treatment and Value Percent Evaluation
procedures.
Staff members provide patients/families with honest and accurate
information in a manner they can understand, about their illness, options for
2.8.1 (O,SI)
treatment, proposed treatment, potential benefits, potential complications,
and the likelihood of success of treatment, respecting their choices.
Patients are supported in discussing their plan of care with the physician and
2.8.2 (O, SI)
having all their questions answered.
Patients are provided with all the information regarding the identity and the
2.8.3 (SI)
professional status of his/her treating physician and how to contact him/her.
When a surgery or procedure is performed, the patient/family receive from
2.8.4 the surgeon information related to the surgery and from the (SI, MR)
anesthesiologist information related to anesthesia or sedation.
Total Score

16
 Patients and, when applicable, their families are educated about their
PC.2.9 Value Percent Evaluation
healthcare needs.
Patients’ and families’ education is based on their healthcare needs, which
include, but are not necessarily limited to: the nature of their disease;
2.9.1 necessary treatments; infection control practices; safe use of medications, (MR)
diet, and nutrition; medical equipment use; and preoperative and
postoperative care.
Each patient and his/her family receive education to help them give
2.9.2 informed consent, participate in the care process, and understand any (MR)
financial implications of care choices.
The clinical staff educate patients and families in easily understandable
2.9.3 (O, SI)
language, and the provided education is evaluated for effectiveness.
Total Score

PC.2.10 Informed consent is obtained from the patient or guardian. Value Percent Evaluation
Informed consent is obtained before surgery, invasive procedures,
2.10.1 anesthesia and sedation, the administration of blood and blood products, (DR,MR)
and other high-risk treatments.
Informed consent is obtained prior to taking photographs of body parts,
2.10.2 (MR)
even if this is deemed critical for care.
Informed consent is obtained before involving the patient in a research
2.10.3 (DR)
project.
The center develops and regularly updates a list of procedures and
2.10.4 (DR)
conditions requiring informed consent.
Total Score

Patients planned for a surgery/procedure give their informed consent to

PC.2.11 Value Percent Evaluation
the surgery/procedure and the anesthesia/sedation.
The leaders develop and monitor the implementation of a policy for
2.11.1 obtaining informed consent for a surgery or procedure, or for anesthesia or (MR)
sedation.
The physician/dentist performing the procedure conducts the informed
consent process, which includes an explanation of the nature of the
2.11.2 (O, SI)
procedure, the benefits of the procedure, the risks of the procedure,
alternative modalities, and the risks of not undergoing the procedure.
A qualified physician/dentist conducts the informed consent process for
2.11.3 (PF, MR)
surgery/procedure
A qualified anesthesiologist conducts the informed consent process for
2.11.4 (PF, MR)
anesthesia/moderate and deep sedation.
Total Score

The center has an effective process to safely provide care to patients who
PC.2.12 Value Percent Evaluation
require Cardio Pulmonary Resuscitation (CPR).
The center develops and implements a policy and procedure outlining the
2.12.1 (DR)
process.
Standardized crash cart(s) are available in the patient care areas and are
2.12.2 (O)
age specific.
2.12.3 The crash cart is checked every shift by a qualified staff. (O)
The role of staff involved in the CPR process is clearly defined in the policy
2.12.4 (SI, MR)
and monitored for implementation.
Total Score

17
 Policies and procedures guide the transfer of patients in need of urgent
PC.2.13 Value Percent Evaluation
admission to hospitals.
Transfers are based on the patient's need for continuing care and the
2.13.1 (SI,DR)
center's capabilities.
2.13.2 The receiving hospital clearly accepts responsibility for the patient's care. (DR)
The receiving hospital receives the necessary information to provide care
2.13.3 (DR)
to the patient.
The patient is monitored during the transfer process and the monitoring
2.13.4 data is kept in the patient’s medical record. The time of transfer is (MR)
documented.
The receiving hospital acknowledges receiving the patient, the time of
2.13.5 arrival, and the patient’s condition, and the document is kept in the (MR)
patient’s medical record.
Total Score

PC.2.14 Ambulance services are available and meet the patient’s needs. Value Percent Evaluation
The center owns or contracts with a fully equipped ambulance capable of
2.14.1 (O)
transferring sick patients of all age groups to higher centers when needed.
The required equipment is checked for proper functionality daily and after
2.14.2 each dispatch by the emergency services nurse or technician. Findings are (O, DR)
documented.
Ambulance medications are checked for availability and expiry daily and
2.14.3 after each dispatch by the emergency services nurse or technician. Findings (O)
are documented.
During the transportation, the accompanying staff have the appropriate life
2.14.4 (PF)
support certification.
The ambulance is tested daily for proper operation and periodically
2.14.5 (DR)
maintained. Findings are documented.
The ambulance is included in the center’s infection prevention and control
2.14.6 (O, DR)
program
Total Score

PC.2.15 The center has an emergency services to deal with minor emergencies. Value Percent Evaluation
Qualified staff manage the emergency services with a minimum of two (2)
2.15.1 (PF)
years of experience
2.15.2 At a minimum, a physician and a nurse are ACLS certified per shift (PF)
The emergency service have the necessary equipment for the stabilization
2.15.3 (O)
and resuscitation of major emergencies.
The center has a formal agreement with hospitals to transfer major
2.15.4 (DR)
emergencies after stabilization.
Total Score

18
3. Laboratory Service (LB)

No. Of Sub Sub

Sub Standards
Standard
Laboratory services are available or outsourced to meet the needs of
LB 3.1 10
the patient population served.
The laboratory has the right space and facilities relevant to the
LB 3.2 12
services provided.
The laboratory develops and implements a comprehensive safety
LB 3.3 6
program.
The laboratory develops and implements a comprehensive infection
LB 3.4 6
control program.
The laboratory has a clearly defined and implemented process
LD1.5 describing its role in selecting and evaluating providers of reference 4
laboratory services.
The laboratory has a clearly defined and implemented process for
LB 3.6 4
laboratory instrument and equipment management.
The laboratory develops and implements a policy for the
LB 3.7 5
documentation of specimen receipt and inspection.
The laboratory develops a policy and procedure for the quality
LB 3.8 6
control of test methods.
The laboratory develops a policy and procedure for Proficiency
LB 3.9 Testing (PT) sufficient for the extent, complexity and scope of 11
services.
The laboratory defines the format and contents of laboratory
LB 3.10 8
reports.
The laboratory has a process for correcting or amending reported
LB 3.11 4
results.
The laboratory develops and implements a comprehensive process
LB 3.12 6
for Point-of- Care-Testing (POCT).
Total 82

19
 Laboratory services are available or outsourced to meet the needs of the
LB.3.1 Value Percent Evaluation
patient population served.
The laboratory develops a services and specimens’ manual that is distributed
3.1.1 (O,DR)
to all patient care areas.
The manual includes the available tests either in-house or send-out and
3.1.2 (S,I)
their Turn Around Times (TATs).
The manual includes the prescribed process for requesting the
3.1.3 (SI)
introduction of a new test.
3.1.4 The manual includes patient preparation for specimen collection. (O,SI)

3.1.5 The manual includes positive patient identification. (O,SI)

3.1.6 The manual includes quality and quantity of sample. (O)

3.1.7 The manual includes phlebotomy, sample collection and labeling procedures. (O,DR)

3.1.8 The manual includes requisition and required clinical data. (MR)

3.1.9 The manual includes specimen packing, handling and transportation. (O,SI)

3.1.10 The manual includes specimen rejection reasons. (DR)

Total Score

The laboratory has the right space and facilities relevant to the services
LB.3.2 Value Percent Evaluation
provided.
The laboratory’s design and location meet applicable local and international
3.2.1 (O)
regulations.
3.2.2 The laboratory has adequate patient waiting areas and lavatories. (O)

