Clarification for CBAHI

Standards: Tips for better

implementation
Abdullatif Alokifi – Performance Improvement
General Directorate of Quality Improvement
Content of the workshop
PRORGAM

Time Topic
08:00 – 08:30 Registration
Welcoming and Introduction to the Course
08:30 – 09:00
‫مقدمة وعرض لهدف الدورة‬
Priority list with CBAHI Standards
09:00 – 10:00
‫ترتيب أولوياتنا مع معايير السباهي‬ Abdullatif Alokifi
LD Standards ‫معايير القيادة واإلدارة‬ ‫عبداللطيف العقيفي‬

QM Standards ‫معايير الجودة‬

10:00 – 12:00
MD Standards ‫معايير الطاقم الطبي‬
HR, LB, PC, IPC
12:00 – 13:00 Break / Prayer
FMS Standards ‫معايير أمن وسالمة المنشأءة‬
MM Standards ‫معايير السالمة الدوائية‬ Abdullatif Alokifi
13:00 – 16:00
HR, PFR, AN, OR, NR, SC, PC ‫عبداللطيف العقيفي‬

ESR Standards ‫معايير السالمة األساسية‬

Mr. Abdulaziz Abdulbaqi
16:00 Closing Remarks ‫األستاذ عبدالعزيز عبدالباقي‬
 Total ESR Standards: 20

Total ESR Sub-Standards: 113

LD.1, LD.27.2 and LD.30 Priority list with
LB.57 CBAHI Standards
HR.5 MM.5
HR.5 ‫ترتيب أولوياتنا مع معايير‬ MS.7 MM.6
MS.7.3 and MS.7.4 ‫السباهي‬ PC.25 MM.41
MM.41
PC.26 LB.51
PC.25.5 and PC.16
QM.17 FMS.9
IPC.15 QM.18 FMS.21
QM.5, QM.7, QM.8, QM.9, QM.18, QM.21 QM.17, QM.15 AN.2 FMS.22
and QM.15.3 AN.15 FMS.23
PFR.8.7 IPC.4 FMS.24
AN.15.3 IPC.15 FMS.32
OR.6
FMS.22.1, FMS.23.1, FMS.23.4, FMS.23.5, FMS.23.6 and
FMS.24.5
PC.26, AN.2, IPC.4,
NR.12.2.4 MM.5, MM.6, LB 51,
SC.5 FMS.9, FMS.21, FMS.32
 ‫نظرا ً لما ورد لدنا من‬
‫األستفسارات لعدد من‬
‫المعايير تم عمل هذه الورشة‬
‫بنا ًء على هذا األساس ونسال‬
‫هللا لكم التوفيق والسداد‬
LD.1 The hospital has an effective
governing body.
 LD.1.1 There is a governing body that fulfills its main roles for mission and
strategy setting as well as performance evaluation and oversight on the hospital
processes and outcomes.

 LD.1.2 The governing body has its organization, membership, roles and
responsibilities, meetings procedure, performance evaluation, and committees
defined in a written bylaws or a similar document.

 LD.1.3 The governing body’s responsibilities reflect its ultimate accountability for
the quality of care and patient safety, and include the following:

 LD.1.3.1 Working together with the senior management and hospital leaders to
create and regularly review the hospital’s mission, vision, and values.

 LD.1.3.2 Appointing a qualified hospital director.

 LD.1.3.3 Evaluating on a regular basis the performance of the hospital director.

LD.1 The hospital has an effective
governing body. Cont…
• LD.1.3.4 Ensuring that the hospital has an effective organizational
structure displayed in an organizational chart that shows the titles (or
names) and the reporting relationships.

• LD.1.3.5 Approving the scope of services provided by the hospital.

• LD.1.3.6 Approving the hospital strategic and operational plans.

• LD.1.3.7 Approving the hospital-wide policies and procedures.

• LD.1.3.8 Monitoring, evaluating, and continuously improving the

outcome of the quality and patient safety plans and programs.
LD.1 The hospital has an effective
governing body. Cont…

• LD.1.3.9 Approving the medical staff bylaws.

• LD.1.3.10 Approving the annual budget of the hospital.

• LD.1.3.11 Ensuring the provision of adequate resources (e.g.

manpower, financial resources, and medical supplies).

• LD.1.3.12 Defining and approving delegations of authority.

• LD.1.4 The governing body meets regularly and adequate

minutes of the proceedings are maintained.
‫‪ .1‬يفضل حضور مدير عام الشئون الصحية‬ ‫‪ .1‬هل يتوجب على مدير عام الشئون‬
‫بالمنطقة أو من ينوب عنه‪.‬‬ ‫الصحية الحضور في بداية التقييم و‬
‫مقابلة المقيمين؟‬

‫‪ .2‬ذكر المحاضرون في ورشة عمل التعريف ‪ .2‬بعض السياسات و الخطط يجب ان تعتمد‬
‫من المدير العام إال إذا فوض من ينوب‬ ‫بالمعايير الجديدة بأن السياسات يجب أن‬
‫عنه بالتوقيع بشكل رسمي على ان يتم‬ ‫تعتمد من قبل المدير العام إال إذا فوض‬
‫ذكر ذلك في سياسة الصالحيات و‬ ‫من ينوب عنه بالتوقيع بشكل رسمي‪ .‬هل‬
‫التفويض‬ ‫هذا فعال ما سيتم اعتماد و ان اختلف‬
‫القيمين؟‬
LD.27 The department head addresses all
issues related to the customers of the
department.
 LD.27.1 The department head identifies all internal and
external customers of the department (patients, families,
visitors, staff, suppliers, and contractors).

