‫مستوصف صدر المعمورة‬

‫محـافظـــــة االسكندرية‬

‫‪R0007 – 08 - 25‬‬
 ‫بيانات المنشأة والزيارة التقييمية‬
2025 ‫ يونيو‬3 – 2 :‫تاري خ زيارة التقييم‬ ‫مستوصف صدر المعمورة‬ :‫اسم المنش أة‬
‫اعتماد‬ :‫نوع زيارة التقييم‬ :
‫عنوان المنشأة االسكندرية‬
‫ إسماعيل الفق‬.‫رئيس الفريق د‬ ‫حكوم‬ :‫نوع المنش أة‬
‫أعضاء فريق زيارة‬
‫ ايمان السيد‬.‫عضو الفريق د‬ ‫ وزارة الصحة‬:‫جهة المنش أة‬
:‫التقييم والمراجعة‬
--- ‫عضو الفريق‬ ‫االسكندرية‬ :‫المح اف ظ ة‬
‫معايي اعتماد المراكز الطبية المتخصصة‬
‫ر‬ ‫المعايي الت تم التقييم عىل أساسها‬
‫ر‬

Report Summary

REQUIRMENT M PM NM NA PERCENT
Section 1:
Accreditation Prerequisites and Conditions 5 5 - - - 100%
(APC)
Section 2:
Patient-Cantered Standards
National Safety Requirements (NSR) 22
Patient-Centeredness Care (PCC) 8 8 - - - 100%
Access, Continuity and Transition of care (ACT) 10 10 - - - 100%
Integrated Care Delivery (ICD) 15 10 4 - 1 85.7%
Diagnostic (DAS) 24 13 4 - 7 88.2%
Surgery, Anesthesia and Sedation (SAS) 19 - - - 19 NA
Medication Management Safety (MMS) 7 7 - - - 100%
Section 3:
Organization-Centered Standards
Environmental and Facility Safety (EFS) 13 10 2 - 1 91.7%
Infection Prevention and Control (IPC) 17 13 2 - 2 93.3%
Organization Governance and Management
14 13 1 - - 96.4%
(OGM)
Workforce Management (WFM) 12 10 2 - - 91.7%
Information Management and Technology (IMT) 7 4 1 1 1 75%
Quality and Performance Improvement (QPI) 9 9 - - - 100%
Total Score 85.2%

2
 Report Details

• Findings related to standards and evidence of compliance that noted during the survey.

Section 1:
Accreditation Prerequisites and Conditions(APC)
Standard EOC APC Standard SCORE
APC.01 The ambulatory healthcare center ensures full compliance with Met
national regulations and licensure requirements.
EOC.1 The ambulatory healthcare center has a clear process of 2
frequent assessment of compliance with the national,
applicable regulation requirements.
comment
EOC.2 When a gap is identified, the ambulatory healthcare 2
center has developed a corrective action plan describing
all necessary measures needed to improve
performance and sustain the full compliance.
comment
EOC.3 The ambulatory healthcare center reports to GAHAR 2
any challenges that affect compliance with the national
regulaStion requirements.
comment
APC.02 The ambulatory healthcare center ensures safe medical provision Met
through complying with GAHAR Healthcare Professionals
Registration.
EOC.1 The ambulatory healthcare center has an approved 2
process for registering all members of the required
medical professionals including both current and newly
hired members.
comment
EOC.2 All contracts /agreements either full-time, part-time, 2
visiting, or other types of employment contracts with
the healthcare professionals mentioned in the intent
from
(a) to (i) are to be submitted in GAHAR healthcare
professionals’ registration process.
a. Physicians
b. Dentists
c. Pharmacists
d. Physiotherapists
e. Nurses
f. Nursing technicians
g. Health technicians
h. Chemists and physicists
i. Veterinary doctors
comment
EOC.3 The ambulatory healthcare center has a process to 2
report to GAHAR, other healthcare authorities, and
professional syndicates of any findings that affected
patient safety such as, fake, or falsified credentials.
comment

3
APC.03 The ambulatory healthcare center provides GAHAR with accurate Met
and complete information through all phases of the accreditation
process.
EOC.1 The ambulatory healthcare center has a process to 2
verify all reports for accuracy and completion prior to
GAHAR submission, throughout all stages of
accreditation process.
comment
EOC.2 The ambulatory healthcare center is aware of their 2
commit to report any structural changes in the
ambulatory healthcare center scope of work of addition
or deletion of medical services by more than 15% within
30 days.
comment
EOC.3 The ambulatory healthcare center provides GAHAR 2
access to evaluation results and reports of any
evaluating organization.
comment
APC.04 The ambulatory healthcare center uses the accreditation process to Met
improve safety and effectiveness.
EOC.1 The ambulatory healthcare center permits GAHAR to 2
perform on-site evaluations of compliance or
verification of quality and safety concerns, reports, or
any regulatory authority sanctions.
comment
EOC.2 The ambulatory healthcare center accurately represents 2
its accreditation status and scope.
comment
EOC.3 The ambulatory healthcare center has a process to 2
inform staff and patients on mechanisms to report safety
issues to GAHAR.
comment
APC.05 The ambulatory healthcare center maintains professional standards Met
during the survey.
EOC.1 Any conflict of interest is directly reported to GAHAR 2
with evidence. (if present).
comment
EOC.2 The ambulatory healthcare center maintains 2
professional standards on dealing with surveyors.
comment
EOC.3 The ambulatory healthcare center ensures that the 2
environment does not pose any safety or security risks
to surveyors during the survey.
comment
EOC.4 Social media releases are not allowed without GAHAR’s 2
prior approval and notification.
comment

4
 Section 2:
Patient- Centered Standards
Patient-Centeredness Culture (PCC)
PCC
Standar EOC PCC Standard Score
d
PCC.01 The ambulatory healthcare center advertisements are clear and Met
comply with applicable laws, regulations, and ethical codes of
the healthcare professionals' syndicates.
EOC.1 The ambulatory healthcare center has an approved 2
policy guiding the process of providing clear,
updated, and accurate advertisements of services.
comment
EOC.2 Advertisements are done in compliance with ethical 2
codes of healthcare professionals’ syndicates.
comment
EOC.3 Patients and their families receive clear, updated, 2
and accurate information about the ambulatory
healthcare center’s services, healthcare
professionals, and working hours.
comment
PCC.02 Patient and family rights are protected and informed to patients Met
and families.
EOC.1 The ambulatory healthcare center has an approved 2
policy that describe the process of defining patient
and family rights, as mentioned in the intent from (a)
through (k).
The policy
addresses at least the following:
a) Patient and family right to access care if provided
by the ambulatory healthcare center.
b) Patient and family right to know the name of the
treating, supervising, and/or
responsible medical staff member.
c) Patient and family right to receive care that
respects the patient’s personal values,
beliefs and personal preferences.
d) Patient and family rights to be informed and
participate in making decisions related to
their care.
e) Patient and family right to refuse care and
discontinue treatment.
f) Patient and family right to have security, personal
privacy, confidentiality, and dignity.
g) Patient and family right to have pain assessed and
treated.
h) Patient and family right to make a complaint or
suggestion without fear of retribution.
i) Patient and family right to know the price of

5
 services and procedures.
j) Patient and family right to seek a second opinion
either internally or externally.
k) Patient and family right to have protection from
any violations or abuse.
comment
EOC.2 All staff members are aware of patient and family 2
rights.
comment
EOC.3 An approved statement on patient rights and family 2
is available in all public areas in the ambulatory
healthcare center.
comment
EOC.4 Patient and family rights are protected in all areas 2
and at all times.
comment
EOC.5 Any violations to patient rights are managed and 2
reported through a defined process.
comment
EOC.6 Information about patient rights is provided in 2
writing or in another manner in which the
patients and their families understand.
comment
PCC.03 Patients and families are empowered to assume their Met
responsibilities.
EOC.1 The ambulatory healthcare center has an approved 2
policy that describe the process of defining patient
and family responsibilities as mentioned in the
intent from (a) through
(e ..)
The policy addresses at least the following:
a) Patients and their families have the responsibility
to provide clear and accurate
information on the disease/condition including the
current and past medical history.
b) Patients and their families have the responsibility
to comply with the policies and
procedures of the ambulatory healthcare center.
c) Patients and their families have the responsibility
to comply with financial obligations
according to laws and regulations and ambulatory
healthcare center policy.
d) Patients and their families have the responsibility
to show respect to other patients and
healthcare professionals.
e) Patients and their families have the responsibility
to follow the recommended treatment
plan.

6
 comment
EOC.2 All staff members are aware of patients and families 2
responsibilities.
comment
EOC.3 An approved statement on patient and family 2
responsibilities is available in all public
areas in the ambulatory healthcare center .
comment
EOC.4 Information about patient responsibilities is provided 2
in writing or in another manner that
the patient understands.
comment
PCC.04 The ambulatory healthcare center ensures that patients and Met
families’ education is provided clearly.
EOC.1 The ambulatory healthcare center has an approved 2
policy guiding the process of patient and family
education and includes at least item a) to d) in the
intent.
The policy addresses at least the following:
a) Identifying patient and family educational needs.
b) Multidisciplinary responsibility to educate patients
and families.
c) Method for education provided, according to
patient and family values and level of
learning, and in a language and format that they
understand.
d) Process of recording patient’s educational
activities.
comment
EOC.2 All staff members are aware of patients and families’ 2
education process.
comment
EOC.3 Patients receive education relevant to their 2
condition.
comment
EOC.4 Patient education activities such as patient education 2
needs, the responsibility of providing education, and
the method used are recorded in the patient’s
medical record.
comment
EOC.5 Appropriate patient education materials are 2
available as per center’s policy.
comment
PCC.05 The ambulatory healthcare center has a defined process to Met
obtain informed consent for certain medical processes.
EOC.1 The ambulatory healthcare center has an approved 2
policy guiding the process of informed consent that
includes all elements mentioned in the intent from
(a) through (c).