3.2.3 Adequate spaces are available for each laboratory activity/section.68 (O)
The laboratory has adequate storage space for reagents, supplies,
3.2.4 (O)
consumables, samples, waste holding, and records.
3.2.5 The laboratory has adequate space for administrative and clerical staff. (O)
The laboratory has adequate water taps and sinks for hand washing and for
3.2.6 (O)
washing contaminated equipment.
The laboratory is equipped with adequate electrical outlets and emergency
3.2.7 (O)
power.
The laboratory has adequate lighting, ventilation and adequate temperature
3.2.8 (O)
and humidity controls.
The laboratory corridors are not obstructed and maintain access control and
3.2.9 (O)
adequate emergency exits.
3.2.10 Safety signs are adequately displayed and distributed in the laboratory. (O)
The laboratory workplace is free of hazards, clutter and distractions, with
3.2.11 (O)
clean and well-maintained floors, walls, ceilings, bench tops, and sinks.
Means of communication and telephones are conveniently located in the
3.2.12 (O)
laboratory.
Total Score

20
LB.3.3 The laboratory develops and implements a comprehensive safety program. Value Percent Evaluation
The laboratory safety program complies with the national and international
3.3.1 laboratory safety standard and is readily available to all laboratory (O,DR)
personnel.
The safety program includes a chemical hygiene plan, control of compressed
3.3.2 and flammable gases, and the monitoring of fumes and vapors, as well as (O,DR)
their respective Safety Data Sheets.
The safety program includes biological safety procedures, the use of
3.3.3 standard precautions, and the use of eyewash stations and emergency (O,DR)
showers.
The safety program includes electrical safety as well as fire prevention and
3.3.4 (SI,DR)
control plans.
The safety program mandates an annual safety training and competency
3.3.5 (SI,PF)
assessment.
The laboratory has a process for the monitoring of the safety program
through regular safety inspections and analysis of the findings. The process is
3.3.6 (SI,DR)
used to improve the laboratory’s safety, and its findings are integrated with
the center’s quality improvement and patient safety program.
Total Score

The laboratory develops and implements a comprehensive infection

LB.3.4 Value Percent Evaluation
control program.
The laboratory infection control program complies with the national and
3.4.1 international laboratory infection control standards and is readily available (DR)
to all laboratory personnel.
The infection control program includes the provision and use of Personal
3.4.2 (O)
Protective Equipment.
The infection control program includes biological safety procedures, the use
3.4.3 of standards precautions, and the use of fume hoods and biological safety (O)
cabinets.
The infection control program includes an infectious disease and viral
3.4.4 (SI,DR)
exposure plan.
The infection control program mandates an annual training and competency
3.4.5 (PF)
assessment.
The laboratory maintains a process for monitoring the infection control
program through regular infection control inspections and analysis of the
3.4.6 (SI,DR)
findings, which are utilized to improve the laboratory infection control
and integrated with the center’s infection control program.
Total Score

The laboratory has a clearly defined and implemented process describing

LB.3.5 its role in selecting and evaluating providers of reference laboratory Value Percent Evaluation
services.
3.5.1 The process requires selection criteria, including accreditation status. (DR)

3.5.2 The process outlines an inclusive list of send-out tests. (DR)

The process describes specimen collection, labeling, handling,
3.5.3 (O,SI)
transportation, and results reporting.
A service contract specifies agreements’ conditions with the reference
3.5.4 (DR)
laboratory.
Total Score

21
 The laboratory has a clearly defined and implemented process for
LB.3.6 Value Percent Evaluation
laboratory instrument and equipment management.
The process defines the selection, receipt, installation, and identification of
3.6.1 (DR)
equipment.
The process outlines the validation of laboratory equipment for its intended
3.6.2 (S,I)
use.
Manufacturer instructions related to monitoring, maintenance, calibration,
3.6.3 (SI)
and standardization are referenced.
The process includes the required investigation and follow-up of equipment
3.6.4 (SI ,Dr)
malfunction or failure.
Total Score

Laboratory services are available or outsourced to meet the needs of the

LB.3.7 Value Percent Evaluation
patient population served.
3.7.1 The policy includes the required checks for proper packaging. (DR)
The policy includes the required checks for quality and quantity of the
3.7.2 (SI)
specimen.
The policy includes the required checks for the adequacy of specimen
3.7.3 (O)
labeling.
3.7.4 The policy includes the required checks for request completion. (DR)

3.7.5 The policy includes the required checks for label/request discrepancies. (O)

Total Score

The laboratory develops a policy and procedure for the quality control of
LB.3.8 Value Percent Evaluation
test methods.
3.8.1 Quality control follows the manufacturer’s instructions. (DR)
The policy and procedure clearly identify the performance and review
responsibility. Control specimens are handled and tested in the same
3.8.2 (S,I)
manner and by the same laboratory personnel who are testing patient
samples.
The policy and procedure highlight the number and frequency of running
3.8.3 (SI)
controls.
The policy and procedure mandate the acquisition of the correct reference
3.8.4 (DR)
range when the reagents/methodology change.
The policy and procedure mandate the establishment of tolerance limits for
3.8.5 (DR)
results.
The policy and procedure highlight the corrective action(s) to be taken in the
3.8.6 (SI)
event of unacceptable results.
Total Score

22
 The laboratory develops a policy and procedure for Proficiency Testing (PT)
LB.3.9 Value Percent Evaluation
sufficient for the extent, complexity and scope of services.
3.9.1 The policy and procedure ensure all analytes are covered with PT. (DR)
The policy and procedure highlight alternative PT performed when
3.9.2 (S,I)
appropriate.
The policy and procedure have clear instructions for the receipt, processing,
3.9.3 (SI)
and reporting of PT results.
3.9.4 PT samples are tested by the same personnel handling the patient samples. (SI)
PT samples are tested using the same method used for testing the patient
3.9.5 (SI)
samples.
3.9.6 PT samples are not referred to another external laboratory for testing. (SI)

3.9.7 PT results are not shared with another external laboratory. (SI)

3.9.8 PT results are evaluated and compared to the acceptable performance. (O, DR)
Unacceptable performance is investigated, and appropriate corrective
3.9.9 (DR)
actions are taken.
3.9.10 Laboratory management review and approve PT records. (DR)

3.9.11 Corrective actions are implemented and monitored. (DR)

Total Score

LB.3.10 The laboratory defines the format and contents of laboratory reports. Value Percent Evaluation

3.10.1 The report identifies the testing laboratory. (MR)

3.10.2 The report includes full patient identification. (MR)

3.10.3 The ordering physician is identified. (MR)

The date and time of specimen collection and the source of the specimen
3.10.4 (MR)
are clearly written.
3.10.5 The reporting date and time are identified. (MR)

3.10.6 The test result(s) and reference intervals/range are highlighted. (MR)
The condition of the specimen that may limit the test’s adequacy is written
3.10.7 (MR)
down.
3.10.8 Identification of the authorized person releasing the report is highlighted. (MR)

Total Score

LB.11.1 The laboratory has a process for correcting or amending reported results. Value Percent Evaluation
The process highlights the definitions of report corrections and
3.11.1 (DR)
amendments.
3.11.2 The process describes the format of the corrected report. (DR)
The process requires the inclusion of the previous result in the corrected
3.11.3 (DR)
report.
3.11.4 The process requires the notification of the ordering physician. (SI)

Total Score

23
 Laboratory services are available or outsourced to meet the needs of the
LB.3.12 Value Percent Evaluation
patient population served.
3.12.1 POCT is defined in writing. (DR)

3.12.2 The responsibility of managing the POCT is assigned to the laboratory. (SI)
Guidelines are available describing the process of acquiring POCT devices/
3.12.3 (SI, DR)
methods.
3.12.4 The process defines the training and competency testing requirements. (PF)

3.12.5 A list and location of all POCT devices is available around the center (O)
The process defines the maintenance and quality control of POCT
3.12.6 (DR)
devices/methods.
Total Score

24
4. Radiology Services (RD)

No. Of Sub Sub

Sub Standards
Standard
Radiology services are available or planned with other institutions to
RD 4.1 meet patient needs and in accordance with applicable national 3
standards, laws and regulations.