 LD.27.2 Whenever required, there is written agreement or

verbal understanding between the department and other
clinical departments and/or external customers, explaining
the expectations of each party.
‫‪ .1‬أن يكون هناك اتفاقية معتمدة بين‬ ‫‪ .1‬ماهي الوثائق المطلوبة ليتحقق هذا‬
‫األقسام الطبية أو باقي األقسام في‬ ‫المعيار نظرا الختالف اإلجابات بين‬
‫المنشأة الواحدة و بين المنشآت‬ ‫المقيمين اثناء ورشة عمل التعريف‬
‫المختلفة‬ ‫بالمعايير الجديدة و أثناء دورة‬
‫تدريب المدربين‬
‫‪ .2‬أن يكون هناك سياسة مشتركة بين‬
‫األقسام في المنشأة الواحدة و‬
‫اتفاقية معتمدة بين المنشآت‬
‫المختلفة‬
LD.30 The department head ensures sufficient
resources and staffing are available for the delivery of
safe and quality service.
 LD.30.1 The department head defines and requests the resources required by
the department for a safe and quality service (e.g., space, equipment, supplies,
staffing, and other resources).
 LD.30.2 The department head provides a written departmental staffing plan that
defines the number, type, and qualifications required for each position to fulfill
the department’s responsibilities.
 LD.30.3 The department head defines the qualifications- education, training,
experience, license, and any other relevant certification- required by all
categories of staff in the department.
 LD.30.4 The department head ensures the provision of orientation, training, and
continuing education for the staff working in the department.
 LD.30.5 The department head monitors the performance of the staff.
‫‪.1‬توفير مايثبت تحديد رئيس القسم‬ ‫‪.1‬كيف سيتم التحقق من‬
‫احتياجه من الموارد البشرية و‬ ‫تطبيق المعيار؟‬
‫غير البشرية وانه تم الرفع بها‬
‫للجهات العليا في المنشأة‬
LB.57 The blood bank has a process for request,
approval, and execution of therapeutic procedures.
 LB.57.1 The process ensures all therapeutic procedures are ordered and
justified by an authorized physician.

 LB.57.2 The process ensures the blood bank medical director or designee
is responsible for reviewing therapeutic procedures orders for
appropriateness and evaluating patient clinical and laboratory data
before approving the procedure.

 LB.57.3 The process ensures therapeutic procedures are explained to the

patient and consented.

 LB.57.4 The process ensures that blood/ blood components discarded

immediately after collection.
‫‪.1‬بتطبيق جميع المعايير السابقة‬ ‫‪.1‬كيف سيتم التحقق من‬
‫ومراجعة االجراءات العالجية‬ ‫تطبيق المعيار؟‬
‫من خالل المدير الطبي أو من‬
‫ينوب عنه‬
HR.5 The hospital has a process for proper credentialing
of staff members licensed to provide patient care.
 HR.5.1 The hospital has a written policy describing the process used for the
verification of credentials.

 HR.5.2 The hospital gathers, verifies, and evaluates the credentials (license,
education, training, certification and experience) of those medical staff, nursing
staff, and other health professionals licensed to provide patient care.

 HR.5.3 Credentials are verified from the original source.

 HR.5.4 Job responsibilities and clinical work assignments/ privileges are based on
the evaluation of the verified credentials.

 HR.5.5 The hospital ensures the registration of all healthcare professionals with
the Saudi Commission for Health Specialties.
HR.5 The hospital has a process for proper credentialing
of staff members licensed to provide patient care.
 HR.5.6 Staff licensed to provide patient care must always have and maintain a
valid license to practice only within their profession.

 HR.5.7 The hospital maintains an updated record of the current professional

license, certificate, or registration, when required by laws, regulations, or by
the hospital for every medical staff, nursing staff and other healthcare
professionals.

 HR.5.8 When verification of credentials is conducted through a third party, the

hospital must request for a confirmatory documentation.

 HR.5.9 Verification process applies to all clinical staff categories (full time, part
time, visitor, and locum).
‫المعيار ذكر أن يجب التحقق من خمسة امور لكل مقدمي الرعاية الصحية‬
‫و هي كالتالي‪:‬‬
‫‪ .1‬الشهادات (‪)Data Flow‬‬
‫‪ .2‬الخبرات (باالتصال بمكان العمل السابق و ارفاق الرد و محتوى المكالمة‪ /‬ايميل الرد في ملف‬
‫الموظف)‬
‫‪ .3‬رخصة الممارسة من الهيئة ال داعي للتحقق منها لكن يجب أن تكون ضمن تاريخ الصالحية‬
‫‪ .4‬دورات االنعاش (التحقق من مصدرها من موقع الويب الخاص بكل دورة و نرفق التحقق في‬
‫ملف الموظف)‬
‫‪ .5‬التدريب (مع اختالف تخصصات مقدمي الرعاية الصحية كيف يمكن التحقق من التدريب؟ و‬
‫أي تدريب يتطلب التحقق منه؟‬
 ‫• بالنسبة لمعيار التأكد من المؤهالت‪/‬الوثائق‪ ،‬فالتحقق مطلوب من أربعة‬
‫أمور (الشهادات التعليمية‪ ،‬الخبرات‪ ،‬التدريب و رخصة الممارسة)‪.‬‬

‫• المعيار يطلب التحقق من الجهة التي أصدرت المؤهل او الوثيقة (بما فيها‬
‫رخصة الممارسة وال يكتفى بالصالحية) سواء صدرت من جهه محلية أو‬
‫دولية‪.‬‬

‫• التحقق يمكن أن يكون بتواصل المستشفى مباشرة مع مصدر الوثيقة‪ ،‬أو‬

‫عن طريق جهة متخصصة في التحقق تقوم بدوره (مثال للجهه المتخصصة‬
‫الداتا فلو)‪.‬‬

‫• الداتا فلو ليس مطلوب بذاته بالمعيار‪.‬‬

 ‫ما هو المطلوب للتحقق من المصدر سواء محلي أو دولي‪:‬‬

‫• من الجهة المصدرة للوثيقة (خطاب أو إيميل رسمي للجهة) يوضع بملف الموظف‪.‬‬

‫• عن طريق الموقع االلكتروني الرسمي للجهة إذا كانت تتيح هذه الخدمة‪( .‬بعض الجهات في‬
‫الخارج تتيح لك التحقق عن طريق موقعهم االلكتروني بمقابل مادي)‬

‫• عن طريق االتصال الهاتفي بالجهة المصدرة للوثيقة‪ .‬يمكن أن يكتب المخول للتحقق في المستشفى‬
‫(على األغلب مسؤول في شؤون الموظفين) في ملف الموظف أو في نموذج أو على صورة من‬
‫الشهادة أنه تم االتصال بالجهة الفالنية على الرقم كذا والتحدث مع فالن ووظيفته كذا و تم‬
‫التحقق من صحة الشهادة‪ .‬و يكتب اسمه و التاريخ و التوقيع‪.‬‬