7
 a) The list of medical processes when informed
consent is needed, this list includes:
i. Surgery and invasive procedures.
ii. Anesthesia, moderate and deep sedation.
iii. Use of blood and donation of blood.
iv. High-risk procedures or treatments including but
not limited to (electroconvulsive
treatment, radiation, therapy, and
chemotherapy…...(
v. Research, if applicable.
vi. Photographic and promotional activities, for in
which the consent could be for
specific time or purpose
Certain situations when consent can be given by
someone other than the patient, and
mechanisms for obtaining and recording it according
to applicable laws and regulations and
approved ambulatory healthcare center policies.
Specific informed refusal consent shall be
used to document the refusal process. In case of
refusing or discontinuing a step or steps
in the medical care process, the patient informed
refusal consent should be used to
document the refusal process.
b) Consent forms availability in all applicable,
relevant locations.
c) The validity requirements for informed consent.
comment
EOC.2 The informed consent forms are available in all 2
relevant areas as per center’ policy.
comment
EOC.3 Informed consent is obtained in a manner and 2
language that the patient understands.
comment
EOC.4 Informed consent is recorded and kept in the 2
patient’s medical record.
comment
EOC.5 The most responsible physician obtaining the 2
informed consent signs the form with the
patient.
comment
EOC.6 All relevant staff members are aware of the consent 2
process.
comment
PCC.06 The ambulatory healthcare center’s responsibility towards the Met
patient’s belongings is defined.
EOC.1 The ambulatory healthcare center has an approved 2
policy guiding ambulatory healthcare center
responsibilities for patient’s belongings from a)

8
 through c) in the
intent.
Ambulatory healthcare center policy address at least
the
following:
a) Clarify the accountability of staff who have the
responsibility for managing patient’s
property.
b) Ensure that there are safe and appropriate
procedures in place to manage patient’s
property.
c) Define lost and found process, lost and found
items shall be recorded, protected, and
returned when possible; the ambulatory healthcare
center shall define a clear process
to follow when items are not returned within a
defined timeframe.
comment
EOC.2 Responsible staff members are aware of the 2
ambulatory healthcare center’s policy.
comment
EOC.3 Records of patient’s property management are 2
available and matching the cabinet’s
contents.
comment
PCC.07 The ambulatory health care center improves its provided Met
services based on measured patient and family feedback.
EOC.1 The ambulatory healthcare center has an approved 2
policy guiding the process of patient and family
feedback measurement.
comment
EOC.2 There is evidence that the ambulatory healthcare 2
center has received, analyzed, and interpreted
feedback from patients and families.
comment
EOC.3 The interpreted feedbacks have been communicated 2
with the concerned staff members and used for
services improvement.
comment
EOC.4 There is evidence that patient and family feedback is 2
used to improve the quality of service.
comment
PCC.08 Patients and families are able to make oral, written complaints Met
or suggestions through a defined process.
EOC.1 The ambulatory health care center has an approved 2
policy guiding the process of managing patients'
complaints and suggestions as mentioned in the
intent from (a) through (d).
Ambulatory health care center policy shall address at

9
 least the following:
a) Mechanisms to inform patients and families of
communication channels to voice
their complaints and suggestions.
b) Tracking processes for patient and family
complaints and suggestions.
c) Responsibility for responding to patient complaints
and suggestions.
d) Timeframe for giving feedback to patients and
families about voiced complaints or
suggestions and advising the patient of progress and
outcome.
comment
EOC.2 The ambulatory health care center allows the 2
complaining process to be publically available.
comment
EOC.3 Complaints and suggestions are investigated and 2
analyzed by the ambulatory health care center.
comment
EOC.4 Patients and families receive feedback about their 2
complaints or suggestions within approved
timeframes and according to the level of urgency of
the complaint.
comment
EOC.5 Staff is aware of complaints and suggestion process. 2
comment
Access, Continuity, Transition of care (ACT)
ACT
Standar EOC ACT Standard Score
d
ACT.01 The ambulatory healthcare center grants patients access to its Met
services according to pre-set eligibility criteria.
EOC.1 The ambulatory healthcare center has an approved 2
policy for granting access to patients that addresses
all elements mentioned in the intent from a) through
c).
The ambulatory healthcare center shall develop and
implement a policy and procedures to
guide the process of patient granting access. The
policy addresses at least the following:
a) The process of general, non-specific screening of
patients that aims to determine that
the ambulatory healthcare center scope of services
can meet their healthcare needs.
b) How to inform patients of the accessibility
methods.
c) Actions to be taken if the patient needs do not
match the ambulatory healthcare center
scope of service

10
 comment
EOC.2 The ambulatory healthcare center has a defined 2
process for informing patients and families about
services that are suitable for their needs.
comment
EOC.3 Patients are referred and/or transferred to other 2
healthcare organizations when healthcare needs are
not matching with the ambulatory healthcare center
scope of service
comment
ACT.02 Accurate patient identification through at least two unique Met
identifiers to identify the patient and all elements associated
with his/her plan of care.
NSR.01 EOC.1 The ambulatory healthcare center has an approved 2
policy and procedure for patient identification that
addresses all elements mentioned in the intent from
a) through f).
The policy addresses at least the following:
a) Two unique identifiers (personal).
b) Occasions when verification of patient
identification is required.
c) Elements associated with care such as
medications, clinical specimens, blood and
blood products and others.
d) Methods to document identifiers such as
wristbands, ID cards, and others.
e) The exclusion criteria for the patient identification
such as the patient’s bed number,
patient’s room number and others.
f) Special situations when patient identification may
not follow the same process, such as
for unidentified patients, disasters and others.
comment
EOC.2 All healthcare professionals are aware of ambulatory 2
healthcare center policy.
comment
EOC.3 The patient's identifiers are recorded in each sheet of 2
the patient’s medical record.
comment
EOC.4 The ambulatory healthcare center tracks, collects, 2
analyzes, and reports data on the staff compliance
with the patient’s identification process.
comment
EOC.5 Corrective actions are taken in accordance with the 2
findings and results of patient identification
compliance monitoring process.
comment
ACT.03 The ambulatory healthcare center works in collaboration with Met
other community stakeholders to provide comfortable and easy

11
 physical access.
EOC.1 The ambulatory healthcare center has a defined 2
process that guides safe physical access through
multiple means of transportation, either private,
public, or both.
comment
EOC.2 The ambulatory healthcare center’s services are 2
accessible for patients with disabilities.
comment
EOC.3 Measures as ramps, wheelchairs and trollies are 2
available for served patients.
comment
EOC.4 Barriers to access the ambulatory healthcare center 2
services are identified and proper corrective actions
are taken.
comment
ACT.04 Appropriate and clear wayfinding signage are used to help Met
patients and families to easily reach their destination inside the
ambulatory healthcare center.
EOC.1 Clear, readable, illuminated wayfinding signs are 2
used in all relevant places and areas during working
hours to reduce patient and family confusion.
comment
EOC.2 When color-coded signage is used, clear instructions NA
on what each color means should be available.
comment There was no color-coded signage
EOC.3 Staff is fully aware of wayfinding signage used. 2
comment
ACT.05 Patient flow in the ambulatory healthcare center is designed to Met
provide efficient care and uniform access based on the needs of
the patient.
EOC.1 There is a standardized process in place for 2
registering patients based on the scope of services
provided.
comment
EOC.2 The registration process is managed to give priority 2
to patients with urgent needs.
comment
EOC.3 When there will be a delay in care and/or treatment, 2
the patient is informed of the reasons for the delay
or wait.
comment
EOC.4 Patients are provided with information on available 2
alternatives consistent with their clinical needs.
comment
ACT.06 The ambulatory healthcare center designs and carries out Met
processes to ensure continuity of patient care services.
EOC.1 The ambulatory healthcare center has an approved 2

12
 policy that addresses all components of coordination
and continuity of care.
comment
EOC.2 Continuity and coordination of care are evidenced 1
and documented throughout all phases of patient
care.
comment By ten medical records review, all of care was
documented but three TB cases files didn’t include
the patient follow up documentation for treatment
completeness
EOC.3 The patient’s medical record(s) is available and 2
categorized to involve and document all phases of
patient care.
comment
ACT.07 The ambulatory healthcare center ensures safe, effective and Met
clear responsibilities for patient care.
EOC.1 The ambulatory healthcare center has an approved 2
policy and procedure for assigning patient care
responsibility that address all elements mentioned in
the intent from (a)
through (d).
The ambulatory healthcare center shall develop and
implement a policy and procedures to
guide the process of assigning patient care
responsibility. The policy addresses at least the
following:
a) Each patient is assigned to one Most Responsible
Physician (MRP) as relevant to a
patient’s clinical condition.
b) Conditions to request and grant transfer of care
responsibility.
c) How information about assessment and care plan,
including pending steps, can be
transferred from the first most responsible physician
to the next one.(handover)
d) The process to ensure clear identification of
responsibility between transfer of
responsibility parties.
comment
EOC.2 The patient's medical record identifies the physician 2
who has overall responsibility for directing and
coordinating the patient care and management
(MRP).
comment
EOC.3 In cases of transfer of care responsibility, clear 2
handover is signed by the most responsible physician
and documented in patient medical record.
comment
ACT.08 The ambulatory healthcare center ensures standardized accurate Met

13
 and complete hand over communication process.
NSR.06 EOC.1 The ambulatory healthcare center has an approved 2
policy that addresses all elements mentioned in the
intent from a) through d).
a) Use of standardized methods, forms, or tools to
facilitate consistent and complete
handovers of patient care; such as SBAR, ISOBAR, I
PASS the BATON, and others.
b) Situations that require implementing handover
process and tools
c) Assign staff responsibilities.
d) Recording of the process, such as handover
logbook, endorsement form, electronic
handover tool, and/or other methods as evidence of
implementation.
comment
EOC.2 All healthcare providers are aware of how to apply 2
the policy.
comment
EOC.3 Handover communications records are available as 2
per center’s policy.
comment
EOC.4 The ambulatory healthcare center tracks, collects, 2
analyzes, and reports data on the staff compliance
with the handover communication process.
comment
EOC.5 The ambulatory healthcare center acts on the 2
findings and results identified in the handover
communication process.
comment
ACT.09 The ambulatory health care center ensures that the Met
transportation services provided comply with relevant laws and
regulations and meet requirements for quality and safe
transport.
EOC.1 The ambulatory healthcare center has an approved 2
policy that addresses all elements mentioned in the
intent from (a) through (d).
The policy addresses at least the following:
a) Safe patient handling to and from examination
bed, trolley, wheelchair, and other
transportation means.
b) Staff safety while lifting and handling patients.
c) Coordination mechanism to ensure safe
transportation within the approved timeframe,
especially in critical conditions.
d) Qualifications of responsible staff members for the
transportation of patients. (The
qualifications required depend on the type of the
patient being transferred).

14
 comment
EOC.2 All staff members involved in the transportation of 2
patients are aware of the ambulatory healthcare
center’s policy.
comment
EOC.3 Staff responsible for monitoring the patient during 2
transportation are qualified according to the type of
patient being transferred.
comment
EOC.4 Requirements for transporting patients in critical NA
conditions are identified, used, and timely recorded
in the patient’s medical record.
comment No critical conditions
ACT.10 Processes of patient transfer outside the ambulatory healthcare Met
center, referral and discharge of patients are defined.
EOC.1 The ambulatory healthcare center has an approved 2
policy that addresses all elements mentioned in the
intent from a) through e).
The discharge, referral, and/or transfer policy
addresses at least the following:
a) Planning for discharge, referral, and/or transfer
out begins once diagnosis or
assessment is settled and, when appropriate,
includes the patient and family.
b) The discharge, referral/transfer process
documentation requirements include at least
the following:
I. Reason for referral/transfer.
II. Collected information through assessments and
care.
III. Medications and provided treatments.
IV. Transportation means and required monitoring.
V. Condition on discharge or referral/transfer.
VI. Destination on discharge or referral/transfer.
VII. Name and signature of the medical staff member
who decided the patient discharge
or referral/transfer.
VIII. Any special discharge instructions for the
patient.
IX. Patient details, discharge or referral/transfer’
date and time.
c) A qualified individual is responsible for ordering
and executing the discharge, referral,
and/or transfer out of patients.
d) Defined criteria determine the appropriateness of
referrals and transfers-out are based
on the approved scope of service and patient’s needs
for continuing care.
e) Coordination with transfer/ referral agencies, if