RD 4.2 The center has a radiation safety program. 6

There is implemented process to keep the radiology equipment in

RD 4.3 4
safe, functional condition.

Total 13

25
 Radiology services are available or planned with other institutions to meet
RD.4.1 patient needs and in accordance with applicable national standards, laws Value Percent Evaluation
and regulations.
When radiology services are provided through a contract, the center is
4.1.1 (DR)
responsible for providing oversight of the contracts.
4.1.2 A licensed radiology technician carries out radiology services. (PF)
Radiology services are supervised by, at a minimum, a radiology specialist
4.1.3 (O, PF)
who reads, reviews, and authorizes all radiology reports.
Total Score

RD.4.2 The center has a radiation safety program. Value Percent Evaluation

4.2.1 The program covers all areas that use ionizing radiation. (DR)
All rooms where ionizing radiation is administered are tested and certified
4.2.2 (DR)
radiation leak proof by the appropriate certifying local authority.
4.2.3 Safety warnings are posted on the doors in clear and appropriate locations. (O)
Prior to X-ray tests, women in the childbearing period with missed
4.2.4 (DR)
menstruation is checked for the possibility of pregnancy.
Personnel are monitored for radiation exposure by thermoluminescence
4.2.5 (DR)
dosimeters (TLD) that are regularly checked.
All types of radiation protection aprons are periodically inspected and
4.2.6 (DR)
tested for integrity and effectiveness with documentation.
Total Score

There is implemented process to keep the radiology equipment in safe,

RD.4.3 Value Percent Evaluation
functional condition.
4.3.1 An operation and service manual is available for all equipment. (O)

4.3.2 Qualified personnel maintain the equipment. (PF)

Maintenance and repair records are properly maintained, including
4.3.3 (DR)
corrective actions.
4.3.4 Equipment is periodically inspected and calibrated for proper functioning. (DR)

Total Score

26
5. Dental Services (DN)

No. Of Sub Sub

Sub Standards
Standard
DN 5.1 Dental staff have appropriate qualifications. 3
A comprehensive assessment is performed and documented for
DN 5.2 1
each patient.
The dentist documents the treatment plan in the patient’s medical
DN 5.3 6
record.
Infection control guidelines are available and implemented by dental
DN 5.4 5
staff.
DN 5.5 Safety rules are applied in the dental laboratory. 6

Total 21

27
DN.5.1 Dental staff have appropriate qualifications. Value Percent Evaluation
The head of the dental services is a dentist qualified by education, training
5.1.1 (PF)
and experience.
Dentists perform dental treatments and procedures within their approved
5.1.2 (DR, PF)
privileges.
5.1.3 During dental procedure the dentist is assisted by dental assistant. (O, PF)

Total Score

A comprehensive assessment is performed and documented for each

DN.5.2 Value Percent Evaluation
patient.
Chief complaint, chronic illnesses, medication history and allergies are
5.2.1 (MR)
assessed and documented for each patient before dental procedures.

Total Score

DN.5.3 The dentist documents the treatment plan in the patient’s medical record. Value Percent Evaluation

5.3.1 The dentist documents the required radiological procedures. (MR)

5.3.2 The dentist documents the type of antibiotic prophylaxis when needed. (MR)

The dentist documents the procedure(s) to be performed and highlights the

5.3.3 (MR)
teeth involved.
The dentist documents the type and dose of local anesthesia or moderate
5.3.4 (MR)
sedation if needed.
5.3.5 The dentist documents the material used for filling. (MR)

5.3.6 The need for informed consent is highlighted. (DR, MR)

Total Score

DN.5.4 Infection control guidelines are available and implemented by dental staff. Value Percent Evaluation

A new pair of gloves and a new mask are used by the dentist and assistant
5.4.1 (O)
for every case
5.4.2 Protective eyewear is used by the dentists and assistant for every case. (O)

5.4.3 Patients receive eye protection by the assistant. (O)

5.4.4 Working area surfaces are cleaned by the assistant between patients. (O, SI)

Evidence-based disinfection and sterilization practices are maintained and

5.4.5 (O, DR)
updated by the assistant.

Total Score

28
DN.5.5 Safety rules are applied in the dental laboratory. Value Percent Evaluation

5.5.1 Fire detection and abatement equipment is available. (O)

5.5.2 Butane and other flammable gases are stored safely outside the laboratory. (O)

5.5.3 A hooded exhaust is available in the casting area. (O)

5.5.4 Oxygen cylinders are safely stored. (O)

5.5.5 Fumes and dust are safely evacuated. (SI)

An eyewash station is available and in good functioning condition.
5.5.6 (SI)
Explanation

Total Score

29
6. Medication Management (MM)

No. Of Sub Sub

Sub Standards
Standard
Medication use processes are available to meet patient needs and
MM 6.1 3
in accordancewith applicable laws and regulations.
MM 6.2 The center has an updated and well-structured formulary. 3
The center has a process for the appropriate storage of
MM 6.3 4
medications.
The center has a process for ensuring the stability of medication
MM 6.4 2
available in multi-dose containers.
The center has a process for identifying and handling expired
MM 6.5 4
medications.
The center develops a policy and procedure for the safe
MM 6.6 6
prescribing of medications.
The center develops and implements guidelines for the correct
MM 6.7 3
prescribing of antibiotics.
The center develops a process to manage narcotics, psychotropic
MM 6.8 medications, and other controlled medications according to laws 3
and regulations.
The center safely manages high-alert and look-alike, sound-alike
MM 6.9 2
(LASA)medications.
The center evaluates the appropriateness of prescriptions before
MM 6.10 4
dispensing.
Medication preparation areas comply with infection control
MM 6.11 4
measures and safe practices.
The center develops and implements a policy and procedure on
MM 6.12 5
medication error reporting.
MM 6.13 The center monitors allergies to medications. 2
The center develops and implements a policy and procedure for
MM 6.14 5
the reporting of adverse drug reactions (ADR’s).
Total 49

30
 Medication use processes are available to meet patient needs and in
MM.6.1 Value Percent Evaluation
accordance with applicable laws and regulations.
The medication use processes are managed by qualified staff who have
6.1.1 (PF)
a valid registration with the Saudi Commission for Health Specialties.
The center establishes an interdisciplinary mechanism for overseeing and
6.1.2 (SI, LI)
monitoring medication management processes.
An updated list exists of the signatures of medical staff who are authorized
6.1.3 (DR)
to prescribe medications, along with their prescribing privileges.
Total Score

MM.6.2 The center has an updated and well-structured formulary. Value Percent Evaluation
The formulary contains all the essential medications and is updated
6.2.1 (DR)
annually.
The formulary is adopted from a relevant source that is available for Saudi
6.2.2 (DR)
Arabia and approved by the Saudi Food and Drug Authority
6.2.3 The medication formulary is available to the healthcare team.. (O, SI)

Total Score

MM.6.3
Value Percent Evaluation
The center has a process for the appropriate storage of medications.
The center has an appropriate storage area for non-refrigerated medications
6.3.1 (O, SI)
and refrigerators for storing vaccines and commonly refrigerated medications.
6.3.2 Medications are stored as per manufacture guidelines.. (O, DR)
All medication and vaccine refrigerators are connected to alternate power
6.3.3 (O, DR)
source and a temperature log is maintained at all times.
The center develops and implements a process for the handling of
6.3.4 medications and vaccines when temperature monitoring indicates out of (DR)
range.
Total Score