‫• عن طريق جهة ثالثة (مثال ذلك داتا فلو) أو شركات أخرى خارج المملكة ممكن أن يتعاقد معها‬
‫المستشفى لتؤدي هذا العمل‪.‬‬
‫في حال كانت هناك محاوالت لالتصال بالجهة المصدرة‬
‫للوثيقة و لم يرد رد‪ ،‬فيطلب أن توثق هذه المحاوالت‪ ،‬و‬
‫يكتفى بثالث محاوالت‪ .‬طريقة التوثيق‪ ،‬إما صور الخطابات‬
‫أو اإليميالت المرسلة أو نموذج يكتب فيه معلومات االتصال‬
‫(تم االتصال بالجهة الفالنية على الرقم كذا و لم يتم الرد‬
‫للتحقق من صحة الشهادة‪ .‬و يكتب اسمه و التاريخ و‬
‫التوقيع‪.‬‬
‫من الممكن أن يكون في ملف موظف واحد طرق متعددة‬
‫للتوثيق (مثل الشهادة عن طريق الداتا فلو‪ ،‬بطاقة الهيئة‬
‫عن طريق الموقع االلكتروني للهيئة‪ ،‬التدريب عن طريق‬
‫إيميل من مركز التدريب و الخبرة عن طريق االتصال‬
‫المباشر بالمستشفى الذي كان يعمل به)‬
‫بالنسبة لرخصة الهيئة التكفي بنفسها للتحقق من‬
‫الشهادة أو الخبرة‪ .‬البد من التحقق أوال من‬
‫الرخصة عن طريق الموقع‪ ،‬و الشهادة و الخبرة‬
‫يمكن أن يتحقق منها عن طريق الداتا فلو أو طرق‬
‫التحقق األخرى‪.‬‬
‫الداتا فلو ليس مطلوب بالمعيار على اإلطالق‪،‬‬
‫المطلوب التحقق من مصدر الوثيقة سواء عن‬
‫طريق الداتا فلو أو عن طريق شركة أخرى أو‬
‫بالطريق المباشر‪ .‬فلو على سبيل المثال جائت‬
‫شركة أخرى في السعودية تتحقق من جميع‬
‫الوثائق فيكتفى بها‪.‬‬
‫مالحظة أن التحقق لجميع مقدمي الرعاية الصحية‬
‫سعوديين و غير سعوديين سواء درسوا أو عملوا‬
‫داخل السعودية أو خارجها‪ ،‬حيث يغفل الكثير عن‬
‫هذا ألن الداتا فلو ال يعمل لهم‪ .‬مثال خريجي البورد‬
‫أو خريجي جامعة الملك سعود‪ ،‬فيلزم التحقق من‬
‫شهاداتهم‪.‬‬
MS.7 Medical staff members have
current delineated clinical privileges.

 MS.7.3 The hospital identifies the circumstances under which

temporary or emergency privileges are granted.

 MS.7.4 Temporary or emergency privileges are not granted

for more than 90 days and are not renewable.
‫في حال كان الطبيب زائر أو‬ ‫‪.1‬ماهي الحاالت التي يتم فيها‬
‫بدوام جزئي أو في‬ ‫قبول االمتيازات السريرية‬
‫المستشفى بشكل مؤقت‬ ‫المؤقته او الطارئة؟‬
MM.41 The hospital has a process for monitoring, identifying, and
reporting significant medication errors, including near misses, hazardous
conditions, and at-risk behaviors that have the potential to cause patient
harm.
MM.41.1 There is a multidisciplinary policy and procedure on handling medication
errors, near misses, and hazardous situations (e.g., confusion over look-alike/sound-alike
drugs or similar packaging).
MM.41.2 The policy has a clear and acceptable definition of significant medication
error, near misses, and hazardous situations.

MM.41.3 The treating physician is notified of the medication error at the appropriate
time.
MM.41.4 Medication error reporting is completed within the specified time frame after
discovery of the error.
MM.41.5 The hospital has a standard format for reporting medication errors.
Sub-standards
MM.41.6 Staff are educated on the process and importance of medication error
reporting.
MM.41.7 There is active reporting of medication errors, near misses, and hazardous
situations.
MM.41.8 The hospital conducts intensive root-cause analysis for all significant or
potentially significant medication errors.
MM.41.9 Medication errors, near misses, and hazardous situations are documented in
the patient’s medical record.
MM.41.10 The hospital utilizes reported data to improve the medication use process,
prevent medication errors, and improve patient safety.
MM.41.11 Healthcare professionals are provided with feedback on reported medication
errors, near misses, and hazardous situations.
MM.41.12 The hospital reports sentinel events related to serious medication errors to
the relevant authorities.
 ‫كانت اجابات مقيمي سباهي مختلفة و متفاوته وهي‬
‫كالتالي‪:‬‬
‫‪ .1‬ماهي الطريقة التي يجب فيها توثيق‬
‫‪ .1‬عمل نموذج خاص بتوثيق الحدث و تحديد نوعه وشيك ام جسيم و‬
‫األحداث الوشيكة او الجسيمة في ملف‬
‫اإلجراءات التي تم اتباعها وابالغ المريض بالحدث وشيكا كان ام‬
‫المريض علما ان اجابات مقيمي سباهي‬
‫جسيما ووضع النموذج في ملف المريض‪ .‬علما ان هذا النموذج‬
‫اثناء التدريب وورش العمل التعريفية و‬
‫يعتبر غير طبي واليجب ان يكون من محتويات الملف الطبي بناء‬
‫زيارات التقييم كانت متفاوته بشكل كبير‪.‬‬
‫على معايير السجالت الطبية‬

‫‪ .2‬هل يجب توثيق االحداث الوشيكة في ملف‬

‫‪ .2‬عمل ختم أو دالله توضح نوع الحدث ويكون كقائمة اختيارات‬
‫المريض كالخطأ في طلب او صرف الدواء‬
‫مختصرة لماهو موضح بالتفصيل في السياسة ويتم وضعه في ملف‬
‫و اللذي تم تصحيحه قبل ان يصل للمريض؟‬
‫المريض وتعبئته من قبل الطبيب المعالج واخبار المريض‬
‫وهل يجب اخبار المريض بذلك؟‬
‫‪ .3‬األحداث الوشيكة ليس بلضرورة أن توثيق في الملف الطبي‬

‫‪ .4‬ممكن وضع نسخه من نموذج ‪ OVR‬في ملف المريض‬

PC.25 Policies and procedures guide the
handling, use, and administration of
blood and blood products.

PC.25.5 In dire emergencies, patient/family signs

consent for "transfusion without NAT testing".

‫ البد من عمل توثيق وتوقيع‬.1 ‫ هل يجب توثيق ما يتطلبه المعيار في سياسة نقل‬.1
3 ‫االقرار وذلك الن النات يحتاج‬ ‫الدم وتطبيقه؟ حيث يتعارض ذلك مع اللجنة‬
‫أيام لظهور النتائج‬ ‫الطبية الشرعية و سالمة المريض؟‬
IPC.15 Facility design and available
supplies support isolation practices.
 IPC.15.1 There is at least one negative pressure airborne isolation room in the
emergency room and one in patient care areas (one negative pressure room for every
25-30 beds in general hospitals).

 IPC.15.2 The infection prevention and control team decides the need for more airborne
isolation rooms depending on the volume of patients in need for airborne isolation
admitted to the hospital.

