R0075-01-24

‫بيانات المنشأة والزيارة التقييمية‬

‫‪ 26‬و‪ 27‬ديسمبر ‪2023‬‬ ‫تاريخ زيارة التقييم‪:‬‬ ‫مستشفى مركز أورام مدينة نصر‬ ‫اسم المنشــــأة‪:‬‬
‫اعتماد مبدئي أول مرة‬ ‫نوع زيارة التقييم‪:‬‬ ‫القاهرة‬ ‫عنوان المنشأة‪:‬‬
‫د‪ .‬إسماعيل الفقي‬ ‫رئيس الفريق‬ ‫حكومي‬ ‫نوع المنشــــأة‪:‬‬
‫أعضاء فريق زيارة‬
‫د‪ .‬إيمان السيد‬ ‫عضو الفريق‬ ‫هيئة التأمين الصحي‬ ‫جهة المنشـــأة‪:‬‬
‫التقييم والمراجعة‪:‬‬
‫‪---‬‬ ‫عضو الفريق‬ ‫القاهرة‬ ‫المحــــافـظــــة‪:‬‬
‫معايير اعتماد مبدئي مستشفيات‬ ‫المعايير التى تم التقييم على أساسها‬

‫‪Report Summary‬‬
‫‪The hospital speciality is oncology‬‬
‫× ‪Percent‬‬
‫‪REQUIRMENT‬‬ ‫‪M‬‬ ‫‪PM‬‬ ‫‪NM‬‬ ‫‪NA‬‬ ‫‪%‬‬ ‫‪Weight‬‬
‫‪Weight‬‬
‫‪Section 2:‬‬
‫‪National Safety‬‬ ‫‪28‬‬ ‫‪21‬‬ ‫‪6‬‬ ‫‪1‬‬ ‫‪0‬‬ ‫‪85.7%‬‬ ‫‪0.45‬‬ ‫‪38.6%‬‬
‫)‪Requirements (NSR‬‬
‫‪Section 3:‬‬
‫‪Essential Quality‬‬ ‫‪33‬‬ ‫‪23‬‬ ‫‪7‬‬ ‫‪0‬‬ ‫‪3‬‬ ‫‪88.3%‬‬ ‫‪0.45‬‬ ‫‪39.8%‬‬
‫)‪Requirements (EQRs‬‬
‫‪Section 4:‬‬
‫‪Operating Manual‬‬
‫‪10‬‬ ‫‪10‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪100%‬‬ ‫‪0.1‬‬ ‫‪10%‬‬

‫‪Total Score‬‬ ‫‪88.4%‬‬

‫التراخيص‪:‬‬
‫أفاد تقرير الحماية المدنية عدم صالحية لوحة التحكم في الحريق ولذلك لم يتم منح شهادة الحماية المدنية واشترط إصالحها‬ ‫•‬
‫وإعادة المعاينة‪ .‬وأفاد مدير المستشفى بصالحيتها وأنه قد قام بطلب إعادة المعاينة وقام مسؤول السالمة بالتجربة‪.‬‬
‫تراخيص األشعة (السينية‪ ،‬المقطعية‪ ،‬الجاما كاميرا‪ ،‬ماموغرام) منتهية الصالحية وجارى تجديد الترخيص‪.‬‬ ‫•‬
‫جارى تركيب معجل خطى جديد وال توجد له أية تراخيص‪.‬‬ ‫•‬

‫‪2‬‬
 Report Details

● Findings related to standards and evidence of compliance that noted during the survey.
Section 2:
National Safety Requirements (NSR)
NSR Standard
Score Comments
Standard EOC
General Patient Safety
NSR.1 Accurate patient identification through at least two
identifiers to identify the patient and other PM
elements associated with his/her plan of care.
EOC.1 The hospital has an approved policy and
procedure for patient identification that
2
addresses all elements mentioned in the
intent from a) through f).
EOC.2 All healthcare professionals are aware of
2
hospital policy.
EOC.3 The patient's identification occurs according • The patient's identification
to the policy. occurs according to the
policy in the inpatient
departments.
1
• The pathology laboratory
uses the patient's first
name and laboratory
number to identify slides
and blocks, which does not
comply with the policy.
EOC.4 The patient's identifiers are recorded in the By reviewing patient’s
patient’s medical record. medical record from
different departments:
• The patient's identifiers are
recorded in the used sheets
in the inpatients, ICUs, OR
departments.
1
• however, patient's
identifiers were used only
in the cover sheet while all
the used sheets have no
patients’ identifiers in
chemotherapy,
radiotherapy, OPD, and
nuclear medicine
departments.
EOC.5 The hospital tracks, collects, analyzes, and
First provisional
reports data on the patient’s identification NA
accreditation.
process.
EOC.6 The hospital acts on improvement
First provisional
opportunities identified in its patient NA
accreditation.
identification process.
NSR.2 Verbal or telephone orders are communicated
Met
safely and effectively.
EOC.1 The hospital has an approved policy to
guide verbal communications and to define 2
its content that addresses at least all

3
 elements mentioned in the intent from a)
through d).
EOC.2 Healthcare professionals are aware of the
2
elements of the policy.
EOC.3 All verbal orders and telephone orders are
recorded in the patient’s medical record 2
within a predefined timeframe.
EOC.4 The hospital tracks, collects, analyzes, and
First provisional
reports data on verbal and telephone order NA
accreditation.
process.
EOC.5 The hospital acts on improvement
First provisional
opportunities identified in verbal and NA
accreditation.
telephone order process.
NSR.3 Evidence-based hand hygiene guidelines are
adopted and implemented throughout the hospital
Met
in order to prevent healthcare-associated
infections.
EOC.1 Hospital has approved Hand Hygiene
policies and procedures based on current 2
evidence-based guidelines.
EOC.2 Healthcare professionals are trained on
2
these policies and procedures.
EOC.3 Hand hygiene posters are displayed in
required areas and hand hygiene facilities 2
are present in required numbers and places.
EOC.4 The hospital tracks, collects, analyzes, and First provisional
NA
reports data on hand hygiene process. accreditation.
EOC.5 The hospital acts on improvement
First provisional
opportunities identified in hand hygiene NA
accreditation.
process.
NSR.4 Systems are implemented to prevent catheter and
Met
tubing misconnections.
EOC.1 The hospital has an approved policy that
addresses all the elements mentioned in the 2
intent from a) through f).
EOC.2 All staff members using tubes and catheters
2
are aware of the hospital policy.
EOC.3 Competent individuals are responsible for There was no
the management and use of tubes and competency assessment
0
catheters. showed for the relevant
staff.
EOC.4 Management and the use of tubes and
2
catheters is safe.
EOC.5 Management and use of tubes and catheters
2
are recorded in the patient’s medical record.
NSR.5 Patient’s risk of falling is screened, assessed,
periodically reassessed, and managed safely and PM
effectively.
EOC.1 The hospital has an approved policy to
guide screening for patient’s risk for fall and
to define its content and timeframe based on 2
guidelines. Policy includes all elements in
the intent from through f).
EOC.2 Healthcare professionals are qualified and
2
aware of the elements of approved policy.