The center has a process for ensuring the stability of medication available
MM.6.4 Value Percent Evaluation
in multi-dose containers.
The center develops and maintains a set of guidelines for ensuring the
6.4.1 stability of sterile multi-dose vials, vaccines, and other multi-dose (DR)
medications.
The center ensures all open multi-dose containers are labeled with the
6.4.2 (O, DR)
opening date and time, the expiry date and staff initials.
Total Score

31
 The center has a process for identifying and handling expired
MM.6.5 Value Percent Evaluation
medications.
The center has a written and implemented process for detecting and
6.5.1 (SI, DR)
returning the nearly expired medications before the expiration date.
6.5.2 Expired medications are not found in any patient care areas. (O)
The center maintains documents of return of expired medications to the
6.5.3 (DR)
supplier or manufacturer, or evidence of its proper destruction.
All expired and/or nearly expired medications are properly labeled and
6.5.4 (O)
stored separately from other medications.
Total Score

The center develops a policy and procedure for the safe prescribing of
MM.6.6 Value Percent Evaluation
medications.
All prescriptions are identified by accurate patient demographics including
6.6.1 (MR)
name, age and medical record number..
6.6.2 Allergy status is clearly identified on the prescription. (MR)

6.6.3 For all pediatric prescriptions, weight is identified. (MR)

6.6.4 Abbreviations are not used in prescriptions. (MR)

6.6.5 Prescribed medication is documented in the medical record. (MR)

The prescribing of narcotics and controlled medications follows Ministry of
6.6.6 (DR, MR)
Health laws and regulations.
Total Score

The center develops and implements guidelines for the correct

MM.6.7 Value Percent Evaluation
prescribing of antibiotics.
A multidisciplinary team from the center adopts and updates the
6.7.1 (DR)
antibiotics guidelines.
The guidelines for antibiotics prophylaxis are properly implemented before
6.7.2 (MR)
surgery and/or dental procedures and monitored.
The guidelines for empiric and therapeutic use of antibiotics are properly
6.7.3 (DR)
implemented and monitored.
Total Score

The center develops a process to manage narcotics, psychotropic

MM.6.8 medications, and other controlled medications according to laws and Value Percent Evaluation
regulations.
The center has a process for receiving, storing and dispensing narcotics,
6.8.1 (DR)
psychotropic medications, and other controlled medications.
The center maintains an inventory of narcotics, psychotropic medications,
6.8.2 (DR)
and other controlled medications.
The center has a process for prescribing narcotics, psychotropic
6.8.3 (DR)
medications, and other controlled medications.
Total Score

32
 The center safely manages high-alert and look-alike, sound-alike
MM.6.9 Value Percent Evaluation
(LASA)medications.
6.9.1 The center identifies, in writing, its high-alert and LASA medications. (DR)

6.9.2 The center has a process for managing high-alert and LASA medications. (DR)

Total Score

The center evaluates the appropriateness of prescriptions before

MM.6.10 Value Percent Evaluation
dispensing.
The appropriateness review includes allergies, indications, dosage,
6.10.1 frequency, route of administrations therapeutic duplication and possible (O, DR)
interactions.
The center maintains an updated medication profile for each patient
6.10.2 (MR)
treated in the emergency room or day procedure unit.
6.10.3 The review process is done by a pharmacist or a physician. (O)
The reviewer discusses any concerns in the process with the prescriber
6.10.4 (SI, MR)
before medication dispensing.
Total Score

Medication preparation areas comply with infection control measures

MM.6.11 Value Percent Evaluation
and safe practices.
Medication preparation areas are clean and tidy, with clean preparation
6.11.1 (O)
surfaces.
The preparation area is equipped with a wash sink, antiseptic soap, and a
6.11.2 (O)
sharps container of appropriate size.
6.11.3 Parenteral medications are prepared aseptically. (O)
Medications that are prepared and not immediately utilized are labeled
6.11.4 with the medication name, dose, route of administration, and patient’s (O)
identifiers.
Total Score

The center develops and implements a policy and procedure on

MM.6.12 Value Percent Evaluation
medication error reporting.
The pharmacy maintains a written policy and procedure for medication
6.12.1 (DR)
error reporting..
The policy defines significant medication error, the time frame for
6.12.2 (DR)
reporting, and the reporting format.
6.12.3 Medication error reporting is active and ongoing. (DR, LI)
The center performs an intensive root-cause analysis for all significant
6.12.4 (DR)
medication errors.
The center utilizes the reported information to improve the medication
6.12.5
use process and reduce the error rate.
Total Score

33
MM.6.13 The center monitors allergies to medications. Value Percent Evaluation
The center has a process in place to ensure the reporting of medication
6.13.1 (DR)
allergies.
The newly discovered allergies are documented in patient medication
6.13.2 (LI)
profile.
Total Score

The center develops and implements a policy and procedure for the
MM.6.14 Value Percent Evaluation
reporting of adverse drug reactions (ADR’s).
The policy and procedure defines significant ADRs and the time frame for
6.14.1 (DR)
reporting.
6.14.2 An intensive analysis is performed for all significant ADRs. (DR)

6.14.3 Treating physicians are notified of the analysis results. (DR)

The medical record is flagged for significant ADRs and the patient receives
6.14.4 (MR)
the appropriate medical care for the reaction.
Significant ADRs are reported to the relevant authorities as per laws and
6.14.5 (SI, DR)
regulations.
Total Score

34
7. Management of Information (MOI)

No. Of Sub Sub

Sub Standards
Standard
The leaders define in a plan the information that is shared among
MOI 7.1 the staff and with other governmental and non-governmental 7
entities and its format.
The leaders develop standardized diagnosis codes, procedure codes
MOI 7.2 2
and symbols, and minimize abbreviations.
MOI 7.3 All patients seen in the center have unique medical records. 6
The leaders develop a policy on the rules and regulations for writing
MOI 7.4 4
in patients’ medical records.
The leaders develop a process for completing and storing the patient
MOI 7.5 4
medical record.
The center has an implemented policy and procedure for the use of
MOI 7.6 3
information technology.
The center has an effective clinical documentation improvement
MOI 7.7 2
(CDI) program.
Total 28

35
 The leaders define in a plan the information that is shared among the
MOI.7.1 staff and with other governmental and non-governmental entities and its Value Percent Evaluation
format.
The plan highlights how patient demographic and medical information is
7.1.1 (SI)
shared among medical and administrative staff.
The plan identifies how the types of information are communicated by
7.1.2 (DR)
leaders to staff and vice versa.
The plan includes the Ministry of Health required information and the
7.1.3 (DR)
frequency of reporting
The plan highlights the patient’s personal and medical information
7.1.4 (DR)
required to refer the patient to a higher center.
7.1.5 The plan identifies the staff security levels for accessing the information. (DR)
The plan identifies how the various information is secured and safely
7.1.6 (DR)
stored.
The plan highlights the different documents retention time consistent with
7.1.7 (DR)
Ministry of Health rules and regulations.
Total Score

The leaders develop standardized diagnosis codes, procedure codes and

MOI.7.2 Value Percent Evaluation
symbols, and minimize abbreviations.
The staff use diagnosis and procedure codes consistent with Ministry of
7.2.1 (DR)
Health and other regulatory bodies’ requirements.
A list of approved abbreviations and symbols is distributed in all patient
7.2.2 (DR)
care areas for reference.
Total Score

MOI.7.3 All patients seen in the center have unique medical records. Value Percent Evaluation