15
 applicable, other levels of health service
and other organizations.
comment
EOC.2 All staff members involved in discharge, referral, or 2
transfer of patients are aware of how to apply the
policy.
comment
EOC.3 The discharge, referral, and/or transfer out is 2
recorded in the patient’s medical record using all the
required elements from I) through IX).
comment
EOC.4 The referral and/or transfer feedback is reviewed, 2
signed, and recorded in the patient’s medical record.
comment
Integrated Care Delivery (ICD)
ICD
Standar EOC ICD Standard Score
d
ICD.01 The ambulatory healthcare center has a uniform process for care Met
provision and treatment.
EOC.1 Ambulatory healthcare center has a policy for the 2
uniform care provision process.
comment
EOC.2 When similar care is provided in more than one place 2
in the organization or more than one site, care
delivery is uniform.
comment
EOC.3 There is a clear process that explains options for 2
addressing discrimination and\or harassment and
describes methods of investigations and reporting, if
any.
comment
EOC.4 All staff members involved in patient care are aware 2
of the ambulatory healthcare center policy.
comment
ICD.02 The ambulatory healthcare center ensures that the process of PM
clinical practice guidelines’ selection, development, and
consistent use are strictly followed and implemented.
EOC.1 The ambulatory healthcare center has an approved 2
policy that guides all the elements mentioned in the
intent from a) through d).
The policy addresses at least the following:
a) Selection criteria of clinical practice guidelines.
b) How clinical practice guidelines/protocols
implementation are monitored and evaluated
c) Staff training required to apply the selected
guidelines, pathways, or protocols
d) Periodic update of clinical practice guidelines
based on changes in the evidence and

16
 evaluation of processes and outcomes.
comment
EOC.2 Related staff are trained on the implementation of 0
the relevant approved clinical guidelines.
comment By reviewing of the submitted document and related
staff files, there was no evidence for training on the
implementation of the relevant approved clinical
guidelines.
EOC.3 Compliance to clinical guidelines is linked to staff 2
performance evaluation and appraisal processes..
comment
ICD.03 Clinical care standards are used when applicable to the patient’s NA
condition.
EOC.1 The approved list of clinical care standards is
available, easily accessible when needed.
comment
EOC.2 Relevant staff members are trained on the applicable
clinical care standards pertinent to their jobs.
comment
EOC.3 Compliance to clinical care standards is linked to staff
performance evaluation and appraisal processes.
comment
ICD.04 Patient’s healthcare needs are identified through defined Met
screening processes.
EOC.1 The ambulatory healthcare center has an approved 2
policy including elements in the intent from a)
through d) to guide screening for patient’s
healthcare needs to define its
content and timeframe based on center’s policy.
the policy addresses at least the
following:
a) Define screening criteria for assessing the patients’
needs and determine who is
responsible to perform the screenings and the
related further assessments, when
needed.
b) Timeframe to complete and document the
screening.
c) Identifying the process when further assessment
by specific specialty or sub-specialty
is needed.
d) Screening includes at least the following:
i. Nutritional status
ii. Functional status
iii. Psychosocial status
iv. Victims of abuse and neglect and other special
needs population.
comment
EOC.2 All staff who perform the screening process are 2

17
 qualified and aware of how to apply it.
comment
EOC.3 All screenings are completed and recorded within an 2
approved timeframe as per center’s policy.
comment
ICD.05 The ambulatory healthcare center ensures that a Met
comprehensive, effective patient assessment process is
implemented.
EOC.1 The ambulatory healthcare center has an approved 2
assessment and re-assessment
policy that contains at least from (a) to (e) in the
intent
a) The scope and content of assessment required by
different specialties and in
different locations.
b) The specific assessments when the initial
screening labels the patient “at risk” for
the screening elements, Identification of special-
needs patient populations that visit
the ambulatory healthcare center which should
include at least the following:
i. Adolescents
ii. Elderly
iii. Disabled
iv. Immunocompromised
v. Patients with communicable diseases
vi. Patients with chronic pain
vii. Victims of abuse and neglect
c) The timeframe for completion the initial
assessment and situations when to consider
the initial assessment not valid.
d) The ambulatory healthcare center also defines
whether ambulatory healthcare
center verifies and/or accept the results of patient’s
assessments performed outside
the ambulatory healthcare center.
e) Assessments are performed by each discipline
within its scope of practice,
licensure, certification and the applicable laws and
regulations.
comment
EOC.2 All staff, who is responsible of patient assessment 2
process, is aware of the components of the policy.
comment
EOC.3 Only qualified individuals conduct the patient’ 2
medical assessments and reassessment.
comment
EOC.4 Patient medical assessment is timely documented in 2
the patient medical record according to the center’s

18
 policy
comment
EOC.5 The assessment process for special patient groups 2
and populations is modified to reflect their needs.
comment
EOC.6 Patient re-assessments are performed and timely 2
documented in the patient’s medical record
according to the center’s policy.
comment
ICD.06 Patient’s risk of falling is screened, assessed, and managed PM
safely.
NSR.05 EOC.1 The ambulatory care center has an approved policy 2
and procedures for fall screening and prevention that
addresses items a) and d) of the intent.
The
policy addresses at least the following:
a) Patient risk screening at first point of care.
b) Timeframe to complete the fall screening.
c) The need and frequency of fall re-assessment.
d) General measures required to reduce risk of falling
such as call systems, lighting,
corridor bars, bathroom bars, bedside rails,
wheelchairs, and trolleys with locks.
comment
EOC.2 Staff is aware of the fall screening and prevention 2
policy.
comment
EOC.3 Patients at high risk of fall are identified and 1
educated on fall prevention measures.
comment By patient interview and process observation, five
out of six were not educated on fall prevention
measures. All are identified.
EOC.4 All fall risk screenings are completed and timely 1
documented in the patient’s medical record
according to the center’s policy.
comment by reviewing ten medical records and interviewing
staff, there are no records of screening of patients
upon arrival at the center according to policy, but
there is an assessment upon entry to the clinics, The
time between the two events may reach a full hour.
EOC.5 Fall preventive general measures are recorded in the 0
patient’s medical record.
comment By reviewing ten medical records, fall preventive
general measures were not recorded in the patient’s
medical record.
By observation:
• There is an office on a stairs' edge at the center's
entrance where fall screening is conducted
without recording. Patients at high risk of falling

19
 are identified by an "F" sign. males are advised to
go to a rest area in the center's courtyard (full of
small stones, potholes and accumulated water),
while females are advised to go to a rest area
inside the center (where the path is slippery and
full of raised sills and the toilets were wet).
• The screening office is located on the edge of the
stairwell and patients stand on the steps, which
exposes them to the risk of falling when moving.
• there are no fall preventive general measures in
place to reduce falls.
ICD.07 patients are screened for pain, assessed, and managed Met
accordingly.
EOC.1 The ambulatory healthcare center has an approved 2
policy to guide pain screening, assessment and
management processes that addresses all elements
mentioned in the
intent from a) through f).
The policy addresses at least the following:
a) Pain screening tool.
b) Complete pain assessment elements that includes
nature, site, and severity.
c) The need and frequency of pain re-assessments.
d) Pain management protocols.
e) Assign responsibility for managing the pain.
f) Process of recording pain management plan in the
patient’s medical record.
comment
EOC.2 Relevant staff members are aware of how to apply 2
the policy.
comment
EOC.3 All patients are screened for pain using a valid, 2
approved tool.
comment
EOC.4 Pain assessment, re-assessment, and management 2
plans are recorded in the patient’s medical record.
comment
ICD.08 An individualized plan of care is developed for every patient. PM
EOC.1 Patient’ plan of care is performed by all relevant 2
disciplines based on their assessments and addresses
all the elements mentioned in the intent from (a)
through (f).
The plan of care is:
a) Developed by all relevant disciplines providing
care under the supervision of the most
responsible physician (MRP).
b) Based on assessments of the patient performed by
the various healthcare disciplines
and healthcare professionals, (including the

20
 investigations’ results, if any).
c) Developed with the involvement of the patient
and/or family through shared decision
making, with discussion of benefits and risks that
may involve decision aids.
d) Includes identified needs, interventions, and
desired outcomes with timeframes.
e) Updated, as appropriate, based on the re-
assessment of the patient.
f) The progress of patient/service user in achieving
the goals or desired results of
treatment, care or service is monitored.
comment
EOC.2 Individualized plan of care is recorded in each 1
patient's medical file.
comment By reviewing ten medical records, plan of care
includes identified needs and interventions, but not
desired outcomes with timeframes.
EOC.3 Healthcare professionals are aware of the plan of 2
care components.
comment
EOC.4 Plan of care is revised/updated based on a re- 0
assessment findings or any change of patient
condition.
comment By reviewing ten medical records, there was no
evidence.
ICD.09 The consultation process is available, safe and effective. Met
EOC.1 The ambulatory healthcare center has an approved 2
policy of consultation that addresses all elements
mentioned in the intent from a) through e).
The policy addresses at least the following:
a. Defined criteria for patient consultation.
b. Type and urgency of consultation.
c. A clear process of communicating consultation
requests to concerned medical staff
member.
d. Timeframe to respond to consultation requests.
e. Consultation feedback’ documentation process to
ensure safe and appropriate care
planning especially in case of urgency.
comment
EOC.2 Medical staff members who are involved in the 2
consultation process are aware of how to apply the
policy.
comment
EOC.3 Consultations are performed and timely documented 2
in the patient’s medical record according to the
center’s policy.
comment

21
ICD.10 Verbal or telephone orders are communicated safely and PM
effectively throughout the ambulatory healthcare center.
NSR.02 EOC.1 The ambulatory healthcare center has an approved 1
policy to guide verbal communications and to define
its content that addresses at least all elements
mentioned
in the intent from a) through d).
The policy addresses at least the
following:
a) Process of recording verbal orders
b) Process of recording telephone orders
c) Read-back by the recipient
d) Confirmation by individual giving the order
comment By reviewing the center policy only verbal orders are
allowed (item b) was not applicable), however, in the
details of the other three items there is a problem in
the chronological order of the steps, as the order
used to be recorded immediately then read-back and
confirmation, which is time consuming.
EOC.2 Healthcare professionals are aware of how to apply 1
the policy.
comment Based on the above.
EOC.3 All verbal orders and telephone orders are recorded NA
in the patient’s medical record within a pre-defined
timeframe.
comment There was no history during the look back period.
EOC.4 The ambulatory healthcare center tracks, collects, NA
analyzes, and reports data on compliance with the
verbal and telephone order process.
comment There was no history during the look back period.
EOC.5 The ambulatory healthcare center acts on the NA
findings identified in verbal and telephone order
process.
comment There was no history during the look back period.
ICD.11 Critical results are communicated timely, accurately and safely Met
throughout the ambulatory healthcare center.
NSR.07 EOC.1 The ambulatory healthcare center has an approved 2
policy to guide critical results communications and to
define its content that addresses at least all elements
mentioned
in the intent from a) through d).
The policy addresses at least the
following:
a) Lists of critical results and values.
b) Critical test results reporting process including
timeframe and read-back by the
recipient.
c) Process of recording.
i. Date and time of notification.