4
 EOC.3 Patients who have higher level of fall risk
and their families are aware and involved in 2
fall prevention measures.
EOC.4 All fall risk screens are completed and
recorded within an approved timeframe and 2
responsibilities.
EOC.5 General measures and tailored care plans General measures are
are recorded in the patient’s medical record. recorded, but there was no
recorded tailored care
1 plan in the medical
records. (five out of five
reviewed medical
records).
EOC.6 All fall risk reassessments are done within There were no fall risk
an approved timeframe. reassessments done (five
0
out of five reviewed
medical records).
NSR.6 Patient’s risk of developing pressure ulcers is
PM
screened, assessed, periodically reassessed, and
managed safely and effectively.
EOC.1 The hospital has an approved policy to
guide screening for patient’s pressure ulcer
risk and to define its content and timeframe
2
based on guidelines. Policy addresses all
elements mentioned in the intent from a)
through e).
EOC.2 Healthcare professionals are aware of the By interviewing seven staff
elements of the pressure ulcer screening 0 members, they did not aware
process and of prevention measures. of the policy.
EOC.3 Patients who have higher level of pressure
ulceration risk and their families are aware 2
and involved in prevention measures.
EOC.4 All pressure ulcer risk screens are
completed and recorded within an approved 2
timeframe and responsibilities.
EOC.5 General measures and tailored care plans General measures are
are recorded in the patient’s medical record. recorded, but there was no
recorded tailored care
1 plan in the medical
records. (four out of four
reviewed medical
records).
EOC.6 All pressure ulcer risk reassessments are There were no fall risk
done within an approved timeframe. reassessments done (four
0
out of four reviewed
medical records).
NSR.7 A standardized approach to hand over
communications, including an opportunity to ask Met
and respond to questions, is implemented.
EOC.1 The hospital has an approved policy that
addresses all elements mentioned in the 2
intent from through f).
EOC.2 All healthcare professionals are aware of 2

5
 hospital policy.
EOC.3 Handover communications are recorded and
2
available when required.
EOC.4 The hospital tracks, collects, analyzes, and
First provisional
reports data on the handover NA
accreditation.
communication process.
EOC.5 The hospital acts on improvement
First provisional
opportunities identified in the handover NA
accreditation.
communication process.
NSR.8 The hospital has an approved policy and procedure
Met
for managing critical alarms.
EOC.1 The hospital has an approved policy that
addresses all the elements mentioned in the 2
intent from a) through f).
EOC.2 All staff members using devices with
critical alarms are aware of the hospital 2
policy.
EOC.3 Competent individuals are responsible for
2
the management and use of critical alarms.
EOC.4 Management and the use of critical alarms
2
is safe.
EOC.5 Management and use of critical alarms are
recorded according to policy including
evidence of responsible staff members,
2
responsible company, schedule, agreed
settings, evidence of function, reporting of
malfunction, and remedial action.
NSR.9 The hospital has an approved policy and
procedures to ensure hospital-wide recognition of Met
and response to clinical deterioration.
EOC.1 The hospital has an approved policy that
addresses all the elements mentioned in the 2
intent from a) through g).
EOC.2 All staff members involved in direct patient
2
care are aware of the hospital policy.
EOC.3 Competent individuals are responsible for
the recognition of and response to clinical 2
deterioration.
EOC.4 Recognition of and response to clinical
2
deterioration occurs safely.
EOC.5 Recognition of and response to clinical
deterioration are recorded in the patient’s 2
medical record.
NSR.10 Patient’s risk of developing venous
thromboembolism (deep venous thrombosis and
pulmonary embolism) is screened, assessed, Met
periodically reassessed, and managed safely and
effectively.
EOC.1 The hospital has an approved policy to
guide screening for patient’s VTE risk and
to define its content and timeframe based on 2
guidelines. Policy addresses all elements
mentioned in the intent from a) through e).
EOC.2 Healthcare professionals are aware of the
2
elements of the VTE screening process and

6
 of prevention measures.
EOC.3 Patients who have higher level of VTE risk
and their families are aware and involved in 2
prevention measures.
EOC.4 All VTE risk screens are completed and
recorded within an approved timeframe and 2
responsibilities.
EOC.5 There is evidence that compliance to
2
guideline is monitored.
NSR.11 Critical results are communicated timely,
Met
accurately and safely.
EOC.1 The hospital has an approved policy to
guide critical results communications and to
define its content that addresses at least all 2
elements mentioned in the intent from a)
through d).
EOC.2 Healthcare professionals are aware of the
2
elements of the policy.
EOC.3 All critical results are recorded in the
patient’s medical record within a predefined
2
timeframe including all elements in the
intent from i) through vii).
EOC.4 The hospital tracks, collects, analyzes, and
First provisional
reports data on critical results reporting NA
accreditation.
process.
EOC.5 The hospital acts on improvement
First provisional
opportunities identified in critical results NA
accreditation.
reporting process.
Medication Management Safety (MMS)
NSR.12 The hospital defines standardized diagnosis codes,
procedure codes, definitions, symbols, and PM
abbreviations.
EOC.1 The hospital has an approved policy that
includes all the elements in the intent from 2
a) through d).
EOC.2 All staff who records in the patient’s By interviewing seven
medical record are aware of the policy staff, four of them were
1
requirements. aware of the policy
requirements.
EOC.3 Approved codes are matching those
There were no approved
provided by health authorities and/or 3rd 0
codes used.
party payers.
EOC.4 Symbols and abbreviations (even the
approved list) are not used in informed
consent and any record that patients and 2
families receive from the hospital about the
patient’s care.
NSR.13 Medications are reconciled across all interfaces of
NM
care in the hospital.
EOC.1 The hospital has an approved policy for
medication reconciliation that includes all
2
elements mentioned in the intent from a)
through e).
EOC.2 Staff responsible for reconciling 0 There were no training

7
 medications are trained to take the best documents submitted.
possible medication history (BPMH) and By interview, six
reconcile medications. physicians they didn’t
aware of medication
reconciliation
EOC.3 Medication reconciliation occurs on By review ten medical
admission, during the transition of care and records, there was no
upon discharge within a defined timeframe. medication reconciliation
0 documentation on
admission, during the
transition of care and upon
discharge.
EOC.4 Medication prescribers compare the list of
current medications with the list of There was no evidence of
0
medications to be prescribed and make medication comparison.
clinical decisions based on the comparison.
EOC.5 Reconciled medications are clearly
recorded, and related information is clearly There was no evidence of
communicated to healthcare professionals 0 recorded reconciled
involved in the patient’s medication medications.
prescribing
EOC.6 Patients and families are involved in
0 There was no evidence.
medication reconciliation.
NSR.14 Medications are safely and securely stored in
stores, pharmacies, and patient care areas Met
according to laws and regulations
EOC.1 Medications are safely and securely stored
under manufacturer/marketing
2
authorization holder recommendations and
kept clean and organized.
EOC.2 Psychotropic, controlled, and narcotic
medications are stored according to 2
applicable laws and regulations.
EOC.3 The hospital has an approved process for the
use and storage of multi-dose medications 2
to ensure its stability and safety.
EOC.4 The hospital has a clear process to deal with
an electric power outage to ensure the
2
integrity of any affected medications before
use.
EOC.5 Medications in stores, pharmacies, and
patient care areas are periodically (at least
2
monthly) inspected to confirm compliance
with proper storage conditions.
EOC.6 Medications, medication containers, other
solutions, and the components used in their
preparation are clearly labeled (if not
apparent on the original packages or boxes) 2
with the name, concentration/ strength,
expiration date, batch number, and any
applicable warnings.
NSR.15 High-Alert medications and concentrated
electrolytes are identified, stored, and dispensed in Met
a way that assures that risk is minimized
EOC.1 The hospital has an approved policy that 2