 IPC.15.3 The ventilation system serving airborne isolation facilities provides pressure
patterns that prevent airborne pathogens from being distributed to other areas of the
hospital.

 IPC.15.3.1 Rooms designed for airborne isolation patients are under negative pressure.
 IPC.15.3.2 Air is exhausted to the outside and is not re-circulated unless it is filtered
through High Efficiency Particulate Air (HEPA) Filter.
 IPC.15.3.3 There is evidence of daily air exchange monitoring (12 air changes per hour)
when a patient is isolated. Weekly monitoring of the air exchange is needed when no
patient is isolated.
 IPC.15.4 The entry of the isolation room is through a work area or ante-room that serves as
a site for hand washing, gowning and storage of protective clothing (gloves, aprons, masks).
 IPC.15.5 Toilet, shower, or tub and hand washing facilities are provided for each isolation
room.
 IPC.15.6 Transmission-based precaution cards (isolation signs) are consistent with the
patient diagnosis and are posted in Arabic and English and indicate the type of precautions
required.
 IPC.15.6.1 Transmission-based precaution cards (isolation signs) are color coded for isolation
of different categories (e.g., contact: green, airborne: blue, droplet: pink or red).
 IPC.15.6.2 Transmission-based precaution cards (isolation signs) should contain short
statements and supported with the required figures.

 IPC.15.6.3 Isolation instructions must highlight the transmission-based precaution cards

(isolation signs) needed while transporting the patients under transmission-based
precautions to other department (e.g. ,radiology).
 IPC.15.7 Respirator (high filtration) masks (N-95, N-99) are
used by staff during direct care of patients on airborne
precautions and are available on all units likely to admit patients
on airborne precautions.

 IPC.15.8 Respirator (high filtration) masks (N95, N-99) can be

reused by the same patient care giver as per the period
specified by the manufacturer.
 ‫‪ .1‬هل الهيبا فلتر المتنقل يعمل كبديل‬
‫للضغط السلبي في غرف العزل؟ حيث ‪ .1‬الهيبا فلتر المتنقل ال يعمل كبديل‬
‫للضغط السلبي في غرف العزل‬ ‫انه يغير الهواء و يعمل كضغط سلبي‬

‫‪ .2‬غرف العزل سالبة الضغط غير‬

‫متوفرة في المنشأة فما العمل علما ان ‪ .2‬البد من عمل الغرفه سالبه‬
‫للحصول على درجة المعيار‬ ‫مقيم سباهي لم يقبل بالهيبا فلتر؟‬
QM.5 There is a multidisciplinary committee
responsible for the coordination of the
quality improvement program.

 QM.5.1 The hospital has a multidisciplinary quality

improvement committee that has members from the
leadership group (the hospital director, medical director, nursing
director, quality management director) and other
members/invitees as appropriate.

 QM.5.2 The quality improvement committee provides

coordination and oversight of the quality improvement
program throughout the hospital.
• QM.5.2.1 The quality improvement committee is responsible
for development, implementation, and evaluation of the
quality improvement program.

• QM.5.2.2 The quality improvement committee approves all

quality improvement initiatives.

• QM.5.2.3 The quality improvement committee receives

quality reports and provides feedback to the relevant
stakeholders.

• QM.5.3 The quality improvement committee meets regularly

and maintains appropriate documentation of its activities.
 ‫يمكن االستغناء عن أي من‬ ‫‪ .1‬هل باإلمكان تقليص اعضاء اللجان المحددة األعضاء‬
‫األعضاء إذا كان هناك من ينوب‬ ‫مسبقا في دليل سباهي و على سبيل المثال لجنة‬
‫عنهم‬ ‫الجودة‪ :‬االستغناء عن رئيس الصيدلية و العمليات و‬
‫المختبر في ظل وجود المدير الطبي و في حال وجود‬
‫محور خاص يستدعي الوجود الفعلي لقسم ما يتم‬
‫توجيه دعوة لرئيس القسم المعني بالمحور للحضور‪.‬‬
‫و ذلك حتى يتسنى لنا االستمرارية في الحد االدنى‬
‫السنوي النعقاد اللجان من خالل تقليص االعضاء قدر‬
‫االمكان في ظل انعدام الحوافز المساعدة اللتزام‬
‫االعضاء بالحضور‬
QM.7 Hospital leaders select a set of structure
indicators based on the mission
and scope of services.
 QM.7.1 Hospital leaders utilize the information provided by structure
indicators.
 QM.7.2 Structure indicators may include, but are not limited to, the following:
 QM.7.2.1 Availability of essential supplies and equipment.
 QM.7.2.2 Availability of medical records.
 QM.7.2.3 Availability of blood and blood products.
 QM.7.2.4 Availability of emergency medications.
 QM.7.2.5 Vacancy rates in all departments.
 QM.7.2.6 Surgical volumes.
 QM.7.2.7 Staffing ratios.
QM.8 Hospital leaders select a set of process
indicators based on the mission
and scope of services.
 QM.8.1 Hospital leaders utilize the information provided by process
indicators.
 QM.8.2 Process indicators may include, but are not limited to, the following:
 QM.8.2.1 The timing and use of antibiotics prior to surgery.
 QM.8.2.2 Blood and blood products administration.
 QM.8.2.3 Documentation in medical records.
 QM.8.2.4 Delay of physicians answering nurses’ phone calls and pagers.
 QM.8.2.5 Waiting times for treatment.
 QM.8.2.6 Venous thrombo-embolism prophylaxis for surgical patients.
 QM.8.2.7 Neuropathy testing in diabetic patients.
QM.9 Hospital leaders select a set of outcome indicators based
on the mission and scope of services.
 QM.9.1 Hospital leaders utilize information provided by outcome indicators.
 QM.9.2 Outcome indicators may include, but are not limited to, the following:

 QM.9.2.1 Mortality rates.

 QM.9.2.2 Healthcare associated infections.
 QM.9.2.3 Staff satisfaction.
 QM.9.2.4 Patient satisfaction.
 QM.9.2.5 Unplanned return to the operating room.
 QM.9.2.6 Return to the emergency room within 24 hours.
 QM.9.2.7 Unplanned transfer to the critical care unit.
 QM.9.2.8 Resuscitation of patients (cardiac/respiratory arrest).
 QM.9.2.9 Readmission to the hospital within 30 days of discharge.
 QM.9.2.10 Various adverse events (e.g., falls, injuries, and pressure ulcers).
 QM.9.2.11 Medication errors.
 QM.9.2.12 Sentinel events.
 QM.9.2.13 Patient complaints.
 QM.9.2.14 Length of stay.
‫‪ .1‬يجب قياس جميع المؤشرات كي ال تؤثر‬ ‫‪ .1‬هل يجب العمل على كافة‬
‫على التقييم النهائي للمعيار‪.‬‬ ‫المؤشرات المذكورة في هذه‬
‫المعايير؟ علما ان المعيار‬
‫يوضح انها على سبيل المثال و‬
‫ليس الحصر‪ .‬علما انها قد‬
‫التكون ذات اولوية للقياس في‬
‫جميع المنشئات‬
QM.15 The hospital has a process to handle
sentinel events.
 QM.15.1 There is a policy for management of sentinel events.
 QM.15.2 Sentinel events are identified in the hospital’s policy and
include the following:

 QM.15.2.1 Unexpected death.