22
 ii. Identification of the notifying responsible staff
member.
iii. Identification of the notified person.
iv. Examination results conveyed.
v. Identification of what information needs to be
documented in the patient medical
record.
d) Measures shall be taken in case of non-
compliance with the critical results reporting
process.
comment
EOC.2 Healthcare professionals are aware of how to apply 2
the policy.
comment
EOC.3 All critical results are recorded in the patient’s 2
medical record within a pre-defined timeframe.
comment
EOC.4 The ambulatory healthcare center tracks, collects, 2
analyzes, and reports data on compliance with the
critical results reporting process.
comment
EOC.5 The ambulatory healthcare center acts on the 2
findings identified in critical results reporting
process.
comment
ICD.12 Systems are implemented to prevent catheter and tubing Met
misconnections.
NSR.04 EOC.1 The ambulatory healthcare center has an approved 2
policy of catheter and tubing misconnections that
addresses all the elements mentioned in the intent
from a) through
f).
The policy addresses at least the following:
a) Responsibility of connection and disconnection of
tubes should not be left to nonmedical
staff members, families, or visitors.
b) Labeling of high-risk catheters (e.g. arterial,
epidural, intrathecal).
c) Avoidance of use of catheters with injection ports
for these applications.
d) Tracing of all lines from their origin to the
connection port to verify attachments before
making any connections or re-connections, or
administering medications, solutions, or
other products.
e) Standardized line reconciliation, re-checking
process, and catheter maps as part of
handover communications.
f) Acceptance testing and risk assessment (failure

23
 mode and effects analysis, etc.) to
identify the potential for misconnections when
purchasing new catheters and tubing.
comment
EOC.2 All staff members using tubes and catheters are 2
competent and aware of the ambulatory healthcare
center policy.
comment
EOC.3 Documents of tubes and catheters used as catheter 2
map are recorded in the patient’s medical record.
comment
ICD.13 Response to medical emergencies and cardio-pulmonary arrests Met
throughout the ambulatory healthcare center is managed safely
for both adult and pediatric patients.
EOC.1 The ambulatory healthcare center has an approved 2
policy that addresses all the elements mentioned in
the intent from a) through f).
The
policy addresses at least the following:
a) Defined criteria of recognition of emergencies and
cardio-pulmonary arrest including
adults and pediatrics.
b) Education and training of staff members on the
defined criteria.(at least BLS)
c) Identification of involved staff members to
respond according to the appropriate training
provided and age of population served.
d) Mechanisms to call staff members; including
code(s) that may be used for calling
emergency.
e) The time- frame for response.
f) Recording of response and management process.
comment The required policy is in place, however, it was stated
that the recording sheet is the verbal order sheet
while the verbal order policy stated that code blue
events recorded in the code blue sheet.
EOC.2 All staff members involved in medical emergencies 2
and cardiopulmonary resuscitation are aware of the
ambulatory healthcare center policy.
comment
EOC.3 All staff who provide patient care, including the 2
independent healthcare practitioners, are trained to
provide basic life support services.
comment
EOC.4 Qualified individuals are responsible for the 2
management of medical emergencies and cardio-
pulmonary arrests.
comment
EOC.5 Management of medical emergencies and cardio- 2

24
 pulmonary arrests are timely recorded in the
patient’s medical record.
comment
ICD.14 Urgent and emergency services are delivered according to Met
applicable laws and regulations.
EOC.1 The ambulatory healthcare center has an approved 2
policy for triage and emergency services as
mentioned in the intent from a) to d).
The policy addresses at least the following:
a) Qualified staff members are available during
working hours.
b) Defined criteria are developed to determine the
priority of care according to a
recognized triage process.
c) Assessment, reassessment, and emergency care
management follow approved clinical
guidelines and protocols.
d) Availability of medical equipment and medications
required for resuscitation.
comment
EOC.2 Qualified staff members offer emergency services 2
according to the policy of triage and emergency
services.
comment
EOC.3 Patients and families are informed of their priority 2
level and expected time to wait before being
assessed by a medical staff member.
comment
EOC.4 Medical equipment and medications for resuscitation 2
are standardized and available for use based on the
needs of the population served.
comment
EOC.5 Records of triage and emergency plan of care are 2
recorded in the patient’s medical record.
comment
ICD.15 The ambulatory healthcare center has a uniform recording Met
process for emergency care services.
EOC.1 The medical records of emergency patients include 2
arrival and departure times.
comment
EOC.2 The medical records of emergency patients include 2
the patient’s condition at time of discharge or
transfer.
comment
EOC.3 Departure order and follow up instructions are 2
signed by the treating physician and recorded in
time, in patient medical record.
comment
EOC.4 Equipment and devices used for time recording as 2

25
 watches, clocks, digital clocks, and timers are
functionally available in all emergency care areas.
comment
Diagnostic and Ancillary Services (DAS)
DAS
Standar EOC DAS Standard Score
d
DAS.01 Medical Imaging services are planned, operated, and provided Met
uniformly according to applicable laws, regulations.
EOC.1 Medical Imaging services are provided, either onsite 2
or through outside source, meet laws, regulations,
and applicable guidelines.
comment
EOC.2 All related licenses, permits and guidelines are 2
available.
comment
EOC.3 List of medical Imaging services meets the scope of 2
clinical services of the ambulatory healthcare center.
comment
EOC.4 The ambulatory healthcare center demonstrates 2
evidence of monitoring of the quality and safety of
outsourced medical imaging services.
comment
EOC.5 There is evidence of annual evaluation of the medical NA
imaging services provided in a report discussed by
the ambulatory healthcare center leaders and
presented
to the governing body.
comment First accreditation.
DAS.02 Medical imaging services are performed by licensed competent Met
healthcare professionals and specific duties are assigned
according to applicable laws and regulations and assessed
competencies.
EOC.1 The ambulatory healthcare center has an approved 2
policy that addresses all the mentioned elements
from a) through d) in the intent.
The ambulatory healthcare center shall develop and
implement a policy and procedures
that addresses at least the following:
a) Direct observation of routine work processes and
procedures, including all
applicable safety practices.
b) Direct observation of equipment maintenance,
function checks;
and monitoring, recording and reporting of
examination results
c) Review of imaging professionals’ human resources
records;
d) Training on special modalities, equipment, and

26
 studies.
comment
EOC.2 Privileges are granted for performing each medical 2
imaging service function based on assessed
competencies.
comment
EOC.3 Competency assessment is performed annually and 2
recorded in the staff file.
comment
EOC.4 There is a mechanism to grant privileges temporarily NA
in emergencies.
comment There was no history during the look back period.
DAS.03 Performance of medical imaging studies and procedures is PM
standardized and effective.
EOC.1 The medical imaging service has a written procedure 2
for each study type.
comment
EOC.2 Procedure manuals are readily available. Each 2
procedure manual includes all the required elements
from a) through f) in the intent.
For each modality, procedure manuals
address at least the following:
a) Scope and general overview
b) Equipment description
c) Maintenance procedures
d) Quality control
e) Safety procedures
f) Critical findings
comment
EOC.3 Staff is trained and knowledgeable of the contents of 0
procedure manuals.
comment By staff file review, there was no evidence for training.
EOC.4 Review the procedures manual are performed and NA
reviewed on predefined intervals authorized staff
members.
comment First accreditation.
DAS.04 Medical imaging pre-examination process is effective. Met
EOC.1 The ambulatory healthcare center has an approved 2
policy to guide the medical imaging pre-examination
process that includes elements from a) to f) in the
intent.
The policy includes at least the following:
a) Proper completion of request form to include:
patient identification (Full patient
name, date of birth, gender, patient contact, and
location), name of the ordering
physician, studies requested, date and time of study,
clinical information, special
marking for urgent tests request.

27
 b) Patient preparations including specific risks.
c) Description of study techniques.
d) Pre-study review of requests to ensure that the
requested examination is
appropriate to the needs of the referrer and the
patient.
e) Actions to be taken when a request is incomplete,
illegible, or not clinically relevant,
or when the patient is not prepared.
f) Recording informed approvals from patients and
referrers when an additional or
substituted examination is called for.
comment Policy is in place, but missing the item c) Description
of study techniques.
EOC.2 Medical imaging service provides referrers and 0
patients with information regarding the merits of the
various diagnostic imaging techniques, manual is
distributed to all users and available in all technical
areas.
comment By document review and staff (medical imaging staff
and referrers) interview there was no evidence and
there was no manual.
EOC.3 Medical imaging service’ staff member review the 2
patient requests and verify patient
identity.
comment
EOC.4 Medical imaging service’ staff member ensures that 2
the patient has complied with any preparation
requirements (e.g. fasting) for the procedure that is
being performed.
comment
EOC.5 Actions are taken when a request is incomplete, 2
illegible, or not clinically relevant, or when the
patient is not prepared, to ensure patient safety.
comment
EOC.6 When an additional or substituted examination is 2
called for, medical imaging service staff member
informs patients and referrers and records in the
patient’s medical record.
comment
DAS.05 A medical imaging quality control program is developed. met
EOC.1 The ambulatory healthcare center has an approved 2
procedure describing the quality control process of
all medical imaging tests addressing all elements in
the intent from a) through g).
The ambulatory health center shall develop and
implement a procedure for quality control
that include at least the following:
a) Elements of the internal quality control performed

28
 according to risk assessment for
each study/modality.
b) The frequency for quality control testing is
determined by the ambulatory healthcare
center according to the guidelines and the
manufacturer instructions whichever is
more stringent.
c) Quality control methods to be used. It can be
handled and tested in the same
manner and by the same medical imaging staff
member.
d) Quality control performance expectations and
acceptable results should be defined
and readily available to staff so that they will
recognize unacceptable results in
order to respond appropriately.
e) The quality control program is approved by the
designee prior to implementation.
f) Responsible authorized staff member reviews
Quality Control data at a regular
interval (at least monthly).
g) Remedial actions taken for deficiencies are
identified through quality control
measures and corrective actions are taken
accordingly.
comment
EOC.2 Medical imaging service staff members involved in 2
quality control are competent in quality control
performance.
comment
EOC.3 All quality control processes are performed according 2
to quality control procedure.
comment
EOC.4 All quality control processes are recorded. 2
comment
EOC.5 A responsible authorized staff member reviews 2
quality control process and function and check data
at least monthly.
comment
EOC.6 Corrective action is taken whenever targets are NA
unmet.
comment There was no history.
DAS.06 Medical Imaging investigations are reported within approved P M
timeframe.
EOC.1 The ambulatory healthcare center has an approved 2
policy that addresses all elements mentioned in the
intent from a) through d).
The ambulatory healthcare center shall develop and
implement a policy and procedures to

29
 guide the process of reporting medical imaging
investigations that addresses at least the
following:
a) Time frames for reporting various types of images
to healthcare professional and
to patients.
b) Emergency and routine reports.
c) Accountabilities on the medical Imaging services
across the ambulatory healthcare
center.
d) Qualified licensed medical staff member is
responsible for interpretation and
reporting.
comment
EOC.2 Staff members involved in interpreting and reporting 2
results are competent to do so.
comment
EOC.3 Results are reported within approved timeframe. 0
comment By reviewing ten medical records, there was no
evidence that results are reported within approved
timeframe.
EOC.4 The ambulatory healthcare center tracks, collects, 2
analyzes, and reports data on its reporting times for
medical imaging services.
comment
EOC.5 The ambulatory healthcare center acts on 2
improvement opportunities identified in its medical
imaging service reporting times.
comment
EOC.6 Complete medical imaging reports include elements 1
from (I) to (VI) are recorded in the patient’s medical
record.
comment By reviewing ten medical records, the reports were
missing item v) time of reporting. and item vi) name
and signature of the reporting medical staff member.
DAS.07 Radiation safety program is developed and implemented. PM
NSR.20 EOC.1 The ambulatory healthcare center has an approved 1
radiation safety program for patients and staff that
addresses potential safety risks and hazards
encountered in the ambulatory healthcare center in
addition to all elements mentioned in the intent
from a) through h).
a) Compliance to laws, regulations.
b) All ionizing and non- ionizing radiation equipment
are maintained and calibrated.
c) Protocols to identify maximum dose of radiation
for each type of examinations.
d) Staff self-monitoring tools.
e) Appropriate and safe waste disposal for