8
 addresses all elements in the intent from a)
through c).
EOC.2 The hospital provides initial and ongoing
training to the healthcare professionals
2
involved in management and use of high-
alert or concentrated electrolytes.
EOC.3 The hospital has an approved list(s) of high-
alert medications that are regularly updated 2
for concentrated electrolytes.
EOC.4 High-alert medications and concentrated
electrolytes are safely stored and labeled 2
across the hospital.
EOC.5 The hospital implements a process to
prevent inadvertent administration of high-
2
alert medications and concentrated
electrolytes.
EOC.6 The hospital tracks, collects, analyzes, and
reports data on management of high alert
First provisional
medications and concentrated electrolytes. NA
accreditation.
Identified improvement opportunities
identified are acted upon.
NSR.16 Look-alike and sound-alike medications are
identified and stored in a manner to minimize the
Met
risk of medication dispensing and administration
errors.
EOC.1 The hospital has an approved policy that
addresses all elements in the intent from a) 2
through d).
EOC.2 There is a list of LASA medications that is
2
updated at least annually.
EOC.3 The hospital provides initial and ongoing By interview, ten
training to the healthcare professionals pharmacists and nurses,
1
involved in management and use of LASA. three out of ten were not
aware of the policy
EOC.4 LASA medications are stored, segregated, By observation, LASA
and labeled safely and uniformly in all medications were
locations. segregated, and labelled
1 safely and uniformly in all
locations but chemotherapy
LASA medications were not
segregated or labelled.
EOC.5 LASA medication are checked properly
2
upon dispensing.
EOC.6 The hospital tracks, collects, analyzes, and
reports data on management of LASA. First provisional
NA
Identified improvement opportunities accreditation.
identified are acted upon.
Surgery, Anaesthesia and Sedation (SAS)
NSR.17 Precise site where a surgery or invasive procedure
shall be performed is clearly marked by the met
physician with patient’s involvement.
EOC.1 The hospital has an approved policy for site
2
marking in the hospital.
EOC.2 Staff are trained on the implementation of
2
site marking.

9
 EOC.3 Site marking is a unified mark all over the
hospital and performed by the responsible
2
physician for the surgery and invasive
procedure.
EOC.4 Site marking is performed before the patient
2
enters the operation room.
EOC.5 The hospital tracks, collects, analyzes and First provisional
NA
reports data on site marking process. accreditation.
EOC.6 The hospital acts on improvement
First provisional
opportunities identified in its site marking NA
accreditation.
process.
NSR.18 Documents and equipment needed for procedures
and anesthesia or sedation are verified to be on
Met
hand, correct, and properly functioning before
calling for the patient.
EOC.1 The hospital has an approved policy for
preoperative verification of all needed 2
documents and equipment.
EOC.2 There is recorded evidence of preoperative
verification of all needed documents and
2
equipment before each surgery and invasive
procedure.
EOC.3 The hospital tracks, collects, analyzes and
First provisional
reports data on preoperative verification NA
accreditation.
process.
EOC.4 The hospital acts on improvement
First provisional
opportunities identified in its preoperative NA
accreditation.
verification process.
NSR.19 Correct patient, procedure, and body part is
confirmed preoperatively and just before starting a met
surgical or invasive procedure (time out).
EOC.1 The hospital has an approved policy to
ensure the correct patient, procedure, and 2
body part.
EOC.2 Time out is implemented before all surgery
and invasive procedures immediately before 2
the start of surgery or invasive procedure.
EOC.3 The surgery or invasive procedure team is
involved in the time out process, including
2
the performing physician, the nurse, and the
anaesthesiologist when applicable.
EOC.4 The hospital tracks, collects, analyses and First provisional
NA
reports data on time out process. accreditation.
EOC.5 The hospital acts on improvement First provisional
NA
opportunities identified in time out process. accreditation.
NSR.20 Accurate counting of sponges, needles, and
PM
instruments pre and post-procedure is verified.
EOC.1 Counting of sponges, needles, towels, or
instruments is done pre, during, and after the
surgery or invasive procedure by two staff 2
as the second one is acting as a witness for
the first one.
EOC.2 There is a record for the preoperative, By reviewing ten medical
intraoperative and postoperative count of 1 records, there is a record for
sponges, needles, towels, or instruments. the preoperative,

10
 intraoperative and
postoperative count in six
out of it.
EOC.3 The performing physician confirmed the Based on the above
1
process and signed the count sheet. comment.
EOC.4 The hospital tracks, collects, analyses and First provisional
NA
reports data on the counting process. accreditation.
EOC.5 The hospital acts on improvement
First provisional
opportunities identified in the counting NA
accreditation.
process.
Environmental and Facility Safety (EFS)
NSR.21 Fire and smoke safety plan addresses prevention,
early detection, response, and safe evacuation in PM
case of fire and/or other internal emergencies.
EOC.1 The hospital has an approved fire and smoke
safety plan that includes all elements from 2
a) through j) in the intent.
EOC.2 The hospital fire alarm, firefighting and Fire alarm, firefighting and
smoke containment system are available, smoke containment system
functioning and comply with civil defense are available, functioning, in
requirements. all hospital departments
- except in outpatient
medical records store there
was no detector and its
closed.
- outpatient department was
1 under renovation and was
not covered by detectors,
just monitored by the
security man who
controlling the door between
the hospital and the
neighbouring hospital)
- There was fire detector in
only three out of four
medical records’ stores.
EOC.3 Inspection, testing and maintenance of fire
alarm, firefighting and smoke containment 2
systems are performed and recorded.
EOC.4 The hospital provides education for fire
response and evacuation to all staff at least 2
once annually.
EOC.5 The hospital guarantees safe evacuation By observation,
processes for all occupants in case of fire - there was no emergency
and/or other internal emergencies. exit in OR, radiology
departments, outpatient,
CSSD, and Lab.
- There are two stairs and
0 two exits but
• the first one (the
outpatient entrance)
is the used one, it
was observed that
the emergency exit
sign next to it is not