 QM.15.2.2 Unexpected loss of limb or function.
 QM.15.2.3 Wrong patient, wrong procedure, or wrong site.
 QM.15.2.4 Retained instrument or sponge.
 QM.15.2.5 Serious medication error leading to death or major
morbidity.
 QM.15.2.6 Suicide of a patient in an inpatient unit.
 QM.15.2.7 Infant abduction or discharge to a wrong family.

 QM.15.2.8 Maternal death.

 QM.15.2.9 Hemolytic blood transfusion reaction.

 QM.15.2.10 Air Embolism.

 QM.15.3 Reportable sentinel events are reported to CBAHI within five working
days of the internal notification of the event.

 QM.15.4 The hospital forms a team to complete the root cause analysis along with
an action plan for all sentinel events. The team should bring together those who
have an intimate knowledge of the normal process.

 QM.15.5 The root cause analysis and risk reduction plan are sent to CBAHI within
thirty working days from the date of the internal notification of the event.

 QM.15.6 Reportable sentinel events are reported as required to other relevant

authorities.
 ‫نكتفي بتبليغ الوزارة‬ ‫‪.1‬اليوجد اي توجيهات من وزارة الصحة‬
‫تختص بتبليغ االحداث الجسيمة لسباهي من خالل موقع االحداث‬
‫او ألي منشئة خارجية كون هذه االحداث الجسيمة والوزراة‬
‫تعتبر سرية‪ .‬فكيف سيتم تحقيق المعيار؟ بدورها تتكفل بالتواصل‬
‫مع السباهي‬
QM.17 The hospital has a process to ensure
correct identification of patients.
 QM.17.1 At least two patient identifiers (e.g., patient full name
and medical record number) are required whenever taking
blood samples, administering medications or blood products, or
performing procedures.

 QM.17.2 The hospital has a standardized approach to patient

identification (e.g., use of ID bands with standardized
information).

 QM.17.3 Patients are actively involved in the process of

patient identification.
 ‫‪ .1‬عند زيارة بعض مقيمي سباهي‬ ‫‪ .1‬كيف يتم تحقيق سياسة التعرف على المريض‬
‫للمستشفيات النفسية لتقييم معايير‬ ‫في مستشفيات الصحة النفسية او المرضى‬
‫السالمة اصرو على وجود اسوارة‬ ‫النفسيين المنومين في المستشفيات العامة‬
‫تعريف المريض فلذلك البد من عمل‬ ‫للعالج علما اننا نجد صعوبة في استخدام‬
‫شي مشابه لتحقيق المعيار‬ ‫اسوارة اليد كون المريض النفسي و الفصامي‬
‫لديه هالوس و ضالالت و يعتقد انها بمثابة‬
‫تجسس عليه ويمكن استخدامها فقط في بعض‬
‫الحاالت‪ .‬نحتاج سياسة واضحة و معتمدة من‬
‫المركز الوطني علما اننا عملنا بحوث فوجدنا ان‬
‫الدول شرق آسيوية يستخدمون الصورة‬
‫الشخصية في الملف هل يمكن استخدام الصورة‬
‫الشخصية مثال في الملف الطبي او يمكن‬
‫استخدام البصمة مثال ؟‬
QM.18 The hospital has a process to prevent wrong
patient, wrong site, and wrong surgery/procedure.
 QM.18.1 There is a process implemented to prevent wrong patient, wrong site,
and wrong surgery/procedure during all invasive interventions performed in
operating rooms or other locations.
 QM.18.2 The process consists of three phases: verification, site marking, and time
out.
 QM.18.3 A pre-procedure verification of the patient information is carried out
including the patient’s identity, consent, full details of the procedure, laboratory
tests and images, and any implant or prosthesis.
 QM.18.4 The surgical/procedural site is marked before conducting the
surgery/procedure.
 QM.18.4.1 The site is marked especially in bilateral organs and multiple structures
(e.g. fingers, toes, and spine).
 QM.18.4.2 The site is marked by the individual who will perform the procedure.
 QM.18.4.3 The patient is involved in the marking process.
 QM.18.4.4 The marking method is consistent throughout the hospital.
 QM.18.4.5 The mark is visible after the patient is prepped and draped.
 QM.18.5 A final check (time-out) is conducted before the procedure is initiated.
 QM.18.5.1 The time-out is conducted in the location where the procedure will be
done, just before starting.
 QM.18.5.2 The time-out is initiated by a designated member of the team and
involves the members of the team, including the individual performing the
procedure, the anesthesia providers, and the nurse(s) involved.
 QM.18.5.3 The entire procedure team uses active communication during the time
out.
 QM.18.5.4 During the time-out, the team members agree on the correct patient
identity, the correct procedure to be performed, the correct site, and when
applicable, the availability of the correct implant or equipment.
 QM.18.6 The hospital documents its processes for preventing wrong patient, wrong
site, and wrong surgery/procedure.
‫‪ .1‬البد ان يكون هناك نموذج سوء‬ ‫‪ .1‬هل يجب استخدام النموذج نفسه‬
‫كان نفس النموذج أو نموذج‬ ‫‪Time out‬المعمول به للعمليات‬
‫مستحدث‬ ‫لإلجراءات خارج غرف العمليات‬
‫كعيادات االسنان او االجراءات في‬
‫غرف المرضى علما ان الكثير من‬
‫المحتويات قد ال تنطبق ام باإلمكان‬
‫عمل نموذج مختلف لالجراءات‬
‫خارج غرف العمليات؟ وهل عيادات‬
‫االسنان يجب عمل ‪ Time out‬فيها؟‬
QM.21 The hospital ensures appropriate communication
of patient care information during patient handovers.

• QM.21.1 Patient care information is appropriately

documented in a clearly understandable form to all care
providers within and between care settings.