7.3.1 Each patient has a unique medical record number. (SI)

Each patient has only one medical record or historical volumes of the
7.3.2 (MR)
same.
The medical record’s contents are arranged according to a standardized
7.3.3 (MR)
process.
Medical record contains the required patient demographics, including
7.3.4 national identification, contact information, emergency contacts and (MR)
insurance category.
Medical record contains updated medical information sufficient to safely
7.3.5 (MR)
manage the patient and promote continuity of medical care.
Patient allergies, prior adverse reactions, and chronic infections are
7.3.6 confidentially documented and consistently displayed in a specified area of (MR)
the patient’s record.
Total Score

36
 The leaders develop a policy on the rules and regulations for writing in
MOI.7.4 Value Percent Evaluation
patients’ medical records.
The policy identifies the category of staff allowed to write in the
7.4.1 (DR, MR)
medical record.
7.4.2 All entries are legible, dated, timed, and signed by the author. (MR)
Entries written in error are not deleted or erased. Instead, a line is passed
7.4.3 (MR)
through the error text and dated, timed, and signed by the author.
Only standardized and approved abbreviations and symbols are used in
7.4.4 (MR)
medical records.
Total Score

The leaders develop a process for completing and storing the patient
MOI.7.5 Value Percent Evaluation
medical record.
7.5.1 The center has a dedicated and secure storage area for medical records (O)
Regular checks are made on returned medical records to ensure their
7.5.2 (SI)
completion.
Non-completed medical records are clearly separated from completed
7.5.3 ones in the storage area and are completed within a timeframe that the (O)
organization defines.
The center maintains a record of the percentage of incomplete records
7.5.4 over time and uses this information to improve staff compliance with (DR)
record completion.
Total Score

The center has an implemented policy and procedure for the use of
MOI.7.6 Value Percent Evaluation
information technology.
The policy and procedure highlight how the generated information is
7.6.1 (DR)
stored and regularly backed up.
The policy and procedure describe the manual procedures required to
7.6.2 execute the various activities in the event of system failure, maintenance (DR)
or repair
7.6.3 Staff can demonstrate the manual procedure for the downtime regulation. (SI)

Total Score

The center has an effective clinical documentation improvement (CDI)

MOI.7.7 Value Percent Evaluation
program.
There is a policy and procedure for clinical documentation improvement
7.7.1 (SI)
in the center.
The center has at a minimum a physician and a nurse who are properly
7.7.2 (SI)
trained on clinical documentation improvement.
Total Score

37
8. Infection Prevention and Control (IPC)

No. Of Sub Sub

Sub Standards
Standard
The center implements a coordinated program to reduce the risk of
IPC 8.1 5
healthcare-associated infections.
Infection prevention and control activities are integrated and
IPC 8.2 4
coordinated by an interdisciplinary team.
The leaders develop and ensure the implementation of infection
IPC 8.3 control policies and procedures targeting the most important 7
infection risk processes.
Communicable diseases are tabulated and reported as required by
IPC 8.4 1
laws and regulations.
The leaders develop and implement a policy and procedure for
IPC 8.5 2
healthcare associated infection prevention.
The leaders design and ensure the implementation of an effective
hand hygiene program. Hand hygiene (HH) is the most effective
IPC 8.6 2
method of preventing infectious disease transmission. The center
should develop.
Centers providing sterilization services strictly follow rigorous
IPC 8.7 8
sterilization rules.
Patients with communicable diseases and those who are colonized
IPC 8.8 or infected with epidemiologically important organisms are 5
separated from other patients, staff and visitors.
Personal protective equipment is readily accessible and available
IPC 8.9 3
and is used correctly by staff in all patient care areas.
The leaders define in a policy the cleaning, decontamination and
IPC 8.10 3
disinfection processes in all patient care areas.
The leaders define in a policy the safe procedures for waste
IPC 8.11 2
collection, strong and disposal.
The leaders develop and ensure the implementation of a program
IPC 8.12 2
for the prevention and management of sharp injuries.
IPC 8.13 Sharps are discarded in appropriate containers. 2

IPC 8.14 Sharps are discarded in appropriate containers. 3

Total 49

38
 The center implements a coordinated program to reduce the risk of
IPC.8.1 Value Percent Evaluation
healthcare-associated infections.
A qualified individual, acting on a full-time or part-time basis, is
8.1.1
responsible for the infection control program.
8.1.2 The program involves patients, visitors, staff, and volunteers.

8.1.3 The program involves all patient care areas and support services.
The infection control program is based on current scientific knowledge,
8.1.4
accepted practice guidelines, and applicable laws and regulations.
The infection control program’s components are contained in a manual
8.1.5
that is available to all staff members.
Total Score

Infection prevention and control activities are integrated and

IPC.8.2 Value Percent Evaluation
coordinated by an interdisciplinary team.
The interdisciplinary team reviews and approves the infection control
8.2.1
policies and procedures and the improvements plans.
The interdisciplinary team evaluates and revises, on a continuous basis,
8.2.2 the procedures and mechanisms that the center develops to serve
established standards and goals.
The interdisciplinary team brings to the center’s attention new infection
8.2.3 control issues arising in different departments and suggestions for
solutions.
The interdisciplinary team evaluates the infection control program
8.2.4
annually and suggests any necessary additions or changes.
Total Score

The leaders develop and ensure the implementation of infection control

IPC.8.3 policies and procedures targeting the most important infection risk Value Percent Evaluation
processes.
8.3.1 Disinfection and sterilization.

8.3.2 Handling of sharps.

8.3.3 Infectious materials and waste disposal.

Prevention and management of patients’ and workers’ exposure to
8.3.4
healthcare-associated infections.
8.3.5 Laundry and linen management processes.

8.3.6 Renovation projects guidelines.

8.3.7 Practices for support services departments.

Total Score

39
 Communicable diseases are tabulated and reported as required by laws
IPC.8.4 Value Percent Evaluation
and regulations.
The center tabulates and reports communicable diseases to the Ministry of
8.4.1
Health.
Total Score

The leaders develop and implement a policy and procedure for

IPC.8.5 Value Percent Evaluation
healthcare associated infection prevention.
8.5.1 Evidence based bundles are used for the insertions of devices.
Staff regularly collect and analyze data on device related and surgical site
8.5.2 (DR)
infections.
Total Score

The leaders design and ensure the implementation of an effective hand

IPC.8.6 hygiene program. Hand hygiene (HH) is the most effective method of Value Percent Evaluation
preventing infectious disease transmission. The center should develop.
Written policies and procedures for implementing and monitoring
8.6.1
appropriate hand hygiene are available.
8.6.2 The center provides hand washing facilities sufficient to meet its needs.

Total Score

Centers providing sterilization services strictly follow rigorous

IPC.8.7 Value Percent Evaluation
sterilization rules.
8.7.1 Qualified staff conduct the sterilization processes.
Adequate space is available for sterilization services that support
8.7.2 sterilization processes, and no instrument or equipment sterilization takes
place outside this area.
A policy and procedure on the safe reprocessing of single-use items have
8.7.3
been implemented.
Personal protective equipment is available and used during
8.7.4 decontamination: heavy-duty gloves, waterproof aprons, facemasks,
goggles, and face shields.
Sterilizers are in good working order, and instructions for their use are
8.7.5
available.
8.7.6 Proper sterilization parameters are recorded.