11
 lit. The assembly
area in front of it
was occupied by
patient waiting
chairs and garden
trees. The space on
the street in front of
the hospital is also
used as a parking
area. and the main
exit.
• The second exit
door is the main
door of the hospital
and it was closed. If
it was opened, there
would be the same
notes as at the first
door.
EOC.6 The fire and smoke safety plan is evaluated
First provisional
annually and, whenever indicated, with NA
accreditation.
aggregation and analysis of necessary data.
NSR.22 Fire drills are performed in different clinical and
non-clinical areas, including at least one Met
unannounced drill annually.
EOC.1 Fire drills are performed based on a
2
predefined time interval.
EOC.2 Staff members participate in fire drills at
2
least once annually.
EOC.3 Fire drill results are recorded from a)
2
through e) in the intent.
EOC.4 Fire drill results evaluation is performed
2
after performing each drill.
EOC.5 The hospital plans a corrective action,
2
whenever indicated.
NSR.23 The hospital plans safe handling, storage, usage
and transportation of hazardous materials and Met
waste disposal.
EOC.1 The hospital develops hazardous material
and waste management plan that addresses 2
all elements from a) through j) in the intent.
EOC.2 The hospital ensures staff safety when
2
handling hazardous materials/or waste.
EOC.3 Waste disposal occurs according to laws Waste disposal occurs
and regulations. according to laws and
regulations; however, it was
noticed; There are medical
and regular waste bins in
1 three bathrooms and in two
places under the stairs. Also,
there was a wheelbarrow
containing regular waste
beside the patients’ waiting
area in the garden.
EOC.4 The hospital ensures safe usage, handling, 2

12
 storage, and labeling of hazardous
materials.
EOC.5 The hospital has an approved document for
spill management, Investigation, and
2
recording of different incidents related to
hazardous materials.
EOC.6 The plan is evaluated and updated annually
First provisional
with aggregation and analysis of necessary NA
accreditation.
data.
NSR.24 A safe work environment plan addresses high-risk
areas, procedures, risk mitigation requirements, Met
tools, and responsibilities.
EOC.1 The hospital has an approved plan to ensure
a safe work environment that includes all 2
elements from a) through g) in the intent.
EOC.2 Staff are aware of safety measure pertinent
2
to their job.
EOC.3 Safety measures are implemented in all
2
areas.
EOC.4 Safety instructions are posted in all high-
2
risk areas.
EOC.5 Safety management plan is evaluated and
First provisional
updated annually with aggregation and NA
accreditation.
analysis of necessary data.
NSR.25 Radiation safety program is developed and
Met
implemented.
EOC.1 The hospital has an approved radiation
safety program for patients and staff that
addresses potential safety risks and hazards
2
encountered in the hospital in addition to all
elements mentioned in the intent from a)
through h).
EOC.2 Identified radiation safety risks are
mitigated through processes and safety
2
protective devices, for both staff and
patients.
EOC.3 Staff members involved in medical imaging
are aware of radiation safety precautions
2
and receive on-going education and training
for new procedures and equipment.
EOC.4 Radiation doses measured and monitored
for patients and does not exceed approved 2
maximum level.
EOC.5 Radiation doses for patients in all radiology By review ten medical
areas are recorded in the patient’s medical records of patients who
record. 0 performed radiology
imaging the dose was not
recorded.
EOC.6 The radiation safety program is part of the
hospital environment and facility safety 2
program.
NSR.26 A comprehensive documented laboratory safety
Met
program is implemented.
EOC.1 A written program that describes safety
2
measures for laboratory services and

13
 facilities is available and includes the items
in the intent from a) to i).
EOC.2 Laboratory staff is trained on the safety
2
program.
EOC.3 Laboratory risk assessment is performed
and safety reports are issued at least semi-
2
annually to the hospital environment and
facility safety committee.
EOC.4 Spill kits, safety showers and eye washes
2
are available, functioning and tested.
EOC.5 Safety precautions are implemented. 2
EOC.6 The hospital tracks, collects, analyzes and
reports data on laboratory safety program First provisional
NA
and it acts on identified improvement accreditation.
opportunities.
NSR.27 Medical equipment plan ensures safe selection,
inspection, testing, maintenance, and safe use of Met
medical equipment.
EOC.1 The hospital has an approved medical
equipment management plan that addresses 2
all elements from a) through k) in the intent.
EOC.2 The hospital has qualified individuals to
2
oversee medical equipment management.
EOC.3 Staff is educated on the medical equipment
2
plan at least annually.
EOC.4 Records are maintained for medical
equipment inventory, user training,
equipment identification cards, and
company emergency contact, testing on 2
installation, periodic preventive
maintenance, calibration and malfunction
history.
EOC.5 The hospital ensures that only trained and
competent people handles the specialized 2
equipment(s).
EOC.6 The plan is evaluated and updated annually
with aggregation and analysis of necessary 2
data.
NSR.28 Essential utilities plan addresses regular
Met
inspection, maintenance, testing and repair.
EOC.1 There is a hospital approved plan for utility There is a hospital approved
management that includes items a) through plan for utility management
i) in the intent. that includes items a)
1
through i) for all utilities
except for medical gases but
it modified during survey.
EOC.2 The hospital has qualified staff members to
2
oversee utility systems.
EOC.3 Staff is educated on the utility systems plan
2
at least annually.
EOC.4 Records are maintained for utility systems
inventory, testing, periodic preventive 2
maintenance and malfunction history.
EOC.5 Critical utility systems are identified and
2
back up availability is ensured.

14
 EOC.6 The plan is evaluated and updated annually
First provisional
with aggregation and analysis of necessary NA
accreditation.
data.
Section 3:
Essential Quality Requirements (EQRs)
EQR Standard
Score Comments
Standard EOC
PCC.4 Patient and family rights are protected and
met
informed to patients and families.
EOC.1 The hospital has an approved policy guiding
the process of defining patient and family
2
rights, as mentioned in the intent from a)
through k).
EOC.2 All staff members are aware of patients' and
2
families’ rights.
EOC.3 An approved statement on patient rights is
posted in all public areas in the hospital in a
2
way that makes it visible to staff, patients,
and families.
EOC.4 Patient and family rights are protected in all
2
areas and at all times.
EOC.5 Information about patient rights is provided
in writing or in another manner, the 2
patient’s and their families understand.
PCC.15 Patient-centered waiting spaces are available for
PM
various services.
EOC.1 Waiting spaces are lit, ventilated, clean, and
2
safe.
EOC.2 Waiting spaces are planned to accommodate The waiting areas are
the expected number of patients and spacious. But about half of
families. 1 the chairs in the waiting
areas are worn out/ broken,
and it is a risk to sit on them.
EOC.3 Waiting spaces provide access to satisfy
basic human needs such as toilets, potable 2
water, and food.
EOC.4 Patients receive information on how long By observations Patients
they may wait. did not receive
0
information on how long
they may wait.
PCC.21 Patients and families are able to make oral or
written complaints or suggestions through a PM
defined process.
EOC.1 The hospital has an approved policy guiding
the process of managing patients'
2
complaints and suggestions as mentioned in
the intent from a) through d).
EOC.2 The hospital allows the complaining process
2
to be publically available.
EOC.3 Patients and families are allowed to provide
2
suggestions and complaints.
EOC.4 Complaints and suggestions are There was no documented
0
investigated and analyzed by the hospital. evidence.