• QM.21.2 The hospital implements a standardized approach to

handover communication between staff (e.g., Situation,
Background, Assessment, Recommendation-SBAR), change of
shift, and between different patient care units in the course of a
patient transfer.
‫‪.1‬اثناء تسليم المرضى بين المناوبات و ‪.1‬البد من وجود آلية‬
‫للتوثيق أيا ً كانت‬ ‫األقسام هل يتحقق المعيار بتوثيق‬
‫التسليم و االستالم في ‪Nursing‬‬
‫‪Progress Note and Doctors‬‬
‫‪ Progress Notes‬ام البد من وجود‬
‫نموذج مخصص لذلك و يتم توقيعه‬
‫من الطرفين عند االستالم و التسليم؟‬
FMS.22 The hospital has a fire suppression
system available in the required area(s).

 FMS.22.1 The hospital has a functional sprinkler

system.
 ‫‪.1‬اذاكانت المنشأة قديمة و التحتوي على نظام توضح لفريق‬
‫السباهي بالوثائق‬ ‫مكافحة الحريق وهو بحد ذاته مشروع‬
‫ضخم وتم طلبه في اصالحات البنية التحتية ومن الممكن أن تعطي‬
‫التي التي رفعت لوزارة الصحة فكيف سيتم على األقل جزء من‬
‫الدرجة‬ ‫تحقيق المعيار؟‬
FMS.29 The hospital implements a
preventive maintenance plan.
 FMS.29.1 There is a preventive maintenance plan
that covers at least the following:

 FMS.29.1.5 Medical gas system.

‫نكتفي باالسطوانات‬ ‫‪.1‬المستشفيات النفسية ال تتوفر فيها‬
‫هذه األنظمة كونها ال تنطبق ومع ذلك بحيث يكون هناك‬
‫آلية واضحة‬ ‫تم تقييم المستشفى النفسي ان هذا‬
‫المعيار غير متحقق‪ .‬نأمل استيضاح لالستخدام‬
‫ذلك‬
PFR.8 Staff members assist patients and
their families to participate in making
informed decisions about the care process,
treatment and services.

 PFR.8.7 Staff members respond appropriately to

patients’ requests of a second opinion if necessary.
 ‫يحق للمريض‬ ‫‪.1‬الرجاء توضيح المطلوب من المعيار و هل‬
‫طلب رأي أخر‬ ‫انظمة وزارة الصحة تسمح بأخذ رأي طبيب‬
‫والطبيب البد له من‬ ‫من خارج الوزارة ؟‬
‫تفهم الموضوع‬
‫‪.2‬هل يحق للمريض تغيير طبيبه و لو رفض‬
‫الطبيب اللذي طلبه المريض هل من حقه‬
‫الرفض الن ذلك في اخالقيات المهنة و حقوق‬
‫الطبيب من الهيئة تقر رفض الطبيب لحالة من‬
‫طبيب بنفس التخصص؟‬
FMS.24 The hospital and its occupants are
safe from fire and smoke.
 FMS.24.5 Fire rated doors are available according to
the hospital zones with no separation between walls
and ceiling to prevent smoke spread between rooms
and areas.
‫البد من وجود عزل‬ ‫‪.1‬يتطلب المعيار ان تكون اسقف الغرف‬
‫معزولة عن بعضها حتى ال يتسرب الدخان ونكتفي بأطالع‬
‫السباهي على‬ ‫في حال الحرائق و جميع المستشفيات‬
‫اسقفها معلقة يعني يمر بها مواسير السباكة التقارير المرفوعة‬
‫و المكيفات و اسالك الكهرباء فكيف يتم عمل مع الرد من المديرية‬
‫جدران بين الغرف و الوحدات و هذا اليوجد الخذ جزء من‬
‫في المستشفيات فكيف يتم تحقيق المعيار ؟ الدرجة‬
AN.15 Qualified staff perform moderate
and deep sedation/analgesia.
 AN.15.3 Clinical staff who participate in conducting
sedation must successfully complete a proper
education/training on moderate and deep sedation.
 ‫أرجع للتدريب‬ ‫‪.1‬عند مراجعة ملفات الموظفين كان‬
‫ومكوناته النه بعد‬ ‫يوجد بها ما يثبت حصولهم على‬
‫تدريب التخدير الواعي ولكن تم تقييم التدريب البد من‬
‫المعيار انه غير متحقق فهل هناك أصدار شهادة وأيضا‬
‫يقدم التدريب‬ ‫متطلبات اخرى غير واضحه من‬
‫أستشاري فقط‬ ‫سياق المعيار؟‬
OR.6 There is a policy for patient
acceptance into the operating room.
 OR.6.1 There is a policy for accepting patients in the operating room that mandates
the following:
 OR.6.1.1 Patient identification by name and medical record number as listed on the
patient’s ID band.
 OR.6.1.2 The consent form is checked for completion.
 OR.6.1.3 The operation/ procedure and the surgeon’s name are checked.
 OR.6.1.4 The site of surgery and its preparation and whether it is marked or not are
checked.
 OR.6.1.5 The laboratory and radiology results and pregnancy test as appropriate are
checked.
 OR.6.1.6 The pre-anesthesia sheet is checked for completion.
 OR.6.1.7 The history and physical examination are checked for documentation.
 OR.6.1.8 The requisition for blood is verified to ensure blood is reserved in the blood
bank, if needed.
 OR.6.2 The policy is collaboratively developed by the head of surgery, head of
anesthesia, and the nurse manager.
 ‫‪.1‬في المستشفيات التي ال تخدم ‪.1‬البد ان يكون المريض الطفل‬
‫تحت رعاية استشاري اطفال أو‬ ‫سن االطفال في العمليات سوى‬
‫من ينوب عنه‬ ‫في االسنان هل تنويم المرضى‬
‫االطفال تحت اسم طبيب اسنان‬
‫االطفال وتحت التخدير العام‬
‫لعمل اجراء اليوم الواحد و‬
‫الخروج يعد مخالفا للمعايير؟‬
FMS.23 There are fire exits that are
properly located in the hospital.

 FMS.23.1 Fire exits are available and are properly located

in the hospital.
 FMS.23.2 Fire exits are not locked.
 FMS.23.3 Fire exits are not obstructed.
 FMS.23.4 Fire exits have panic hard ware.
 FMS.23.5 Fire exits are fire resistant.
 FMS.23.6 Fire exits are clearly marked with illuminated
exit sign.
‫قد يكون هو‬ ‫‪.1‬اثناء زيارة سباهي لمعايير‬
‫السالمة تمت مالحظة باب واحد الباب الوحيد‬
‫فقط موقعه غير مالئم ومع ذلك تم اللذي الحظة‬
‫تقييم المعيار انه غير متحقق لذا المقيم‬
‫نرجو توضيح المطلوب من المعيار‬
NR.12 The nursing department ensures
adequate supplies and equipment for the
safe and effective provision of care.