30
 radioactive materials.
f) Staff suitable personal protective equipment.
g) Patients’ safety precautions.
h) MRI safety plan.
comment The required program is in place, the findings are:
- items e) and h) are out of scope.
- The program did not include how to deal
with: Item f) there was only one apron for
two x-ray rooms and three technicians. And
there was no any thyroid collar.
- The program did not include how to deal
with: Item g) there was no protective
equipment for patients including pregnant
women.
EOC.2 Identified radiation safety risks are mitigated through 0
processes and safety protective devices, for both
staff and patients.
comment - there was only one apron for two x-ray rooms and
three technicians. And there was no any thyroid
collar. There no apron examination.
- there was no protective equipment for patients
including pregnant women.
- Identified radiation risks were not including:
o There were holes in the windows (present) in
the two x-ray rooms.
o The windows were open in one of the rooms
during the tracer, which raised the risk that they
might be left open during x-ray examinations.
o The windows in one of the rooms opens onto
the male waiting area in the courtyard, and the
other opens onto the back garden.
o There was a square-shaped opening (30*30 cm)
in the wall of one of the x-ray rooms covered
with an unleaded wooden plank.
EOC.3 Staff members involved in medical imaging are aware 2
of radiation safety precautions and receive on-going
education and training for new procedures and
equipment.
comment Staff are aware. And there were no new procedures
or equipment to train on.
EOC.4 Radiation doses for patients in all radiology areas are 2
recorded in the patient’s medical record.
comment
EOC.5 The radiation safety program is part of the 2
ambulatory healthcare center environment and
facility safety program.
comment
DAS.08 Laboratory services are planned, provided, and operated Met
according to applicable laws, regulations, and applicable

31
 guidelines
EOC.1 Laboratory services meet applicable national 2
guidelines, standards of practice, laws and
regulations.
comment
EOC.2 Laboratory services are available to meet the needs 2
related to the ambulatory healthcare center mission
and patient population.
comment
EOC.3 Scope of services defined and documented in the 2
ambulatory healthcare center Laboratory.
comment
EOC.4 The plan for services is periodically reviewed and 2
modified as the requirements for services evolve and
change.
comment
EOC.5 The designated laboratory area is available and 2
separate from any other activities
comment
EOC.6 Presence of dedicated area for sample collection. 2
comment
DAS.09 Licensed, competent healthcare professionals are assigned to Met
operate laboratory services and duties.
EOC.1 The ambulatory healthcare center has an approved 2
policy and procedure that address all the mentioned
elements from a) through e) in the intent.
a) Direct observation of routine work processes and
procedures, including all
applicable safety practices.
b) Direct observation of equipment maintenance,
function checks;
and monitoring recording and reporting of
examination results.
c) Review of work records.
d) Assessment of problem-solving skills.
e) Examination of specially provided samples, such as
previously examined samples,
inter-laboratory comparison materials, or split
samples.
comment
EOC.2 Competency assessment is performed annually and 2
recorded in laboratory staff file.
comment
EOC.3 Privileges are granted for performing each laboratory 2
function based on assessed competencies.
comment
DAS.10 Referral laboratory services are selected and monitored met
effectively.
EOC.1 The ambulatory healthcare center has an approved 2

32
 policy that addresses all elements mentioned in the
intent from a) to c).
The referral laboratory services control shall include:
a) Selection
Selection should be based primarily on quality of
performance.
Whenever possible, referral specimens are sent to a
national or international
accredited laboratory.
b) Evaluation:
The laboratory should implement an evaluation
process either before starting
contracting, during the contract, or upon renewal of
the contract for the referral
laboratory through monitoring the quality of
performance, turnaround time, and
result reporting.
c) Requirements:
A signed document specifying the expectations of
the two parties involved should
be readily available for quick referral. The document
includes at least the following:
i. Scope of Service
ii. Agreement conditions (including accreditation
status).
iii. Sample requirements
iv. Turnaround Time (TAT)
v. Result reporting
vi. Release of information to the third party
vii. Mean of solving disputes
viii. The validity of the agreement and review
schedule.
comment
EOC.2 There is a written agreement between the two 2
laboratories describing the expectations of the two
parties fulfilling items in the intent from i) to viii).
i. Scope of Service
ii. Agreement conditions (including accreditation
status).
iii. Sample requirements
iv. Turnaround Time (TAT)
v. Result reporting
vi. Release of information to the third party
vii. Mean of solving disputes
viii. The validity of the agreement and review
schedule.
comment
EOC.3 Referral laboratory meets the selection criteria. 2
comment

33
 EOC.4 Referral laboratory is evaluated based on a 2
predefined criteria and timeframe.
comment
EOC.5 Records of send-out tests support compliance. 2
comment
DAS.11 Laboratory pre-examination process is effective. Met
EOC.1 The ambulatory healthcare center has an approved 2
policy to guide the pre-examination process that
includes elements from a) to h) in the intent.
The laboratory shall develop and implement a pre-
examination policy that include all
needed information for the patient and laboratory
staff including at least the following:
a) Proper completion of request form to include:
patient identification (Full patient
name, date of birth, gender, patient contact, and
location), name of the ordering
physician, tests requested, date and time of
specimen collection, identification of
the person who collected the specimen, clinical
information, type of specimen
(source of specimens), special marking for urgent
tests request.
b) Patient preparations including instructions for
dietary requirements (e.g., fasting
and special diets).
c) Description of specimen type collection
techniques.
d) Proper specimen labeling.
e) Criteria for safe disposal of materials used in the
collection.
f) Proper handling and transportation of specimens.
g) Turnaround time of tests
h) Minimal Retesting Interval (defined as the
minimum time before a test should be
repeated, based on the properties of the test and the
clinical situation in which it
is used).
comment
EOC.2 There is a laboratory service manual distributed to all 2
users and available in all technical areas.
comment
EOC.3 The ambulatory healthcare center has an approved 2
policy to guide the process of minimal retesting
interval.
comment
EOC.4 All staff involved in requesting laboratory tests are 2
aware of the pre-examination policy.
comment

34
 EOC.5 Preparation of specimen collection and labeling 2
requirements are implemented.
comment
EOC.6 Specimens are handled, transported and disposed 2
safely.
comment
DAS.12 Specimen reception, tracking, and storage processes are effective. Met
EOC.1 The laboratory has an approved policy that addresses 2
all elements in the intent from a) through e).
The laboratory shall develop and implement a pre-
examination policy that include all
needed information for the patient and laboratory
staff including at least the following:
a) Proper completion of request form to include:
patient identification (Full patient
name, date of birth, gender, patient contact, and
location), name of the ordering
physician, tests requested, date and time of
specimen collection, identification of
the person who collected the specimen, clinical
information, type of specimen
(source of specimens), special marking for urgent
tests request.
b) Patient preparations including instructions for
dietary requirements (e.g., fasting
and special diets).
c) Description of specimen type collection
techniques.
d) Proper specimen labeling.
e) Criteria for safe disposal of materials used in the
collection.
f) Proper handling and transportation of specimens.
g) Turnaround time of tests
h) Minimal Retesting Interval (defined as the
minimum time before a test should be
repeated, based on the properties of the test and the
clinical situation in which it
is used).
comment
EOC.2 All staff involved in receiving specimens are aware of 2
the policy requirements.
comment
EOC.3 All received and accepted specimens are recorded 2
including date and time of specimen’s reception and
the identity of the person receiving the sample.
comment
EOC.4 Records for specimen rejection and specimens 2
referred to other laboratories are maintained and
include all data mentioned in the intent

35
 comment
EOC.5 Evidence of traceability of all portions of the primary 2
sample to the original primary sample.
comment
EOC.6 Samples are stored in appropriate conditions during 2
all pre-examination activities.
comment
DAS.13 Verified/validated analytical test methods are selected and Met
performed.
EOC.1 The laboratory has an approved policy to guide the 2
selection of the examination methods for all tests
provided by the laboratory.
comment
EOC.2 The laboratory follows verification/validation 2
methods endorsed by reliable and updated
guidelines.
comment
EOC.3 The responsible authorized staff member 2
demonstrates competence and in-depth knowledge
of the introduced or changed test.
comment
EOC.4 Records of verification and /or validation results 2
fulfilling acceptable criteria based on predetermined
guidelines.
comment
EOC.5 There is recorded evidence of 2
reverification/revalidation whenever indicated.
comment
DAS.14 Instructions for performing test methods and procedures are PM
consistently and effectively followed.
EOC.1 The laboratory has a written procedure for each 2
analytical test method.
comment
EOC.2 The technical laboratory procedures are readily 2
available when needed.
comment
EOC.3 Each procedure includes all the required elements 2
from a) through I) in the intent.
They include at least the following:
a) Principle and clinical significance of the test.
b) Requirements for patient preparation and
specimen type, collection, and
storage.
c) Criteria for acceptability and rejection of the
sample.
d) Reagents and equipment used.
e) Verification/validation of examination procedures
f) The test procedure, including test calculations and
interpretation of results.

36
 g) Calibration and control procedures and corrective
actions to take when
calibration or control results fail to meet the
laboratory’s criteria for acceptability.
h) Verified/Validated biological reference
intervals/clinical decision values.
i) Critical test results.
j) Analytical measurement range and instructions for
determining results when it
is not within the measurement interval.
k) Limitations in methodologies including interfering
substances.
l) References.
comment
EOC.4 Staff are trained and knowledgeable of the contents 0
of procedure manuals.
comment By reviewing the staff personnel files, there was no
training evidence.
EOC.5 The procedures are consistently followed. 0
comment By document review and staff interview, there was
no evidence.
EOC.6 Authorized staff member reviews the procedures on NA
predefined intervals.
comment According to the center's policy, there was no
scheduled review during the review period.
DAS.15 Quality control programs are developed and implemented for all Met
tests.
EOC.1 The laboratory has an approved procedure 2
describing the internal quality control process of all
laboratory tests addressing all elements in the intent
from a) through g).
a) The frequency for quality control testing is
determined by the ambulatory healthcare
center according to guidelines and manufacturer
instructions whichever is more
stringent.
b) Quality control materials to be used. They shall be
handled and tested in the same
manner and by the same laboratory staff member
testing patient samples.
c) Quality control performance expectations and
acceptable ranges should be defined
and readily available to staff so that they will
recognize unacceptable results and
trends in order to respond appropriately.
d) Acceptance-rejection rules for internal quality
control results.
e) The IQCP is approved by the designee prior to
implementation.