15
 EOC.5 Patients and families receive feedback about
There was no documented
their complaints or suggestions within 0
evidence.
approved timeframes.
ACT.01 The hospital grants patients access to its services
according to applicable laws and regulations and Met
pre-set eligibility criteria.
EOC.1 The hospital has an approved policy The hospital granting access
granting access to patients that addresses all to patients through the OPD
elements mentioned in the intent from a) only as there was no ER in
through c). the hospital (out of scope;
2
emergency cases are
transferred to the
neighbouring general
hospital).
EOC.2 Patients are made aware of available
services, including operating hours, types of
2
services, cost of each service (when
relevant), and access path.
EOC.3 The hospital defines a system for informing
patients and families about services that is
suitable for different literacy levels and is 2
available at points of contact and public
areas.
EOC.4 Patients are referred and/or transferred to
other healthcare organizations when
2
healthcare needs are not matching hospital
scope of service.
ACT.14 The hospital grants access to intensive care and
specialized care units and discharge from these Met
units based on clear criteria.
EOC.1 The hospital has an approved policy that
addresses all elements mentioned in the 2
intent from a) through b).
EOC.2 All staff members involved in the admission
and discharge of patients from specialized
2
and critical care units as aware of the
approved criteria.
EOC.3 Only competent staff members are allowed
to admit and discharge patients from critical 2
and specialized care units.
EOC.4 Admission and discharge of patients from
critical and specialized care units occur 2
when criteria are met.
ICD.14 An individualized plan of care is developed for
PM
every patient.
EOC.1 There is evidence that plan of care is
developed by all relevant disciplines based
on their assessments that addresses all the 2
elements mentioned in the intent from a)
through g).
EOC.2 There is evidence that plan of care is
developed with the participation of patient
2
and/or family in decision making.

EOC.3 Plan of care is changed / updated based on a 0 - By reviewing ten inpatient

16
 reassessment of patient changing condition. medical records, plan of care
was not changed / updated
based on a reassessment of
patient changing condition.
- by reviewing seven OPD
medical records for patients
who came to repeating the
treatment, there was no
reassessment performed.
ICD.38 Response to medical emergencies and cardio-
pulmonary arrests in the hospital is managed for Met
both adult and pediatric patients.
EOC.1 The hospital has an approved policy that
addresses all the elements mentioned in the 2
intent from a) through g).
EOC.2 All staff members involved in medical
emergencies and cardiopulmonary
2
resuscitation are aware of the hospital
policy.
EOC.3 Competent individuals are responsible for
the management of medical emergencies 2
and cardio-pulmonary arrests.
EOC.4 Management of medical emergencies and
2
cardio-pulmonary arrests occurs safely.
EOC.5 Management of medical emergencies and
cardio-pulmonary arrests are recorded in the 2
patient’s medical record.
DAS.5 A medical imaging quality control program is
Met
developed.
EOC.1 The hospital has an approved procedure
describing the quality control process of all
2
medical imaging tests addressing all
elements in the intent from a) through g).
EOC.2 Medical imaging service staff members
involved in quality control are competent in 2
quality control performance.
EOC.3 All quality control processes are performed
2
according to quality control procedure.
EOC.4 All quality control processes are recorded. 2
EOC.5 Responsible authorized staff member
reviews quality control and function check 2
data at least monthly.
EOC.6 Corrective action is taken whenever targets
2
are unmet.
DAS.19 An individualized internal quality control program
Met
is developed and implemented for all tests.
EOC.1 The hospital has an approved procedure
describing the internal quality control
2
process of all laboratory tests addressing all
elements in the intent from a) through h).
EOC.2 Laboratory staff members involved in
internal quality control are competent in 2
internal quality control performance.
EOC.3 All quality control processes are performed
2
according to the internal quality control

17
 procedure.
EOC4 All quality control processes are recorded. 2
EOC.5 Responsible authorized staff member
reviews quality control and function check 2
data at least monthly.
EOC.6 Corrective action is taken when indicated. 2
DAS.28 Processes of collection, handling, testing of blood,
and blood components are performed safely and NA Out of scope.
effectively.
EOC.1 The hospital has an approved policy that
describes all elements mentioned in the
intent from a) through d) and based on
national guidelines.
EOC.2 Blood bank staff is aware of the hospital’s
policy.
EOC.3 Blood and/or blood components are
collected and handled as elements from a)
through b) and based on national guidelines
EOC.4 Blood and/or blood components are tested
and prepared as elements from c) through d)
and based on national guidelines
SAS.08 Procedure details are recorded immediately after
PM
the procedure.
EOC.1 The procedure report is readily available for
all patients who underwent a procedure 2
before leaving the procedural unit.
EOC.2 The report includes at least a) through h) in By reviewing nine reports,
the intent. there were missing items as
following: a) Missing in
three reports, b) missing in
1 five reports, c) post
procedure diagnosis was
missing in four reports, h)
missing in three reports.
While e) was NA.
EOC.3 The report is kept in the patient’s medical By reviewing ten OR
record. 1 medical records, the report
was kept in six out of it.
SAS.18 A competent anesthesiologist performs continuous
monitoring of the patient's physiological status Met
before and during anesthesia.
EOC.1 The patient physiologic status is monitored
before and during anesthesia based on
2
hospital approved clinical practice
guidelines.
EOC.2 The monitoring of patient physiologic status
2
is performed by a qualified anesthesiologist.
EOC.3 The results of the monitoring are recorded
in the patient’s medical record regularly
2
according to the approved hospital clinical
guidelines/protocols
MMS.03 Hospital medications are selected, listed, and
Met
procured based on approved criteria.
EOC.1 The hospital (represented by the drug and 2

18
 therapeutic committee) has a hospital’s
approved process for appropriate selection
and procurement of medications according
to the applicable laws and regulations,
hospital mission, patient needs and safety,
and services provided to ensure
uninterrupted availability of medication
supply.
EOC.2 The hospital has an approved list of the
approved medications (often referred to as a
2
formulary), which includes at least items
from a) to f) in the intent.
EOC.3 A controlled printed and/or electronic
formulary copy of the approved medications
shall be readily available and accessible to 2
all those involved in medication
management.
EOC.4 Medication list (formulary) is monitored,
2
maintained, and updated
EOC.5 The hospital has an approved process to
guide the addition/deletion of medication 2
to/from the medication list (formulary).
EOC.6 The hospital has an approved process on
proper communication about medication
2
shortage and outage to prescribers and other
healthcare professionals.
MMS.05 Emergency medications are available, accessible,
Met
and secured at all times.
EOC.1 The hospital has an approved policy to
guide emergency medications availability
2
that addresses at least all elements
mentioned in the intent from a) through c).
EOC.2 Emergency medications are uniformly
2
stored in all locations.
EOC.3 Emergency medications are appropriately
available and accessible to the clinical areas 2
when required.
EOC.4 Emergency medications are replaced within
a predefined timeframe when used, 2
damaged, or outdated.
IPC.12 Patients with clinically suspected and/or confirmed
communicable diseases follow isolation precautions Met
according to probable mode(s) of transmission.
EOC.1 The hospital has an approved policy to
2
guide transmission-based precautions.
EOC.2 Healthcare professionals are trained and
2
educated on approved policies.
EOC.3 The hospital has one or more standardized
isolation room(s) according to laws and 2
regulations
EOC.4 Patients with suspected/ confirmed clinical
communicable diseases are identified and 2
separated in separate assigned areas/room.
EOC.5 Healthcare professionals caring for patients
2
with a suspected communicable disease are