 NR.12.2.4 There is a method to track issues with

supplies and linen so that patterns can be studied for
quality improvement.
SC.5 The social worker documents all relevant
patient information in the medical record.
• SC.5.1 The social worker documents relevant information in the patient’s
medical record , which include:
• SC.5.1.1 Reason for referral.
• SC.5.1.2 Patient/family assessment and reassessment findings.
• SC.5.1.3 Plan of care including goals and interventions such as counseling,
education, and facilitation of resources.
• SC.5.1.4 Evaluation of the plan of care.
• SC.5.1.5 Regular progress notes that include the patient/family
understanding, care progress, and needs for different or additional
services.
 ‫البد من التوثيق‬ ‫‪.1‬اغلب األخصائيين االجتماعيين يتحدثون‬
‫باللغة االنجليزية اذا‬ ‫ويكتبون باللغة العربية فقط فهل يتنافى ذلك‬
‫كان هناك متحدثين‬ ‫مع التوثيق المهني الصحيح؟ وكيف يتحقق‬
‫بغير اللغة العربية‬ ‫المعاير اذا كان توثيقهم باللغة العربية فقط؟‬
‫وممكن عمل نوذج‬
‫باللغتين‬
IPC.16 Disinfectants use is supervised by the
infection prevention and control team.
 IPC.16.1 The purchase of equipment and supplies used
for sterilization and disinfection is reviewed by the
infection prevention and control team.

 IPC.16.2 Antiseptics and disinfectants are used in

accordance with current scientific guidelines and
recommended practice (e.g., approved by recognized
professional organizations such as the Food and Drug
Administration and Environmental Protection Agency).
‫‪.1‬بناء على النماذج الوزارية فإن كل ال يتطلب المعيار عدد‬
‫تخصص يقوم بتدوين خطة الرعاية من النماذج بل االمر‬
‫في نموذج خاص به هل ذلك يتنافى متروك للمستشفى‬
‫مع المعايير ام يجب ان يتم التوثيق‬
‫لكل الخطط في نموذج واحد علما‬
‫انه تم محاولة ذلك مسبقا ولم يكن‬
‫عمليا‬
 ‫استفسارات عامة‬
‫‪ ‬هل سيتم تقييم تطبيق المستشفيات للمعاييرأبتداء من تفعيل المعايير‬
‫‪ 2016‬ام من تاريخ تسجيل المستشفى لالعتماد ؟ حيث أن المستشفى‬
‫قبل التسجيل غير ملزم بالمعايير؟ من ‪2016‬م‬

‫‪ ‬هل باالمكان توفير نسخة عربية من دليل المعايير؟ خالل هذا العام أن‬
‫شاء هللا‬

‫‪ ‬هل يوجد رقم مباشر او حساب مفعل لالستفسار المباشر؟ عن طريقنا‬

 Priority list with
CBAHI Standards
‫ترتيب أولوياتنا مع معايير‬
‫السباهي‬

PC.26, AN.2, IPC.4,

MM.5, MM.6, LB 51,
FMS.9, FMS.21, FMS.32
PC.26, AN.2, IPC.4, MM.5,
MM.6, LB 51, FMS.9,
FMS.21, FMS.32
PC.26 Patients at risk for developing venous
thromboembolism are identified and managed.

 PC.26.1 Patients are screened for the risk of

developing venous thromboembolism.

 PC.26.2 Patients at risk receive prophylaxis according

to current evidence-based practice.
AN.2 Anesthesia staff members have
the appropriate qualifications.
 AN.2.1 Qualified anesthesiologists provide anesthesia services.
 AN.2.2 Qualified anesthesiologist is present inside the operating room
throughout the operation.
 AN.2.3 Anesthesia consultant administers and supervises anesthesia
for major/specialized operations or high risk patients, including:

 AN.2.3.1 Pediatric operations.

 AN.2.3.2 Cardio-pulmonary operations.
 AN.2.3.3 Neurosurgery operations.
 AN.2.3.4 Transplant operations.

 AN.2.4 Anesthesia staff are certified in advanced life support as

appropriate to the patient’s age.
IPC.4 There is a designated multidisciplinary
committee that provides oversight of the infection
prevention and control program.
 IPC.4.1 The infection prevention and control committee is chaired by the
hospital director or the medical director.

 IPC.4.2 The membership of the infection prevention and control committee

includes representatives from the medical staff, nursing staff, microbiology,
operating room, central sterilization service, pharmaceutical care, dietary
services, housekeeping, infection prevention and control staff, and other
departments as needed.

 IPC.4.3 The infection prevention and control committee meets on a regular

basis (at least quarterly).

 IPC.4.4 Functions of the infection prevention and control committee

include, but are not limited to, the following:
 IPC.4.4.1 Review of the hospital infection prevention and control policies
and procedures.
 IPC.4.4.2 Review of the reports of healthcare-associated infections
surveillance submitted regularly by the infection prevention and control
team and suggestion of appropriate actions.
 IPC.4.4.3 Revision of the yearly plan submitted by infection prevention
and control team and suggestion of additions/changes if necessary.
 IPC.4.4.4 Evaluates and revises on a continuous basis the procedures &
the mechanisms developed by the infection prevention & control team to
serve established standards and goals.
 IPC.4.4.5 Brings to the attention of the infection prevention & control
team new infection control issues arising in different departments of the
hospital & suggests solutions.
 IPC.4.4.6 Each member of the committee acts as an advocate of infection
prevention & control in his department, trying to promote its principles,
and ensures application of its rules.
MM.5 The hospital has a system for the safety of high-alert medications.
 MM.5.1 There is a written multidisciplinary plan for managing high-alert medications and
hazardous pharmaceutical chemicals. It includes identification, location, labeling, storage,
dispensing, and administration of high-alert medications.

 MM.5.2 The hospital identifies an annually updated list of high-alert medications and hazardous
pharmaceutical chemicals based on its own data and national and international recognized
organizations (e.g., Institute of Safe Medication Practice, World Health Organization). The list
contains, but is not limited to, the following:
 MM.5.2.1 Controlled and narcotics medications.
 MM.5.2.2 Neuromuscular blockers.
 MM.5.2.3 Chemotherapeutic agents.
 MM.5.2.4 Concentrated electrolytes (e.g., hypertonic sodium chloride, concentrated potassium
salts).
 MM.5.2.5 Antithrombotic medications (e.g., heparin, warfarin).
 MM.5.2.6 Insulins.
 MM.5.2.7 Anesthetic medications (e.g., propofol, ketamine).
 MM.5.2.8 Investigational (research) drugs, as applicable.
 MM.5.2.9 Other medications as identified by the hospital.
 MM.5.3 The hospital plan for managing high-alert medications and
hazardous pharmaceutical chemicals is implemented. This includes, but
is not limited to, the following:
 MM.5.3.1 Improving access to information about high-alert
medications.
 MM.5.3.2 Limiting access to high-alert medications.
 MM.5.3.3 Using auxiliary labels or computerized alerts if available.
 MM.5.3.4 Standardizing the ordering, transcribing, preparation,
dispensing, administration, and monitoring of high-alert medications.
 MM.5.3.5 Employing independent double checks.