37
 f) Quality Control data is reviewed at a regular
interval (at least monthly) by
responsible authorized staff member.
g) Remedial actions taken for deficiencies identified
through quality control measures
and corrective actions taken accordingly.
comment
EOC.2 Laboratory staff members involved in internal quality 2
control are competent and responsible authorized
staff member reviews quality control data at least
monthly.
comment
EOC.3 All internal quality control processes are performed 2
and recorded according to the internal quality
control procedure and the Corrective actions are
taken when indicated.
comment
EOC.4 The laboratory subscribes to an external proficiency- 2
testing program that covers the whole number of
analysts performed by the laboratory and available
from the provider, as well as the complexity of the
testing processes used by the laboratory.
comment
EOC.5 Records of all processes of external quality control 2
including testing, reporting, review, conclusions, and
actions, are present and retained for at least one
year.
comment
EOC.6 Evidence of proficiency testing alternative 0
procedures used according to guidelines whenever
no proficiency testing is available.
comment By document review and staff interview, there was no
evidence.
DAS.16 Laboratory post-examination process is developed and Met
implemented effectively to ensure accurate, Timely reporting
and release of verified laboratory tests.
EOC.1 The ambulatory healthcare center has an approved 2
policy to guide the post examination process that
include all elements mentioned in the intent from a)
through g).
The post examination process includes at least the
following:
a) Final report data fulfillment including at least:
identity of the laboratory, patient
identification, tests performed, ordering clinician,
date and time of specimen collection
and the source of specimen, reporting date and time,
test results and reference interval,
identification of the verifying individual (Approved),

38
 interpretation of results, appropriate,
advisory, or explanatory comment when needed.
b) Reviewing, verifying, and reporting of results by
authorized staff member
c) All laboratory test (TAT) shall be defined by the
laboratory.
d) The laboratory shall define the tests that can be
ordered on STAT base.
e) Criteria for specimen storage.
f) The defined retention time of laboratory results
g) The defined retention time of patient samples
comment
EOC.2 The laboratory defines the authorized staff member 2
who review and release the patient's results.
comment
EOC.3 The laboratory has a STAT List of tests; acceptable 2
STAT reporting time for each laboratory test is
defined.
comment
EOC.4 Delays in turnaround time are notified to requestors, 2
investigated and proper actions are taken according
comment
EOC.5 The retention process of a final laboratory report is 2
implemented with easy retrieval.
comment
EOC.6 Required specimens are easily retrieved. 2
comment
DAS.17 A comprehensive laboratory safety program is implemented. Met
NSR.21 EOC.1 A written program that describes safety measures for 2
laboratory services and facilities is documented and
includes the items in the intent from a) to i).
a) Safety measures for Healthcare professionals.
b) Safety measures for the specimen.
c) Safety measures for the environment and
equipment.
d) Incidents handling and corrective action are taken
when needed.
e) Proper Disposal of Laboratory Waste.
f) Material Safety Data Sheets (MSDS) Requirements.
g) Handling Chemical Spills/Spill Clean Up.
h) Instructions for the use of personal protective
equipment.
i) Risk management process.
comment
EOC.2 Laboratory staff are trained on the safety program. 2
comment
EOC.3 Laboratory risk assessment is performed and safety 2
reports are issued at least semiannually to the
ambulatory healthcare center environment and

39
 facility safety
committee
comment
EOC.4 Spill kits, safety showers and eye washes are 2
available, functioning and tested.
comment
EOC.5 Safety precautions are implemented. 2
comment
EOC.6 The ambulatory healthcare center tracks, collects, 2
analyzes and reports data on laboratory safety
program and it acts on identified improvement
opportunities.
comment
DAS.18 Point-of-care testing is monitored for providing accurate and NA
reliable results.
EOC.1 The laboratory assigns a competent responsible staff
member for supervising the point of care testing
services.
comment Out of scope.
EOC.2 Staff members who are responsible for performing
point of care testing are competent to do so.
comment
EOC.3 There is a defined process for performing and
reporting point of care testing (POCT).
comment
EOC.4 Quality control procedures for POCT are recorded
and implemented.
comment
DAS.19 Blood transfusion services are planned, operated and provided NA
uniformly according to applicable laws, regulations and clinical
guideline /protocol.
EOC.1 There is an approved quality manual that addresses
all elements mentioned in the intent from a) through
j).
comment Out of scope.
EOC.2 There is an approved quality manual that addresses
all elements mentioned in the intent from a) through
j).
a) Organization and Management.
b) Resources, Equipment and Supplies
c) Customer needs
d) Process control
e) Documents and records
f) Deviations, nonconformance and complications
g) Donor Assessments
h) Blood screening
i) Process improvements
j) Facilities and safety
comment

40
 EOC.3 Blood transfusion services have suitable space,
environment, equipment and supplies.
comment
EOC.4 Blood transfusion services are monitored by a
licensed
qualified medical staff member.
comment
DAS.20 Blood donation is accepted only from voluntary, non- NA
remunerated, low risk, safe and healthy donors.
EOC.1 The ambulatory healthcare center has an approved
policy that describes all elements mentioned in the
intent from a) through d).
a) Screening based on:
i. Donor’s history of surgeries, vaccination, receiving
blood and donation interval
ii. Donor’s physical examination including general
appearance, height and weight
and vital signs
iii. Blood bag laboratory testing, including specified
communicable diseases,
Blood grouping and RH typing
b) Mechanisms to ensure voluntary non-
remunerated blood donation.
c) Pre-donation counselling by trained staff that
include risk behaviors and self exclusion
for patient safety, tests carried out on donated blood
and potential side
effects. (Questionnaires may be used)
d) Donor safety and privacy
comment Out of scope.
EOC.2 Blood bank staff are aware of the ambulatory
healthcare center policy.
comment
EOC.3 Blood donors are selected safely
comment
EOC.4 Blood donors receive pre-donation counselling.
comment
EOC.5 Blood donor selection and counselling is recorded.
comment
DAS.21 Processes of collection, handling, testing, labelling and storage of NA
blood, and blood components are performed safely and
effectively according to regulations and national requirements.
EOC.1 The ambulatory healthcare center has an approved
policy that describes all elements mentioned in the
intent from a) through d) and based on national
guidelines.
a) Collection:
i. Donation of blood: Donor area cleanliness and
convenience, Donor Reaction

41
 and Outdoor blood donation campaigns.
ii. Infection control precautions.
b) Handling:
i. Identification of blood/blood components bags and
tubes.
ii. Temperature controls.
iii. Transportation of blood.
c) Testing:
i. Determination of ABO group
ii. Determination of Rh(d) type previous records
iii. Laboratory tests for infectious diseases
iv. Quarantine storage
d) Preparation:
i. Sterility
ii. Seal
iii. Blood components preparation instructions and
protocols
comment Out of scope.
EOC.2 Blood and/or blood components are collected and
handled as elements from a) through b) and based
on national guidelines
comment
EOC.3 Blood and/or blood components are tested and
prepared as elements from c) through d) and based
on national guidelines
comment
EOC.4 Blood and /or blood components are labelled and
stored as elements from e) through f) and based on
national guideline
comment
EOC.5 An alarm system and a provision for alternate power
supply is available.
comment
EOC.6 Expired blood or blood components are managed
effectively.
comment
DAS.22 obtaining blood from a blood bank outside the ambulatory NA
healthcare center has a safe and effective process.
EOC.1 The ambulatory healthcare center has an approved
policy that addresses all elements mentioned in the
intent from a) to d).
a) Selection
Selection should be based primarily on quality of
performance
Whenever possible, blood and blood components
are obtained from an accredited
blood bank .
b) Evaluation:
The blood bank should implement an evaluation

42
 process before starting relationship
by assessing blood bank accreditation status,
inspection reports, performing an onsite
visit to the blood bank, or by other means of
evaluation
The blood bank should implement an evaluation
process during the relationship with
the outside blood bank by monitoring and evaluating
certain quality measures
c) Requirements:
A signed document specifying the expectations of
the two parties involved should
be readily available for quick referral. The document
includes at least the following:
i. Scope of Service.
ii. Agreement conditions (including accreditation
status).
iii. Agreement on safe storage and transportation
conditions.
iv. Role of the involved parties in look back and
transfusion transmitted
diseases investigation.
v. Predefined acceptance criteria for each blood
component received.
vi. Release of blood, blood components or
information to the third party.
vii. Mean of solving disputes.
viii. Validity of the agreement and review schedule.
d) Inspection:
ix. Checking for meeting predefined acceptance
criteria for each blood
component received.
x. Evaluation and verification of units’ identification
information including unit
numbers, ABO/Rh-D and Expiration dates.
xi. Conformation of ABO/Rh-D for RBC components.
xii. Actions taken for unsatisfactory blood or blood
component units.
xiii. Evaluation and verification of the transportation
condition of each blood component.
comment Out of scope.
EOC.2 There is a written agreement between the two blood
banks describing the expectations of the two parties
fulfilling items in the intent from i) to xiii).
x. Evaluation and verification of units’ identification
information including unit
numbers, ABO/Rh-D and Expiration dates.
xi. Conformation of ABO/Rh-D for RBC components.
xii. Actions taken for unsatisfactory blood or blood

43
 component units.
xiii. Evaluation and verification of the transportation
condition of each blood component.
comment
EOC.3 Contracted blood bank meets the selection criteria.
comment
EOC.4 Contracted blood bank is evaluated based on
predefined criteria.
comment
EOC.5 Blood bank staff members involved in receiving
blood or blood components from contracted blood
banks are aware of the predefined acceptance
criteria.
comment
EOC.6 Records of inspecting received blood and blood
components support compliance.
comment
DAS.23 Requesting blood and/or blood component services occurs in a NA
safe and effective way.
EOC.1 The ambulatory healthcare center has an approved
policy that describes all elements mentioned in the
intent from a) through g).
a) Assessment of patient’s clinical need for blood.
b) Education of patient and family about proposed
transfusion and recording in the
patient's medical record
c) Selecting blood product and quantity required and
completing the request form
accurately and legibly.
d) Recording the reason for transfusion, so that the
blood bank can check that the pr
oduct ordered is suitable for diagnosis.
e) Clearly communicate whether the blood is
urgently or routinely needed.
f) Sending the blood request form with blood sample
to the blood bank.
g) When recipient's blood sample is received, a
qualified member of the staff should
confirm, if the information on the label and on the
transfusion request form are
identical. In case of any discrepancy or doubt, a new
sample should be obtained.
comment Out of scope.
EOC.2 Blood bank staff members are aware of the
ambulatory healthcare center policy.
comment
EOC.3 Indication for transfusion is recorded in the patient’s
medical record.
comment

44
 EOC.4 Blood bank staff members receive information about
indication of transfusion, clinical information of the
patient and whether the request is needed on
emergency or routine
basis.
comment
EOC.5 Blood sample label and blood transfusion request are
completed with all required data and cross-checked
before issuing blood or blood components
comment
DAS.24 Blood and/or blood components are distributed from the blood NA
bank and transfused safely.
EOC.1 The ambulatory healthcare center has an approved
policy regarding distribution that describes all
elements mentioned in the intent from a) through h).
a) Blood compatibility testing of all whole blood and
red cells transfused.
b) The cross-matching report form should have
patient's first name with surname, age,
sex, identification number, ABO and Rh (D) type.
c) The form should have donor’ unit identification
number, segment number, ABO and
Rh (D) type and expiry date of the blood.
d) Interpretation of cross matching report and the
name of the person performing the
test and issuing the blood should be recorded.
e) Each unit of blood should visually inspected before
distribution. It should not be
distributed if there is any evidence of leakage,
hemolysis or suspicion of microbial
contamination such as unusual turbidity, or change
of color.
In addition, the policy shall include special situations
such as;
f) Conditions for reissuance of blood: when blood
and/or blood components are
returned to blood bank to be reused/reordered.
g) Urgent requirement of blood.
h) Actions to taken when required blood type is not
available.
comment Out of scope.
EOC.2 The ambulatory healthcare center has an approved
policy regarding blood transfusion that describes all
elements mentioned in the intent from I) through
VIII).
I. Visually checking the bag for integrity.
II. Blood transfusion in emergencies
III. Conditions when the bag shall be discarded.
IV. The rate for blood transfusion.