19
 adherent to suitable PPE and hand hygiene
practices according to the type of isolation.
IPC.14 Patient care equipment are disinfected/sterilized
based on evidence-based guidelines and Met
manufacturer recommendations.
EOC.1 The hospital has an approved policy to
guide the process of disinfection and
2
sterilization that addresses all element in the
intent from a) through g).
EOC.2 Healthcare professionals are trained on
2
approved policy.
EOC.3 The hospital has at least one functioning
2
pre-vacuum class B sterilizer.
EOC.4 The laws and regulations, Spaulding
classification, and manufacturer’s
2
requirements and recommendations guide
sterilization or disinfection.
IPC.21 Food services are safe and effective. Met
EOC.1 The hospital has an approved policy that
addresses all the elements mentioned in the 2
intent from a) through e).
EOC.2 Staff members involved in food services are
2
aware of approved policy.
EOC.3 There are separate areas for receiving, There is a protocol between
storage, and preparation of food and the hospital and another
nutritional products. health facility to provide
NA
meals to patients and
workers as required
according to the policy.
EOC.4 There are measures to prevent the risk of There is a protocol between
cross-contamination. the hospital and another
health facility to provide
NA
meals to patients and
workers as required
according to the policy.
EOC.5 The hospital prepares and distributes food
2
using proper sanitation and temperatures.
OGM.01 The hospital has a defined governing body
Met
structure.
EOC.1 The governing body structure is represented
2
in the hospital’s chart.
EOC.2 Members of the governing body are
2
identified by title and name.
EOC.3 Governing body members are diverse and
represent community interests and desired 2
competencies.
EOC.4 The governing body meets on predefined
intervals, and minutes of meetings are 2
recorded.
EOC.5 The governing body evaluates its
First provisional
performance annually versus the strategic NA
accreditation.
plan.
OGM.02 The governing body works with the hospital
Met
leaders to set the hospital mission statements.

20
 EOC.1 The hospital has a mission statement
2
approved by the governing body.
EOC.2 The mission statement is aligned with
national healthcare initiatives and 2030 2
vision.
EOC.3 The mission statement is evaluated First provisional
NA
annually. accreditation.
EOC.4 The mission statement is visible in public
2
areas to staff, patients and visitors.
OGM.06 There is a clear process for coordination and
communication among the hospital director, staff, Met
and the hospital committees/ structures
EOC.1 The hospital has at least the committees
2
mentioned in the intent a) through e).
EOC.2 Each committee had terms of reference. 2
EOC.3 Committees are meeting regularly. 2
EOC.4 Committees’ minutes of the meetings are
recorded and communicated to involved 2
staff members.
EOC.5 There is an announced process of
coordination and communication between
2
the director and the staff and the hospital
committees/ structures.
OGM.14 The hospital manages the patient billing system. Met
EOC.1 The hospital has an approved policy for
2
billing patients accurately.
EOC.2 There is an approved price list. 2
EOC.3 Patients are informed of any potential cost
2
pertinent to the planned care.
EOC.4 The hospital uses accurate and approved There were no approved
codes for diagnoses, interventions, and codes for diagnoses,
0
diagnostics. interventions, and
diagnostics.
EOC.5 In the case of a third-party payer (or health
insurance), the timeliness of approval 2
processes is monitored.
EOC.6 Billing staff is oriented on various health
2
insurance processes.
OGM.20 The hospital has an approved staff health program
that is monitored and evaluated annually PM
according to laws and regulations.
EOC.1 There is an approved hospital’s staff health
program according to local laws and
2
regulations that cover a) through j) in the
intent.
EOC.2 There is an occupational health risk There was no occupational
assessment that defines occupational risks 0 health risk assessment
within the hospital. submitted.
EOC.3 Staff members are educated about the risks
within the hospital environment, their There was no evidence
0
specific job-related hazards, and periodic about staff education.
medical examination.
EOC.4 All staff members are subject to the There is an implemented
1
Immunization program and to work process for immunization,

21
 restrictions according to laws and but not for work
regulations and approved hospital restrictions.
guidelines.
EOC.5 All test results, immunizations, post-
exposure prophylaxis and interventions are 2
recorded in the staff’s health record.
EOC.6 There is evidence of taking action and
informing employees in case of positive 2
results.
WFM.02 Hospital staffing plan identifies the number of staff
and defines the desired skill mix, education,
knowledge, and other requirements of staff
Met
members needed to meet the hospital mission,
professional practice recommendations, and
provide safe patient care.
EOC.1 Staffing plan matches the mission, strategic
2
and operational plans
EOC.2 Staffing plan complies with laws,
regulations, and recommendations of 2
professional practices
EOC.3 Staffing plan identifies the estimated needed
staff numbers including independent
2
practitioners and skills with staff
assignments to meet the hospital needs.
EOC.4 In critical care and anesthesia services,
Competent staff members’ number matches
2
at least 60% of the required numbers in the
staffing plan.
EOC.5 Staffing plan is monitored and reviewed at First provisional
NA
least annually. accreditation.
WFM.06 A staff file is developed for each workforce
Met
member.
EOC.1 The hospital has an approved policy that
addresses at least elements from a) through 2
f) in the intent.
EOC.2 Staff members who are involved in creation,
storage and use of staff files, are aware of 2
the policy requirements.
EOC.3 Staff files are confidential and protected. 2
EOC.4 Staff files include all the required records. 2
EOC.5 Staff files are disposed as per hospital
2
policy.
WFM.07 Appointed, contracted, and outsourced staff
Met
undergo a formal orientation program.
EOC.1 General orientation program is performed
and it includes at least the elements from a) 2
through c).
EOC.2 Department orientation program is
performed and it includes at least the 2
elements from d) through f).
EOC.3 Job specific orientation program is
performed and it includes at least the 2
elements from g) through i).
EOC.4 Any staff member attends orientation 2

22
 program regardless of employment terms.
EOC.5 Orientation completion is recorded in the
2
staff file.
WFM.09 Staff performance and competency are regularly
Met
evaluated.
EOC.1 Performance and competency evaluation is
performed at least annually for each staff 2
member.
EOC.2 Performance and competency evaluation is
performed also when indicated by the
findings of quality improvement activities 2
and appropriate education and training
provided.
EOC.3 There is evidence of employee feedback on By review ten personal files,
performance and competency evaluation. there was no evidence of
0
competency evaluation
employee feedback.
EOC.4 Actions are taken based on a performance
2
review.
EOC.5 Performance and competency evaluation is
2
recorded in staff members’ files.
IMT.06 Patient’s medical record and information are
protected from loss, destruction, tampering, and Met
unauthorized access or use
EOC.1 Medical records and information are
2
secured and protected at all times.
EOC.2 Medical records and information are
secured in all places, including patient care 2
areas and the medical records department.
EOC.3 The medical records department storage
area implements measures to ensure 2
medical information integrity.
EOC.4 When an integrity issue is identified,
2
Actions are taken to maintain integrity.
IMT.08 Patient’s medical record is managed effectively. PM
EOC.1 The hospital has an approved policy that
includes all the points in the intent from a) 2
through e)
EOC.2 All staff who are using patient’s medical
2
record are aware of the policy requirements
EOC.3 A patient’s medical record is initiated with
a unique identifier for every patient 2
evaluated or treated.
EOC.4 The patient’s medical record contents, By review medical records,
format, and location of entries are there is separate and
standardized. different medical record for
outpatient, inpatient,
0
radiotherapy, nuclear
medicine, and chemotherapy
and the forms’ location were
not standardized.
EOC.5 The patient’s medical record is available There is a process, but not
when needed by a healthcare professional. 1 implemented in some
medical records archives, as