MM.5.4 The hospital develops and implements standard concentrations

for all medications administered by intravenous infusion.
MM.6 The hospital has a system for the safety of look-alike and sound-alike
(LASA) medications.
MM.6.1 There is a multidisciplinary policy and procedure on handling look- alike/sound-alike (LASA)
medications.

MM.6.2 The hospital reviews and revises annually its list of confusing drug names, which include LASA
medication name pairs that the hospital stores, dispenses, and administers.
MM.6.3. The hospital takes actions to prevent errors involving LASA medications including the following,
as applicable:
MM6.3.1 Providing education on LASA medications to healthcare professionals at orientation and as part
of continuing education.
MM.6.3.2 Using both the brand and generic names for prescribing LASA medications.
MM.6.3.3 Writing the diagnosis/ indication of the LASA medication on the prescription.
MM.6.3.4 Changing the appearance of look-alike product package.
MM.6.3.5 Reading carefully the label each time a medication is accessed, and/or prior to administration.
MM.6.3.6 Minimizing the use of verbal and telephone orders.
MM.6.3.7 Checking the purpose/indication of the medication on the prescription prior to dispensing and
administering.
MM.6.3.8 Placing LASA medications in locations separate from each other or in non-alphabetical order.
LB.51 The blood bank develops a process to
prevent disease transmission by Blood/platelet
transfusion.
 LB.51.1 There are policies and procedures mandating that a sample of blood obtained
from the donor during blood/ blood component collection is subjected to the following
infectious diseases testing:
 LB.51.1.1 HBsAg (hepatitis B surface antigen)
 LB.51.1.2 Anti-HBc. (antibody to hepatitis B core antigen)
 LB.51.1.3 Anti-HCV. (Hepatitis C virus)
 LB.51.1.4 Anti-HIV-1/2. (two major types of the human immunodeficiency virus)
 LB.51.1.5 Anti-HTLV-I/II. (Human T-Cell Lymphotropic Virus Types I and II)
 LB.51.1.6 HIV-1 RNA.
 LB.51.1.7 HCV RNA. (amount of hepatitis C virus in the blood)
 LB.51.1.8 HBV DNA. (Hepatitis B virus DNA (HBV DNA) carries the genetic blueprint of the virus)
 LB.51.1.9 Serological test for syphilis. (identification of antibodies in the serum)
 LB.51.1.10 Other additional or supplemental tests as mandated by relevant health
authorities.
 LB.51.2 The blood bank has a process to limit and detect
bacterial contamination in platelet components. The process:

 LB.51.2.1 Describes the blood bank approach to limit

bacterial contamination and the investigations of positive
cases.

 LB.51.2.2 Ensures the employed detection method is

sensitive enough to detect significant bacterial
contamination.
FMS.9 The hospital ensures that all its
occupants are safe from radiation hazards.
FMS.9.1 The hospital has a radiation safety policy and procedure and it is implemented.

FMS.9.2 All radio-active materials are clearly labeled and safely and securely stored.

FMS.9.3 The hospital has the relevant valid license(s) from King Abdulaziz City for Science
and Technology.

FMS.9.4 Staff handling nuclear materials are qualified and certified by King Abdul-Aziz City
for Science and Technology.

FMS.9.5 There is a valid shielding certificate of the x-ray room(s) including regular test to
ensure permissible radiation levels.

FMS.9.6 Lead aprons and gonad/thyroid shields are available to cover patients and staff
needs and are annually tested according to a hospital-wide inventory.

FMS.9.7 Personal radiation dosimeters (TLD cards) are available, tested every 3 months,
and actions taken when test results exceed permissible levels. 87
FMS.21 The hospital has an effective fire
alarm system.

FMS.21.1 There is a fire alarm system that is functioning and regularly

inspected as per civil defense guidelines

FMS.21.2 The fire alarm system testing results are documented.

FMS.21.3 The fire alarm system has preventive maintenance.

FMS.21.4 The elevators are connected to the fire alarm system.

88
 FMS.32 The hospital ensures proper
maintenance of the medical gas system.
 FMS.32.1 The medical gas system is regularly tested for:

 FMS.32.1.1 Pressure.
 FMS.32.1.2 Leaks.
 FMS.32.1.3 Functionality of valves, alarms, pressure gauge, and switches.

 FMS.32.2 There is a policy and procedure that ensures effective use of medical
gas system. Areas covered include, but are not limited to, the following:

 FMS.32.2.1 The procedures to follow for taking any part of the system offline.
 FMS.32.2.2 Commissioning and testing new branching or modifications.
 FMS.32.2.3 The procedure for ordering and filling liquid oxygen.
 FMS.32.2.4 Documenting all repairs/alterations/tests/filling logs/consumption.

 FMS.32.3 Compressed medical air is regularly tested for humidity and purity.
 FMS.32.4 The central medical gas station is in a safe and secure place.
 FMS.32.5 The outlets of medical gases in patient care areas are clearly marked
with the type of gas and have different connections according to the gas type. 89
• FMS.32.6 All medical gas pipes are clearly marked and labeled for the contents and direction
of gas flow.

• FMS.32.7 In case of gas pipe repairs or new extensions, outlets are tested for the type of gas
to ensure the correct type is delivered through the new pipe. Results of testing are recorded
and maintained with engineering and the unit manager.

• FMS.32.8 The hospital keeps standby oxygen and medical air cylinders enough for forty
eight hours of average consumption

• FMS.32.9 The gas cylinders are regularly tested for gas type, amount, and any leaks.

• FMS.32.10 Emergency shut off valves are available in all units and are clearly marked with
areas/rooms affected.

• FMS.32.11 The hospital dedicates the responsibility of the closure of shut off valves to well-
trained individual(s) available in the unit concerned.

• FMS.32.12 The hospital has adequate medical gases outlets in the patient care areas as
appropriate and these outlets are to be error proof medical gas outlets- preferred to be in
accordance with DIN standards related to gases piping, outlets and valves.
 THANK
Abdullatif Alokifi – Performance Improvement

YOU
General Directorate of Quality Improvement