8.7.7 Sterilization records are retained for one year.

Chemical indicators are used in every package. Biological indicators are
8.7.8
used at least weekly. Records of results are kept for one year.
Total Score

40
 Patients with communicable diseases and those who are colonized or
IPC.8.8 infected with epidemiologically important organisms are separated from Value Percent Evaluation
other patients, staff and visitors.
Written and implemented policies and procedures address standard and
8.8.1 isolation precautions for cases of suspected or proven communicable
diseases.
Patients with suspected communicable diseases are dealt with in an
8.8.2
isolation room equipped with a sink and personal protective equipment.
The isolation room is a negative pressure ventilation that is exhausted to
the outside unless it is filtered through a High-Efficiency Particulate Air
8.8.3 (HEPA) filter, or, at a minimum, is equipped with a portable HEPA filter
that is regularly maintained according to the manufacturer’s
recommendation.
Staff are trained to triage suspected communicable disease cases and
8.8.4
isolate them before transfer to the appropriate healthcare setting.
During direct care of patients on airborne precautions, staff use high-
8.8.5
filtration respirator masks (N-95, N-99).
Total Score

Personal protective equipment is readily accessible and available and is

IPC.8.9 Value Percent Evaluation
used correctly by staff in all patient care areas.
Written policies and procedures are available for the appropriate use of
8.9.1
gloves, gowns, facemasks, and protective eyewear.
Gloves are worn when the potential exists for contact with blood/body
8.9.2
fluids.
Gowns, masks, eyewear, or face shields and other protective equipment
8.9.3 are worn during all procedures which are likely to generate splashes,
soiling, or droplets of blood or other body fluids.
Total Score

The leaders define in a policy the cleaning, decontamination and

IPC.8.10 Value Percent Evaluation
disinfection processes in all patient care areas.
The policy has a list of appropriate detergents and disinfectants as defined
8.10.1
and approved by the infection control personnel.
8.10.2 Detergents and disinfectants are available in all patient care areas

8.10.3 Patient care areas are clean, and equipment is properly disinfected.

Total Score

The leaders define in a policy the safe procedures for waste collection,
IPC.8.11 Value Percent Evaluation
strong and disposal.
8.11.1 The policy differentiates between regular waste and infectious waste.
The infectious waste is treated and disposed of in accordance to laws and
8.11.2
regulations.
Total Score

41
 The leaders develop and ensure the implementation of a program for the
IPC.8.12 Value Percent Evaluation
prevention and management of sharp injuries.
Needles are not bent, broken, or recapped except in special and approved
8.12.1
circumstances. If recapping is necessary, the "scoop method" is used.
Needle sticks or sharps injuries are reported in a timely manner and
8.12.2 investigated. Data are trended over time and used to develop
improvement interventions.
Total Score

IPC.8.13 Sharps are discarded in appropriate containers. Value Percent Evaluation

At least one puncture-proof and leak-proof sharps container is available in
8.13.1
a convenient place in every patient care area.
Sharp containers are not overfilled and are disposed of as medical waste
8.13.2 when their contents are three quarters of their sizes. They are not opened
to facilitate the transfer of sharps into other containers.
Total Score

IPC.8.14 Sharps are discarded in appropriate containers. Value Percent Evaluation

All units have a cleaning/disinfection schedule that lists all environmental
8.14.1
surfaces and items to be cleaned.
The infection control staff periodically review the cleaning procedures,
8.14.2
schedules, and agents.
8.14.3 A process is in place to safely handle blood/ body fluids spills and waste.

Total Score

42
9. Facility Management and Safety (FMS)

No. Of Sub Sub

Sub Standards
Standard
The leaders establish and support a facility management and safety
FMS 9.1 7
program.
Interdisciplinary rounds are scheduled and conducted to ensure
FMS 9.2 2
safety.
FMS 9.3 The center’s environment is safe for patients, visitors and staff. 5
The leaders develop and monitor the implementation of a fire
FMS 9.4 8
prevention program.
FMS 9.5 The center is secured and protects its users. 6
The leaders develop a plan for the inspection, testing and
FMS 9.6 6
maintenance of medical equipment.
FMS 9.7 The leaders develop an emergency plan, and staff are trained on it. 7
The leaders develop a hazardous materials (HAZMAT) and waste
FMS 9.8 6
disposal plan.
The leaders develop a policy and procedure for the safe use of
FMS 9.9 5
various types of compressed gasses.
Total 52

43
 The leaders establish and support a facility management and safety
FMS.9.1 Value Percent Evaluation
program.
A qualified individual is responsible for the facility management and safety
9.1.1 (PF)
program as a full-time or part-time employee.
The leaders establish an interdisciplinary team for overseeing and
9.1.2 (DR)
monitoring the facility management and safety program.
The safety management program includes plans for emergency
9.1.3 management, utility systems, hazardous materials, fire safety, medical (DR)
equipment, building safety and security.
The safety management program includes the regular inspection, testing,
9.1.4 (DR)
and maintenance of all the program’s operating components.
Data related to safety concerns are reviewed and analyzed with proper
9.2.5 (DR)
action to prevent reoccurrences.
The leaders maintain adequate and complete documentation for the
9.1.6 (DR)
facility management and safety program.
All staff including new hires, locum and trainees receive education on the
9.1.7 (DR, PF)
program. This education is repeated annually as relevant to their practice.
Total Score

FMS.9.2 Interdisciplinary rounds are scheduled and conducted to ensure safety. Value Percent Evaluation
The interdisciplinary team conducts a facility inspection round at least four
9.2.1 (DR)
times per year.
The resulting information is documented and used for corrective actions,
9.2.2 (DR)
planning, and budgeting for long-term facility upgrading and replacement.
Total Score

FMS.9.3 The center’s environment is safe for patients, visitors and staff. Value Percent Evaluation
The leaders ensure that the building and its services comply with national
9.3.1 standards, environmental protection standards, laws and regulations and (DR)
the recommendations of professional centers.
9.3.2 The building and its surroundings are hazard free. (O)
Periodic preventive maintenance (PPM) and corrective maintenance are
9.3.3 (O, DR)
performed and recorded for all electrical and mechanical systems.
Maintenance records are kept for all electrical and mechanical systems,
9.3.4 (DR)
including periodic preventive maintenance.
9.3.5 The center has adequate parking space, waiting areas and toilets. (O, SI)

Total Score

44
 The leaders develop and monitor the implementation of a fire
FMS.9.4 Value Percent Evaluation
prevention program.
9.4.1 At least annually, staff are trained on fire drills and evacuation plans. (DR)

9.4.2 Records of fire and evacuation training are kept in personal staff files. (PF)
Egress routes, corridors, and fire escapes are marked and free from
9.4.3 (O)
obstacles.
Fire systems, including the fire alarm and fire equipment, are in place and
9.4.4 (O, DR)
functioning.
Fire extinguishers are tested and distributed in the center according to the
9.4.5 (O)
type of extinguisher required.
The fire alarm system is maintained and tested and all maintenance
9.4.6 (DR)
records are maintained.
9.4.7 A no smoking policy is approved and enforced. (O, DR)

9.4.8 “No smoking signs” are posted at all entrances and waiting areas. (O)

Total Score

FMS.9.5 The center is secured and protects its users. Value Percent Evaluation
Trained security personnel are available in the center according to its size
9.5.1 (O, DR)
and design complexity.
9.5.2 The center’s equipment and data are secured. (O, LI)

9.5.3 The patient’s privacy is respected. (O)

Security personnel or security systems restrict access to sensitive and high
9.5.4 (O)
risk areas.
9.5.5 Patient and staff files are accessible only to authorized persons. (O)

9.5.6 All staff wear properly displayed identification badges. (DR)

Total Score

The leaders develop a plan for the inspection, testing and maintenance
FMS.9.6 Value Percent Evaluation
of medical equipment.
9.6.1 An updated inventory list is available of all medical equipment. (DR)
Medical equipment with special installation requirements, HVAC, or room
9.6.2 modifications is installed following the manufacturer’s recommendations (SI, DR)
and safety requirements.
The periodic preventive maintenance (PPM) program is implemented for
9.6.3 all medical equipment, according to the supplied and available (O, DR)
manufacturer’s service manual, and records are maintained.
9.6.4 The medical equipment is tagged with a PPM label. (O)