23
 the review sample of
medical records was
accessed within three
minutes, except for the
nuclear medicine files,
which took approximately
three hours.
IMT.11 Response to planned and unplanned downtime of There was no medical
data systems is tested and evaluated. NA electronic system instilled
yet.
EOC.1 There is a program for response to planned
and unplanned downtime.
EOC.2 The program includes downtime recovery
process.
EOC.3 The staff is trained in response to the
downtime program.
EOC.4 The hospital tests the program at least
annually to ensure its effectiveness.
QPI.11 An incident-reporting system is developed. Met
EOC.1 The hospital has an approved policy defines
an incident-type and reporting system that 2
include a) through e).
EOC.2 All staff are aware of the incident-reporting
system, including contracted and 2
outsourced services
EOC.3 Sentinel events are investigated and gaps in There was no history during
NA
services are identified the look back period.
EOC.4 Hospital communicates with
patient’s/services users about adverse 2
events they are affected by
EOC.5 Corrective actions are taken to close gaps in
2
services in a timely manner.
QPI.12 Significant events and/or near misses are analyzed
PM
and corrected.
EOC.1 There is a document that defines criteria and
process for intensive analysis when
significant unexpected events occur and the
2
time required completing the investigation
and the time required to execute the action
plan.
EOC.2 In case of significant/near miss incident, a A committee was not
committee is formed where the chairperson formed and was replaced by
and relevant staff are trained on intensive a quality committee, but
0
analysis. there were no training
documents in intensive
analysis.
EOC.3 All significant unexpected /near misses There is timely investigation
1
events are timely investigated and analyzed. but there was no analysis.
EOC.4 Corrective actions are taken with clear time
2
frame and responsible person(s).
QPI.13 The hospital defines investigates, analyzes and
reports sentinel events, and takes corrective actions Met
to prevent harm and recurrence.
EOC.1 The hospital has a sentinel events 2

24
 management policy covering the intent from
a) through f) and leaders are aware of the
policy requirements.
EOC.2 All sentinel events are analyzed and
communicated by a root cause analysis in a
There was no history during
time period specified by leadership that NA
the look back period.
does not exceed 45 days from the date of the
event or when made aware of the event.
EOC.3 All sentinel events are communicated to
There was no history during
GAHAR within seven days of the event or NA
the look back period.
becoming aware of the event.
EOC.4 The root cause analysis identifies the main
reason(s) behind the event and the leaders There was no history during
NA
take corrective action plans to prevent the look back period.
recurrence in the future.
ADD.07 Patient rights are protected during research
NA Out of scope.
activities.
EOC.1 The hospital has an approved program that
includes all the points in the intent from a)
through d).
EOC.2 Researchers are aware of the policy
requirements.
EOC.3 Signed patient consent for participation in
research is placed in the research file and in
the patient's medical record.
EOC.4 When patient safety issues are identified
during research, patients are informed and
actions are taken to ensure patient safety.

Section 4:
Operating Manual
Operating Manual Requirements
Score Comments
Item Requirement
1- Patient Centeredness Culture
Policy guiding clear, updated, and
a PCC.01 accurate advertisements of services Met
(Policy)

b PCC.04 Patient & family rights. (Policy)

Patient & family responsibilities

c PCC.05 Met
(Policy)

Patient and family education process.

d PCC.10
(Policy)

e PCC.11 Informed consent. (Policy) Met

f PCC.13 Informed refusal. (Policy)

The hospital responsibilities towards

g PCC.19
patient's belongings. (Policy)

25
h PCC.20 Patient and family feedback. (Policy)

Patient complaints and suggestions.

i PCC.21
(Policy)
2- Access, Continuity, and Transition of Care

Granting patient access to the hospital

a ACT.01
(before registration). (Policy)

b ACT.02 Registration process. (Policy) Met

Hospital scope of services. (approved

c ACT.02
document)

d ACT.04 Hospitalization process. (Policy) Met

Risk assessment and management plan

e ACT.07
for patient flow. (Plan)

Policy guiding the process of assigning

f ACT.08
patient's care responsibility. (Policy)

g ACT.10 Second opinion. (Policy)

h ACT.11 Consultation process. (Policy)

i ACT.12 Multidisciplinary management. (Policy)

j ACT.13 Patient transportation. (Policy)

Special care units' access and discharge.

k ACT.14
(Policy)

Patient flow out: transfer, referral,

l ACT.15 temporary discharge and discharge.
(Policy)
3- Integrated Care Delivery

a ICD.02 Collaborative care. (Policy) Met

Pre-hospital care, ambulance care,

b ICD.03 emergency medical care during
disasters. (Policy)

26
c ICD.04 Emergency services (Policy).

d ICD.05 Emergency care guidelines.

e ICD.07 Outpatient services. (Policy)

Medical patient assessment and

f ICD.08
reassessment. (Policy) ICD.08

Nursing patient assessment and

g ICD.09
reassessment. (Policy)

h ICD.10 Screening of healthcare needs. (Policy) Met

Clinical practice guidelines adaptation

i ICD.15
and adoption. (Policy)

j ICD.17 Orders and requests (Policy)

Pain screening, assessment,

k ICD.19
reassessment and management. (Policy)

Assessment and management of

l ICD.20
patient's nutritional needs. (Policy)

Assessment and management patient

m ICD.21
psychosocial needs. (Policy)

Assessment and management patient's

n ICD.22
functional needs. (Policy)

Identification, screening and assessment

o ICD.23 of special-needs patient populations.
(Policy)

p ICD.24 Safe childbirth process. (Policy)

Assessment and management of the

q ICD.25
pediatric population. (Policy)

Care of terminally ill and dying patients.

r ICD.26
(Policy)

4- Diagnostic and Ancillary Services

27
 Medical imaging service planning
a DAS.01 (licenses, permits, guidelines and list of
services)
Performance and competency
b DAS.02 assessment of medical imaging staff
(policy)

Procedure manual for each medical

c DAS.03
imaging study type.

Medical imaging pre-examination

d DAS.04
process. (policy)

Medical imaging quality control

e DAS.05
program.

f DAS.06 Medical imaging examination protocols.