45
 V. Recording the transfusion.
VI. Monitoring and reporting any adverse event.
VII. Special considerations for use of blood
components.
VIII. Management of transfusion complications.
comment
EOC.3 Blood bank staff members are aware of the
ambulatory healthcare center policy.
comment
EOC.4 Cross matching reports show recipient and donor
data.
comment
EOC.5 Blood or blood component bags are checked before
transfusion.
comment
EOC.6 Monitoring of patient condition during transfusion is
recorded in patient’s medical record.
comment
Surgery, Anesthesia, and Sedation (SAS)
SAS
Standar EOC SAS Standard Score
d
SAS.01 Anesthesia, sedation services is provided according to applicable NA There
laws and regulations and clinical guideline/protocol. was
invasive or
surgical
procedure
s
EOC.1 The provision of sedation and anesthesia service
meets the applicable professional practice
guidelines, national laws and regulations.
comment
EOC.2 Sedation and anesthesia services are available to
meet patient needs.
comment
EOC.3 Anesthesia services are standardized and uniformly
implemented throughout the ambulatory healthcare
center.
comment
EOC.4 Ambulatory healthcare center has an approved
protocol for the management of any potential
anesthesia emergencies or complications.
comment
SAS.02 Anesthesia and sedation services are provided under the NA There
direction of a qualified anesthesiologist. was
invasive or
surgical
procedure
s

46
 EOC.1 Clear, specific job description for the anesthesia and
sedation leader is available in the leader’s staff file,
that include items from a) to e) in the intent.
a. Determines the resources required including
staffing, equipment, medications and
medical supplies.
b. Develop all required policies, procedures,
applicable guidelines and protocols
c. Supervise all activities related to anesthesia and
sedation services
d. Evaluates the outcome of anesthesia and sedation
services
e. Perform anesthesia staff ongoing performance
evaluation.
comment
EOC.2 Sedation and anesthesia services are under the
direction of one or more qualified individuals.
comment
EOC.3 The qualified individual (anesthesiologist) is fully
understand and aware of his responsibilities
mentioned in the job description.
comment
SAS.03 A qualified anesthesiologist performs a pre-anesthesia NA There
assessment and preinduction assessment was
invasive or
surgical
procedure
s
EOC.1 The ambulatory healthcare center has an approved
policy of pre-anesthesia and preinduction
assessment that clearly identify when and how those
assessments are performed.
comment
EOC.2 Pre-anesthesia assessment is performed for each
patient to evaluate risk scoring for receiving
anesthesia.
comment
EOC.3 The pre-anesthesia assessment and pre- induction
assessment are recorded separately in the patient’s
medical record.
comment
EOC.4 Pre- induction assessment is performed for each
patient immediately before induction of anesthesia.
comment
EOC.5 Relevant staff is educated and fully aware of how to
apply the policy.
comment
SAS.04 The ambulatory healthcare center ensures performing NA
anesthesia plan for each patients. out of

47
 scope.
EOC.1 Each patient’ anesthesia care plan is performed and
documented in the patient’s medical record.
comment
EOC.2 The anesthesia care plan includes all items from a) to
g) in the intent.
a. Information from the complete patient
assessments and identifies the appropriate
anesthesia to be used,
b. The method of administration,
c. Other medications and fluids needed,
d. Monitoring procedures,
e. Anticipated post anesthesia outcome.
f. The anesthesia agent, and anesthetic technique
g. Signature and full name of participated anesthesia
team shall be documented in medical file.
comment
EOC.3 The anesthesiologist, anesthesia assistants and all
participated team are identified in the patient’s
medical record.
comment
SAS.05 A qualified anesthesiologist performs continuous monitoring of NA
the patient's physiological status during anesthesia. out of
scope.
EOC.1 The frequency and type of monitoring during
anesthesia and surgery is determined according to
item a) through item f) from the intent.
a. Patient's condition and age,
b. Pre-anesthesia assessment
c. Anesthesia plan
d. Type of anesthesia,
e. Type and duration of surgery or invasive
procedure performed
f. The applicable, approved clinical practice
guidelines.
comment
EOC.2 Monitoring of the patient’s physiological status is
consistent with the ambulatory healthcare center
clinical practice guidelines.
comment
EOC.3 The results of monitoring are documented in the
patient’s medical record.
comment
EOC.4 A qualified anesthesiologist performs the anesthesia
monitoring.
comment
SAS.06 Post anesthesia care, monitoring, and discharge is done by NA
competent individual. out of
scope.

48
 EOC.1 The ambulatory healthcare center has an approved
policy of post anesthesia care and monitoring that
clearly describe the process of post-anesthesia care,
assign responsibility and describe the documentation
requirements.
comment
EOC.2 Post-anesthesia care plan documented in the
patient's medical record including items from a) to k)
in the intent.
a) The patient’s physiologic status
b) Time of receiving the patient
c) Used type of anesthesia.
d) Administered medications with dose, route, and
time of administration.
e) Fluid management includes intake and output.
f) Administered blood or blood products.
g) The occurrence of any unusual event.
h) The patient condition before leaving according to
defined criteria
i) Patient disposition
j) Time of transfer from the post-anesthesia care unit
k) Signature of the physician who order patient
discharge or disposition.
comment
EOC.3 The time of patient arrival at and discharge from the
recovery area are documented in the patient’s
medical record.
comment
EOC.4 The ambulatory healthcare center has a clear process
of monitoring, when the patient is transferred
directly from the operating theatre to a receiving
unit.
comment
SAS.07 Sedation administration is standardized throughout the NA There
ambulatory healthcare center, monitoring and management of was
complications is guided by evidence based guidelines. invasive or
surgical
procedure
s
EOC.1 The administration of procedural sedation is
standardized throughout the ambulatory care center.
comment
EOC.2 Procedural sedation is performed by a qualified
individual with advanced life support training
(appropriate for the age of the patient).
comment
EOC.3 All individuals privileged to perform sedation are
trained for items from a) to c) in the intent.
a. Proper use and administration of sedation

49
 techniques and methods.
b. Management of complications that could occur by
providing sedation and the
process followed, if any.
c. Monitoring requirements
comment
EOC.4 The ambulatory healthcare center has a defined
process for the management of sedation
complications. (If any).
comment
EOC.5 The equipment, medications, and medical supplies
needed during the sedation are readily available in
the ambulatory healthcare center.
comment
EOC.6 Established criteria are identified and documented
for the recovery and discharge from procedural
sedation
comment
SAS.08 The pre-sedation assessment is performed by a qualified NA There
individual. was
invasive or
surgical
procedure
s
EOC.1 There is a pre-sedation assessment performed and
documented that includes at least a) through e) in
the intent.
a. Identify any airway problems.
b. Evaluate at-risk patients
c. Plan the type of sedation and the level of sedation
the patient will need based
on the procedure being performed;
d. Safely administer sedation;
e. Interpret findings from patient monitoring during
procedural sedation and recovery.
comment
EOC.2 Pre-sedation assessment is performed and
documented by a qualified individual.
comment
EOC.3 Sedation care plan is performed safely based on
the outcome of pre-sedation assessment.
comment
EOC.4 A copy of sedation records is kept in the patient’s
medical record.
comment
SAS.09 The post- sedation care' unit is safely designed and appropriately NA There
equipped to meet patients’ needs. was
invasive or
surgical

50
 procedure
s
EOC.1 The post-sedation care unit is equipped with the
required resources and equipment.
comment
EOC.2 A competent, trained healthcare provider is
responsible of the post-sedation care.
comment
EOC.3 Staff involved in post- sedation care and plan is
aware of how to perform the post sedation
monitoring.
comment
SAS.10 The ambulatory healthcare center ensures that provision of NA There
surgeries and invasive procedures is effective, safe and was
appropriate to patient’s needs. invasive or
surgical
procedure
s
EOC.1 The ambulatory healthcare center has an approved
policy to guide the surgery and invasive procedures
safe provision that addresses all elements mentioned
in the intent from a) through h).
a) Scheduling process for surgeries and invasive
procedures.
b) Granting clinical privileges to staff to perform
those types of surgeries and invasive
procedures.
c) Recording of surgeries and invasive procedures,
whether they are scheduled,
performed, or canceled.
d) Patients’ identification verification methods.
e) A clear and safe mechanism to call patients for
surgeries or invasive procedures.
f) The recorded timing of all patient flow steps inside
the unit and the analysis of this
punctuality.
g) Analysis of the postponed and canceled surgeries
and invasive procedures to
support the ambulatory healthcare center with
reliable data for better management.
h) Process to verify availability of all required
resources.
comment
EOC.2 Analysis of postponed and canceled procedures is
continuously monitored, reported and acted upon
comment
EOC.3 Punctuality of the procedural unit is maintained and
recorded starting by patient call until room cleaning
after the procedure.

51
 comment
EOC.4 Staff who permitted to perform surgery and invasive
procedure services are qualified and privileged in the
ambulatory healthcare center to perform those types
of surgeries and invasive procedures.
comment
SAS.11 Patient assessment is performed by the responsible physician NA
before surgery or invasive procedure. out of
scope.
EOC.1 A complete pre- surgical assessment is performed
and documented for all patients planned for surgery
or invasive procedure, with documentation of any
identified risks for
the patient’s conditions.
comment
EOC.2 Pre-operative diagnosis and actions taken for the
management of any risk factors are documented in
the patient medical record before surgery or invasive
procedure.
comment
EOC.3 Patient’s plan of surgical care is performed and
timely documented in the medical record.
comment
EOC.4 In life-threatening emergencies, a brief assessment
and surgical care planning is performed and timely
documented in the patient’s medical record.
comment
SAS.12 The ambulatory healthcare center has a pre-operative NA
verification process to ensure patient safety, availability and out of
appropriateness of care before calling for the patient for surgery. scope.
NSR.10 EOC.1 The ambulatory healthcare center has a defined
process for pre-operative verification including all
needed documents and equipment.
comment
EOC.2 Pre-operative verification of all needed documents
and equipment is documented before each surgery
and invasive procedure.
comment
EOC.3 Responsible staff is aware of the pre-operative
verification process.
comment
SAS.13 Time-out is performed pre-operatively, just before starting a NA
surgical or invasive procedure. out of
scope.
NSR.11 EOC.1 The ambulatory healthcare center has an approved
policy for time-out to ensure the correct patient,
procedure, site and side.
comment
EOC.2 When surgery or invasive procedure is performed

52
 outside the operating theatre, Timeout process
implemented.
comment
EOC.3 Time- out is implemented immediately before the
start of surgery or invasive procedure.
comment
EOC.4 The surgery or invasive procedure team is involved in
the time out process
comment
EOC.5 Relevant staff is fully aware and trained for time-out
process.
comment
SAS.14 The ambulatory healthcare center uses an easily noticeable mark NA
for surgical/invasive procedure site identification that is out of
consistent throughout the center. scope.
EOC.1 Surgical/invasive procedure' site marking is done by
the person performing the procedure.
comment
EOC.2 The patient is actively involved in the site marking
process with exception in some circumstances.
comment
EOC.3 The mark is visible after the patient is prepped,
draped, prepared for surgery or procedure.
comment
SAS.15 Details and information about surgery or procedures are NA
recorded in the operative report immediately after the out of
procedure. scope.
EOC.1 The operative/procedure report is readily available
for all patients who underwent a procedure before
leaving the procedural unit.
comment
EOC.2 The operative/procedure report includes at least
items from a) through h) in the intent.
a) Time of start and time of the end of the
procedure.
b) Name of all staff involved in the procedure,
including anesthesia.
c) Pre-procedure and post-procedure diagnoses.
d) The procedure performed with details.
e) The details of any used implantable device or
prosthesis including the batch number
f) The occurrence of complications or not.
g) Any removed specimen or not.
h) Signature of the performing physician.
comment
EOC.3 The report is kept in the patient’s medical record.
comment
SAS.16 Accurate counting of sponges, needles, and instruments pre and NA There
post procedure is verified. was