9.6.5 All defective medical equipment is labeled accordingly. (O)

Medical equipment is discontinued according to a clear policy including
9.6.6 lifespan, beyond economic repair, and vendor or governmental recalls. (O, DR)
Equipment is disposed of as per governmental rules and regulations
Total Score

45
FMS.9.7 The leaders develop an emergency plan, and staff are trained on it. Value Percent Evaluation
The center’s emergency plan details how to respond to different
9.7.1 (DR)
emergencies and how to minimize risks in the center.
9.7.2 The emergency plan defines the staff roles. (DR)
Staff are trained on the emergency drills annually. Staff are certified in
9.7.3 (PF)
completing the emergency drills.
9.7.4 The emergency plan includes contact persons and authorities. (DR)
The emergency plan identifies the nearest healthcare facilities and staff
9.7.5 (SI, DR)
know where to refer patients during emergencies if needed.
The center has alternative power and water sources as part of its
9.7.6 (LI)
emergency preparedness
The emergency plan is documented, evaluated annually, and updated as
9.7.7 (DR)
needed.
Total Score

The leaders develop a hazardous materials (HAZMAT) and waste disposal

FMS.9.8 Value Percent Evaluation
plan.
The leaders keep an updated register of all hazardous materials in the
9.8.1 (DR)
center, along with their “Safety Data Sheets”.
Staff are trained in dealing with available hazardous materials and waste
9.8.2 (PF)
disposal.
Hazardous materials and waste are controlled. The center exerts a
9.8.3 (O, DR)
continuous effort to reduce hazardous materials.
Hazardous materials are stored, handled, transported, used, and disposed
9.8.4 (O)
of as per the “Safety Data Sheets”.
Waste disposal is done in an effective manner within the facility or through
9.8.5 (O)
an authorized contractor.
9.8.6 Fire-rated cabinets are used for flammable hazardous materials. (O)

Total Score

The leaders develop a policy and procedure for the safe use of various
FMS.9.9 Value Percent Evaluation
types of compressed gasses.
9.9.1 The document highlights the use of cylinder transporters. (O, DR)

9.9.2 The document emphasizes the cylinder storage in well-ventilated areas. (O, DR)
The document describes how to secure the cylinders by positioning upright
9.9.3 (O, DR)
against the wall and securing it by a chain or inside special containers.
The document ensures the timely replacement of empty cylinders and the
9.9.4 (SI, DR)
availability of a backup system.
Centers equipped with piped gas systems follow the regulatory body’s
9.9.5 (DR)
testing and safety requirements.
Total Score

46
10.Day Procedure Unit (DPU)

No. Of Sub Sub

Sub Standards
Standard
All day surgeries and procedures are performed in the day
DPU 10.1 7
procedure unit.
Leaders develop and implement a policy and procedure to guide
DPU 10.2 9
the care of patients in the day procedure unit.
The patient is accepted into the unit by the nursing staff after a
DPU 10.3 6
rigorous verification procedure.

DPU 10.4 The procedure/surgery room is a functional operating room. 6

The day procedure unit is fully equipped for managing difficult

DPU 10.5 5
intubations.
Patients booked for a surgery/procedure shall have a pre-
DPU 10.6 sedation/anesthesia assessment performed by the 4
anesthesiologist prior to the surgery.
The center ensures the correct implementation of the policy on
DPU 10.7 3
preventing wrong patient, wrong site and wrong procedure.
The patient’s condition is continuously monitored during
sedation or anesthesia, including local anesthesia and the
DPU 10.8 6
information is documented in the patient medical record before
the patient leaves the operating room.

DPU 10.9 The unit has a recovery room. 5

Each patient’s post-sedation/anesthesia physiological status is

DPU 10.10 continuously monitored and documented in the patient’s 5
medical record.

DPU 10.11 The leaders develop a policy and procedure for staff recruitment. 7

The patient is discharged home by an attending physician after

DPU 10.12 3
the procedure.

Total 66

47
 All day surgeries and procedures are performed in the day procedure
DPU.10.1 Value Percent Evaluation
unit.
10.1.1 A qualified physician or anesthesiologist directs the unit. (PF)
A Saudi board-certified or equivalent anesthesiologist performs
10.1.2 anesthesia and/or sedation as required and is in charge of monitoring (O, PF)
the patient until the patient is discharged home.
The unit has a patient receiving area, procedure room(s), and a recovery
10.1.3 (O)
area with an ICU setup.
10.1.4 The unit has its own staff changing area. (O)
The unit design follows infection control standards for the segregation
of
10.1.5 (O)
clean and potentially infectious areas and air-conditioning
requirements.
Dental procedures requiring sedation are performed under the same
conditions developed for the day procedure unit, and patients recover
10.1.6 (O)
in either a dedicated recovery room or the same dental room where the
procedure was performed.
10.1.7 The center maintains a registry of all the day cases performed. (DR)

Total Score

Leaders develop and implement a policy and procedure to guide the

DPU.10.2 Value Percent Evaluation
care of patients in the day procedure unit.
The policy highlights the types of operations and procedures that may
10.2.1 (DR)
be performed in the unit.
10.2.2 The policy describes how patients are received in the operating room. (O,DR)

10.2.3 The policy clearly explains the timeout procedure. (DR)

10.2.4 The policy includes the daily checking of anesthesia equipment. (DR)
The policy describes the required pre-sedation/ anesthesia assessment
10.2.5 (DR, MR)
and pre-induction assessment.
The policy describes the intra-procedural/operative monitoring of
10.2.6 (DR, MR)
patients with or without anesthesia or sedation.
The policy describes how patients are received and discharged from the
10.2.7 (O, DR)
recovery room.
The policy highlights the special considerations for surgeries involving
10.2.8 (DR)
implantable devices or lenses.
The policy includes the identification and storage of gametes in assisted
10.2.9 (DR)
reproduction units.
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48
 The patient is accepted into the unit by the nursing staff after a
DPU.10.3 Value Percent Evaluation
rigorous verification procedure.
10.3.1 The patient is properly identified. (O)

10.3.2 Informed consent is available. (MR)

The attending physician documents patient assessment and the
10.3.3 (MR)
operational plan.
10.3.4 Surgical/procedural site marking is done, if required. (MR)

10.3.5 Relevant laboratory and radiology results are available. (O)

10.3.6 The pre-sedation/anesthesia assessment is documented. (MR)

Total Score

DPU.10.4 The procedure/surgery room is a functional operating room. Value Percent Evaluation

10.4.1 The room has an anesthetic machine. (O)

10.4.2 A scavenging system is connected to the room. (O)

10.4.3 An ECG machine is available within the vicinity. (SI)

10.4.4 A cardiac defibrillator is available and regularly checked. (O, DR)

10.4.5 A ventilator is available and regularly checked. (O, DR)

10.4.6 Medical gases and suction are available with a backup system. (SI)

Total Score

The day procedure unit is fully equipped for managing difficult

DPU.10.5 Value Percent Evaluation
intubations.
10.5.1 Laryngeal mask. (O)

10.5.2 Gum elastic bogie. (O)

10.5.3 Lighted stylet. (O)

10.5.4 Cricothyroidotomy kit. (O)

10.5.5 Fiber optic intubations scope. (O)

Total Score

49
 Patients booked for a surgery/procedure shall have a pre-
DPU.10.6 sedation/anesthesia assessment performed by the anesthesiologist Value Percent Evaluation
prior to the surgery.
The pre-sedation/anesthesia assessment is performed no more than
thirty (30) days before the surgery date. If the pre-anesthesia
10.6.1 (DR)
assessment is performed within thirty (30) days, the pre-anesthesia
assessment is updated with documentation in the medical record.
The pre-sedation/anesthesia assessment highlights anesthetic risk score
10.6.2 (MR)
and the patient’s suitability for the type selected.
The assessment results in a sedation/anesthetic plan that is agreeable to
10.6.3 (MR)
both the physician performing the procedure and the patient/family.
The anesthesiologist reassesses the patient immediately before
sedation/anesthesia induction to assess the patient’s immediate
10.6.4 (O, MR)
suitability for the
procedure.
Total Score