Medical imaging investigations

g DAS.07 reporting within approved timeframe.
(policy)

Laboratory services planning (scope of

h DAS.10
services & plan for services)

Performance and competency

i DAS.11
assessment of laboratory staff (Policy)

j DAS.12 Reagents' management. (Policy)

Selection and evaluation of referral

k DAS.13
laboratory. (Policy)

Minimal retesting intervals for

l DAS.14
laboratory investigations. (Policy)

Laboratory pre-examination process

m DAS.15
(Policy)

Specimen reception, tracking, and

n DAS.16
storage processes. (Policy)

Verification/Validation of laboratory
o DAS.17
test methods. (Policy)

Laboratory examination procedures:

p DAS.18 written procedure for each analytical
test.

28
q DAS.19 Laboratory quality control program.

Laboratory post-examination process.

r DAS.21 Met
(Policy)

s DAS.22 Laboratory turnaround time. (Policy)

Laboratory results reporting within

t DAS.23 identified turnaround time (STAT).
(Policy)

Quality control procedures manual of

u DAS.25
point of care tests.

Blood transfusion services quality

v DAS.26
manual.

w DAS.27 Safe blood donation. (Policy)

Management of blood, and blood

x DAS.28
components. (Policy)

y DAS.30 Contracted blood banks. (Policy)

Ordering of blood and blood products.

z DAS.31
(Policy)

5- Surgery, Anesthesia and Sedation

Booking of surgeries and invasive

a SAS.02
procedures. (Policy)

List of implantable devices used in the

b SAS.11
hospital. (list)

Implantable devices tracking policy.

c SAS.11
(Policy)

Organization chart of anesthesia

d SAS.14
department.

Job description of anesthesia head of

e SAS.14
department.

f SAS.16 Anesthesia protocols.

29
g SAS.22 Sedation protocols.

6- Medication Management and Use

a MMS.01 Medication management program.

b MMS.02 Antibiotic stewardship program.

Hospital medication formulary

c MMS.03
(Approved list).

d MMS.05 Emergency medications. (Policy)

e MMS.08 Medication recall. (Policy)

Safe management of medications that

require special considerations
f MMS.09 (Radioactive medications, contrast,
breast milk, medication brought by
patients). (Policy)
Ordering/prescribing and transcribing
g MMS.11,12
medications. (Policy)

Medication errors and near misses

h MMS.18 defining, reporting, analyzing, and
acting upon (Policy).
7- Environmental and Facility Safety

Hospital design drawings, permits,

a EFS.01
licenses.

b EFS.04 Smoking-free environment. (Policy) Met

c EFS.09 Security plan.

Safe management of water services.

d EFS.12
(Policy)

e EFS.13 Disaster plan.

8- Infection Prevention and Control:

Infection control structure in the

a IPC.01
organization chart.

30
 Job description of infection control
b IPC.01
team.

Infection prevention and control

c IPC.02
program.

Safe injection guidelines. (Approved

d IPC.09
clinical guidelines)

e IPC.10 List of cleaning activities.

Sterile technique and aseptic technique

f IPC.11
guidelines. (Approved guidelines)

g IPC.12 Isolation precautions. (Policy)

h IPC.14 Disinfection and sterilization. (Policy)

Disinfection/Sterilization quality
i IPC.15
control. (policy)

laundry and healthcare textile services.

j IPC.16
(Policy)

Infection risk assessment for areas under

k IPC.17 demolition, renovation, or construction.
(Policy)

Surveillance for healthcare associated

l IPC.18
infections. (Policy)

Multi-drug resistant organisms control.

m IPC.20
(Policy)

n IPC.21 Safe food services. (Policy)

o IPC.22 Postmortem Care. (Policy)

9- Organization Governance and Management

Organizational charts (Approved

a OGM.01
document)

Governance structure. (Approved

b OGM.01
document)

31
 Governing body responsibilities and
c OGM.03
accountabilities. (Approved document)

Mission statement. (Approved

d OGM.02
document)

e OGM.05 Job description of hospital director.

Hospital-wide committees' structures

f OGM.06
and functions. (Approved document)

g OGM.07 Strategic plan

h OGM.08 Operational plans.

i OGM.09 Job description of hospital leaders.

j OGM.10 Job description of heads of departments.

k OGM.11 Supply chain management. (Policy)

l OGM.12 Stock management. (Policy)

m OGM.14 Billing system. (Policy)

n OGM.14 Price list of services. (Approved list)

List of all contracted services, including

o OGM.15
clinical and non-clinical services. (List)

Selection and evaluation criteria for

p OGM.15 each contracted service. (Approved
document)

q OGM.17 Positive workplace culture. (Policy)

r OGM.18 Code of ethics. (Policy)

32
s OGM.20 Staff health program.

10- Community Assessment and Involvement

Plan for community involvement

a CAI.01
initiatives.

Community assessment and

b CAI.02
involvement program.

Community suggestions and complaints.

c CAI.05
(Policy)

11- Workforce Management

Staffing plans (departmental and

a WFM.02
hospital-wide).

b WFM.03 Recruitment process. (Policy)

Document describing the credential

c WFM.05 verification process. (Approved
document)

d WFM.06 Staff files. (Policy)

e WFM.07 Orientation programs.

Continuing education and training

f WFM.08
program.

Staff performance evaluation

g WFM.09
(tools/criteria). (Approved document)

Medical staff structure. (Approved

h WFM.10
document)

i WFM.11 Medical staff bylaws.

j WFM.13 Clinical privileges. (Policy)

Medical staff members' performance

k WFM.14 evaluation criteria. (Approved
document)

l WFM.15 Peer review process. (Policy)

33
 Nursing structure. (Approved document)
m WFM.16
WFM.16

n WFM.17 Job description for the nursing director.

12- Information Management and Technology

a IMT.02 Information management plan

Quality management documentation

b IMT.03
system. (Policy)

Confidentiality and security of data and

c IMT.05
information. (Policy)

Retention of data and information.

d IMT.07
(Policy)

Patient's medical record management.

e IMT.08
(Policy)

Medical records review process.

f IMT.09 Met
(Policy)

g IMT.11 Electronic system downtime program.

13- Quality and Performance Improvement:

Performance improvement, patient
a QPI.01 safety and risk management
committee(s) terms of references.

Quality performance improvement and

b QPI.02
patient safety plan.

Job description of quality management

c QPI.03
team.

Approved documented work sheet (Data

d QPI.05 analysis report) for each selected
performance measure.
Written process of data management
e QPI.08 includes the aggregation and analysis.
(Approved document)

34
 Written process for data validation
f QPI.09
(Approved document).

g QPI.10 Risk management program.

h QPI.11 Incident reporting system (Policy).

Written document defines criteria and

i QPI.12 process of investigations for significant
events. (Approved document)

j QPI.13 Sentinel events management (Policy).

Written process or methodology for

k QPI.14
improvement (Approved document).

14- Additional Requirements

Education program for house officers

a ADD.04
and residents.

Professional graduate education

b ADD.05
program.

Research ethics committee structure

c ADD.06 documents, meeting agenda and meeting
notes.

d ADD.07 Research patient rights (Policy).

e ADD.08 Organ/Tissue donation (Policy).

Organ/Tissue transplantation services

f ADD.09
(Policy).

35