The center ensures the correct implementation of the policy on

DPU.10.7 Value Percent Evaluation
preventing wrong patient, wrong site and wrong procedure.
The procedure site is marked before surgery if required, as in multiple
10.7.1 (DR)
organs, laterality, or different levels.
A preoperative verification process is used and documented in the day
procedure unit before the patient is placed in the procedure room to
10.7.2 (DR)
ensure the availability of the appropriate assessments, plans, consents,
diagnostics, equipment, instruments and implants.
The team which comprises of the surgeon, anesthesiologist and
circulating nurse performs and documents a time-out process
10.7.3 (MR)
immediately before
the procedure.
Total Score

The patient’s condition is continuously monitored during sedation or

anesthesia, including local anesthesia and the information is
DPU.10.8 Value Percent Evaluation
documented in the patient medical record before the patient leaves
the operating room.
The patient’s vital signs, oxygen saturation, and ECG findings are
10.8.1 (MR)
recorded by the anesthesiologist.
10.8.2 The anesthetic technique is recorded by the anesthesiologist. (MR)
The anesthetic or sedation agent, IV medications and other medications,
10.8.3 including dosage and the timing of administration are recorded by the (MR)
team.
10.8.4 Any unusual events are recorded. (MR)

10.8.5 Any investigations carried out are recorded. (MR)

10.8.6 The status of the patient at the end of the procedure is recorded. (MR)

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50
DPU.10.9 The unit has a recovery room. Value Percent Evaluation

10.9.1 A qualified anesthesiologist covers the recovery room. (PF)

The recovery room is equipped with continuous vital signs monitoring,
10.9.2 (O)
ECG, and pulse oximetry.
10.9.3 The recovery room is equipped with oxygen and suction. (O)

10.9.4 The recovery room is equipped with a crash cart and defibrillator. (O)
The recovery room is equipped with facilities for mobile ventilation in
10.9.5 (SI)
the event that transportation to a hospital is required.
Total Score

51
 Each patient’s post-sedation/anesthesia physiological status is
DPU.10.10 continuously monitored and documented in the patient’s medical Value Percent Evaluation
record.
The date and time of admission to the day procedure and discharge to
10.10.1 (MR)
recovery are recorded.
The patient’s vital signs, oxygen saturation, and level of consciousness
10.10.2 (MR)
are recorded.
10.10.3 The pain score is recorded. (MR)

10.10.4 Fluid output including urine and drains is recorded. (MR)

10.10.5 Tolerance to oral fluid is recorded. (MR)

Total Score

DPU.10.11 The center has a radiation safety program. Value Percent Evaluation

10.11.1 The report highlights the pre- and post-operative diagnosis.

The operative report documents the name of the surgeon,
10.11.2
anesthesiologist, and assistants.
The operative report clearly documents the operation or procedure
10.11.3
performed.
The operative report includes a description of the surgery or procedure,
10.11.4
findings, and complications, if any.
10.11.5 The amount of blood loss is documented.
The operative report flags any drains or packs left, the type of wound
10.11.6 closure, and the type of dressing used, with instructions on how and
when to remove.
The operative report includes specimens removed and the need for
10.11.7
histopathological examination.
Total Score

The patient is discharged home by an attending physician after the

DPU.10.12 Value Percent Evaluation
procedure.
The physician examines the patient to ensure the patient’s suitability
10.12.1
and stability for home discharge.
Post-procedure instructions are written in the patient medical record
10.12.2
and the patient/family are given a copy and educated on it.
The patient is informed about how to obtain help. An emergency
10.12.3
contact number is available outside normal working hours.
Total Score

52
11.Dermatology & Aesthetics Medicine (DA)

No. Of Sub Sub

Sub Standards
Standard

Dermatology and aesthetics services are managed by an

DA 11.1 3
experienced physician.

Physicians’ privileges outline the exact procedures to be done by

DA 11.2 5
each physician.

The unit performs periodic education and competency testing for

DA 11.3 3
clinical staff.

The managing physician ensures the compliance of procedural

DA 11.4 5
rooms with all required safety rules.

The unit maintains a dated and timed list of the procedures

DA 11.5 3
performed.
Implemented evidence based clinical practice guidelines are
DA 11.6 developed by the unit physicians and approved by the service 4
manager for all procedures performed in the unit.

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53
 Dermatology and aesthetics services are managed by an experienced
DA.11.1 Value Percent Evaluation
physician.
11.1.1 The managing physician is appointed by the center’s director. (DR)
The managing physician is a board-certified dermatologist or plastic
11.1.2 (PF)
surgeon.
The managing physician has a job description that matches his / her
11.1.3 supervisory role and accountability for the provision of safe and effective (PF)
services.
Prior to X-ray tests, women in the childbearing period with missed
11.1.4 (DR)
menstruation is checked for the possibility of pregnancy.
Total Score

Physicians’ privileges outline the exact procedures to be done by each

DA.11.2 Value Percent Evaluation
physician.
Privileges approved by the managing physician based on the physicians’
11.2.1 (PF)
competency and experience.
New procedures are performed by a physician only after updating his / her
11.2.2 (PF)
privilege.
The managing physician ensures that copies of privileges are available at
11.2.3 (DR)
the procedural areas.
The managing physician empowers the nurses to stop and report
11.2.4 (SI)
physicians performing outside the scope of their privileges.
The managing physician ensures that only registered trained nurses
11.2.5 (PF)
perform aesthetics procedures “under physician’s supervision”.
Total Score

The unit performs periodic education and competency testing for clinical
DA.11.3 Value Percent Evaluation
staff.
Education and competency assessment takes place at the initial
11.3.1 (PF)
appointment and for every newly introduced equipment.
11.3.2 The education includes how to manage related procedure complications. (DR)
The education and competency assessment is repeated yearly, and
11.3.3 (DR, PF)
whenever a change takes place in a procedure.
Total Score

The managing physician ensures the compliance of procedural rooms

DA.11.4 Value Percent Evaluation
with all required safety rules.
11.4.1 Safety signs are posted outside the room. (O)
Laser procedural rooms do not have reflecting surfaces and do not store
11.4.2 (O)
flammable material.
Personal eye protective goggles are worn by patient and team performing
11.4.3 (O, MR)
laser procedure.
Laser generated airborne contaminants are controlled by local exhaust
11.4.4 (SI)
ventilation.
The center’s director and the managing physician perform weekly
11.4.5 (DR)
documented safety visits to all procedural rooms.
Total Score

54
DA.11.5 The unit maintains a dated and timed list of the procedures performed. Value Percent Evaluation
The list highlights the medical equipment used and the name of the
11.5.1 (DR)
physician who performed the procedure.
11.5.2 The list highlights the outcomes and any complications of the procedures. (DR)

11.5.3 The list highlights the specimens sent for pathological examination. (DR)

Total Score

Implemented evidence based clinical practice guidelines are developed

DA.11.6 by the unit physicians and approved by the service manager for all Value Percent Evaluation
procedures performed in the unit.
The guidelines highlight the indications and contraindications of the
11.6.1 (DR)
procedures.
The guidelines outline the pre-procedural assessment and investigations
11.6.2 (DR)
required and consent requirements.
11.6.3 The guidelines highlight the safety precautions to be followed. (DR)
The guidelines outline the post-procedural recovery and follow up and any
11.6.4 (DR)
pathology specimen processing required.
Total Score

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