53
 invasive or
surgical
procedure
s
NSR.12 EOC.1 Counting of sponges, needles, towels, or instruments
is done pre, intra and postoperative by two
independent staff.
comment
EOC.2 There is a record for the preoperative, intraoperative
and postoperative count of sponges, needles, towels,
or instruments.
comment
EOC.3 The performing physician confirmed the process and
signed the count sheet.
comment
SAS.17 Surgically removed tissue is sent to the ambulatory healthcare NA There
center laboratory services for pathological examination unless was
present in the list of exempted tissues from the pathological invasive or
examination. surgical
procedure
s
EOC.1 There is a clear process and pathway of any surgically
removed tissue.
comment
EOC.2 There is a list of exempted tissue from pathological
examination.
comment
EOC.3 Surgically removed tissues are sent for pathological
examination, and the results of the examination are
available in the patient’s medical record within the
defined time- frame.
comment
SAS.18 The ambulatory healthcare center requires special NA There
considerations for surgeries involving implantable devices or was
lenses. invasive or
surgical
procedure
s
EOC.1 There is a list of implantable devices used in the
ambulatory healthcare center.
comment
EOC.2 There is a process for the retrospective tracing of any
implantable device.
comment
EOC.3 There is a process for the recall of a patient who has
an implantable device in a defined time- frame after
receiving the notification of a recall.
comment
SAS.19 Post-operative care plan is performed and recorded before NA There

54
 transfer of patient to the next level of care. was
invasive or
surgical
procedure
s
EOC.1 There is a postoperative care plan for all patients
performing the surgery/procedure that includes
items from a) to h) in the intent.
a. Recent level of care,
b. Patient position,
c. Patient activity,
d. Required further monitoring,
e. Diet,
f. Medications, intravenous fluids,
g. Required investigations
h. Follow up instructions.
comment
EOC.2 The postoperative care plan is documented in the
medical record before patient leaving the procedure
room.
comment
EOC.3 Postoperative plan of care is performed by the
physician who performed the procedure and the
anesthesiologist (when applicable)
comment
Medication Management and Safety (MMS)
MMS
Standar EOC MMS Standard Score
d
MMS.01 Medications available for use are managed, selected, listed, and Met
procured based on approved criteria.
EOC.1 The ambulatory healthcare center has an updating 2
program clearly describes the medication use and
management which is under the direct supervision of
qualified healthcare professional(s).
comment
EOC.2 Updated and appropriate medication-related 2
information sources are available in written and/or
electronic formats to those involved in medication
use.
comment
EOC.3 The ambulatory healthcare center has an approved 2
policy and procedures addressing the criteria of
appropriate selection and procurement of
medications in accordance to the organization's
mission, patient needs and safety.
comment
EOC.4 The ambulatory healthcare center has an approved 2
and updated list of the medications, which covers at

55
 least items from a) to e) in the intent.
a) Name(s) of medication(s)
b) Strength(s)/concentration(s) of medication(s)
c) Dosage form(s) of the medication(s)
d) Indication
e) Expiration date
comment
EOC.5 The ambulatory healthcare center implements and 2
evaluates at least one antimicrobial stewardship
activity in place using organization-approved
interdisciplinary protocols and acts accordingly.
comment
MMS.02 Medications are safely and securely stored in a manner to Met
maintain its quality.
NSR.08 EOC.1 Medications are safely and securely stored under 2
manufacturer/marketing authorization holder
recommendations, are kept clean, and organized all
the time.
comment
EOC.2 The ambulatory healthcare center has well- 2
implemented policy and procedures to ensure that
emergency medications including anesthesia
reversing agents and antidotes are accessible,
securely stored and protected from loss or theft in all
storage areas and are uniformly stored
and clearly arranged and managed.
comment
EOC.3 Psychotropic, and narcotic medications are stored in NA
accordance to the applicable laws and regulations.
comment There was no use for Psychotropic, and narcotic
EOC.4 The ambulatory healthcare center has a process for 2
the handling of multi-dose medications to ensure its
stability and safety.
comment
EOC.5 The ambulatory healthcare center has a clearly 2
implemented process to deal with an electric power
outage to ensure the integrity of any affected
medications before use.
comment
EOC.6 Medications, medication containers, and the 2
components used in their preparation are clearly
labeled (if not apparent on the original packages or
boxes) with elements from a) to e) in the intent.
a) The name,
b) concentration/strength,
c) expiration date,
d) batch number, and
e) any applicable warnings
comment

56
MMS.03 High alert medications and look alike sound alike medications, are Met
managed in a way assures that risk is minimized.
NSR.09 EOC.1 The ambulatory healthcare center has an annually 2
updated list(s) of high alert medications, and
concentrated electrolytes (if available)
comment
EOC.2 The ambulatory healthcare organization has an 2
annually updated list of look-alike sound alike
medications.
comment
EOC.3 The ambulatory healthcare center has uniform 2
process for the safe storage and administration of
high alert medications and concentrated electrolytes
(if available), including separation, and labeling.
comment
EOC.4 The ambulatory healthcare center has a defined 2
process for the safe handling of look-alike sound
alike medications including separation, labeling and
administration.
comment
EOC.5 Responsible staff members are aware of the 2
strategies implemented when managing high alert
medications, concentrated electrolytes (if available)
and look alike sound alike medications
comment
MMS.04 The ambulatory healthcare center has a drug recall system in Met
place.
EOC.1 The ambulatory healthcare center has a drug recall 2
system that includes elements from a) to e) in the
intent.
a) Process to retrieve recalled medications
b) Labelling
c) Separation
d) Disposal or removal
e) Patient notification (when applicable)
comment
EOC.2 The ambulatory healthcare center has an approved 2
policy and procedures in place for removal, storing,
and disposing of expired, damaged, or contaminated
medications.
comment
EOC.3 Recalled medications are clearly labeled and 2
separated according to the manufacturer/marketing
recommendation.
comment
EOC.4 Staff members involved in drug recall process are 2
aware of the drug recall system and the process of
handling of expired medications.
comment

57
MMS.05 Medications are safely ordered and prescribed after proper Met
medication reconciliation.
EOC.1 The ambulatory healthcare center is responsible for 2
identifying those individuals permitted
by law and regulation, qualification, training,
experience, and job description to order/prescribe
medications.
comment
EOC.2 The ambulatory healthcare center has an approved 1
policy and procedure for the safe and complete
medication ordering, and prescribing which covers
items elements form a) to k) in the intent.
a) Patient’s identifications
b) Patient’s demographics
c) Medication name
d) Dosage form
e) Strength or concentration
f) Dosage, frequency, and duration of medication
g) Route of administration
h) Rates of administration (when intravenous
infusions are ordered
i) Indications for use and the maximum frequency
and maximum daily dose (for PRN orders)
j) Date and time of the order
k) Prescriber identification
comment By ten medical records review medication
prescription was include only medication name and
doses in Five out of ten medical records
EOC.3 Psychotropic, and narcotic medications are safely NA
prescribed in accordance to the applicable laws and
regulations
comment There was no Psychotropic, and narcotic use
EOC.4 Medication prescribers compare the list of current 2
medications with the list of medications to be
prescribed and make clinical decisions based on the
comparison.
comment
EOC.5 The ambulatory healthcare center has an 2
implemented structured process to ensure that
accurate medication reconciliation is performed for
all patients on admission to and before
discharge from the ambulatory healthcare center.
comment
MMS.06 All medications are safely and accurately prepared and Met
administered.
EOC.1 The ambulatory healthcare center identifies those 2
individuals, by law and regulation, qualification,
training, experience, and job description, authorized
to prepare and/or administer medications and

58
 admixtures, with or without supervision.
comment
EOC.2 Each prescription/order is reviewed by a trained 2
healthcare professional for completion, accuracy and
appropriateness prior to administration and covers
at least elements from
a) to e) in the intent.
a) Suitability of the medication to the patient’s
characteristics and condition
b) Therapeutic duplication,
c) Real or potential allergies,
d) Major drug interactions, and
e) Potential organ toxicity.
comment
EOC.3 The ambulatory healthcare center has a process to NA
guide the preparation and compounding of sterile
and non-sterile preparations including preparation of
cytotoxic medications (if available).
comment There was no compounding of sterile and non-sterile
preparations including preparation of cytotoxic
medications
EOC.4 All medications prepared in the ambulatory 2
healthcare center are correctly labeled in a
standardized manner with at least the elements from
f) to n) in the intent.
f) Patient identifications (2 unique identifiers)
g) Medication name
h) Strength/concentration
i) Amount
j) Expiration date
k) Beyond use date
l) Directions for use
m) Any special/cautionary instructions
n) Date and time of preparation and the diluent for
all compounded intravenous (IV)
admixtures, and parenteral solutions (if available).
comment
EOC.5 The ambulatory healthcare center has a process 2
covers elements form o) to v) in the intent to ensure
safe medication administration.
o) Right patient
p) Right medication
q) Right time and frequency of administration
r) Right dosage amount and regimen
s) Right route of administration
t) Right reasons/indication of medication therapy.
u) Review if the patient allergic to any medication in
the prescription or order.
v) Provision of information about the medications

59
 that they are going to be given and
the patients are given the chance to ask questions.
comment
EOC.6 Psychotropic, and narcotic medications are prepared NA
and administered in accordance to the applicable
laws and regulations.
comment There was no use for Psychotropic, and narcotic
medications
MMS.07 The ambulatory health care center has a process for both Met
monitoring the medication effects on patients, and detecting,
acting on and reporting of adverse drug events, medication
errors, and near misses.
EOC.1 Effect(s) of medication(s) including actual or 2
potential medication adverse effects on patients
is/are monitored and documented in patient’s record
including the action(s) to be taken in response
comment
EOC.2 Adverse drug events (ADEs) are reported in a manner 2
consistent with the national guidelines using
standardized national format.
comment
EOC.3 The ambulatory healthcare center has clear 2
definitions for medication error(s), and near miss(es)
and implements a process for acting on and
reporting of medication errors, and near misses in a
manner consistent with the national guidelines.
comment

Section 3:
Organization centred standards
Environmental and Facility Safety (EFS)
Standar
EOC EFS Standard Score
d
EFS.01 Ambulatory healthcare center facilities comply with laws, regulations, Met
fire, and national building codes.
EOC.1 The ambulatory healthcare center leadership complies 2
with environmental safety laws, regulations, and
national building codes.
comment
EOC.2 The ambulatory healthcare center maintains basic 2
requirement for development of environment and
facility safety program.
comment
EOC.3 The ambulatory healthcare center has a committee 2
overseeing environmental safety with approved terms of
references.
comment
EOC.4 Environment and facility safety committee meets 2
regularly (at least quarterly) and meeting minutes

60
 including actions taken are recorded.
comment
EOC.5 The ambulatory healthcare center's leadership ensures 2
compliance with external inspection reports and
correction of observations within the required
timeframe.
comment
EFS.02 Fire and smoke safety plan addresses prevention, early detection, PM
response, and safe evacuation in case of fire and/or other internal
emergencies.
NSR.13 EOC.1 The ambulatory healthcare center has an approved fire 1
and smoke safety plan that includes all elements from a)
through j) in the intent.
a) An ongoing risk assessment that will have the
following features:
I. Assesses ccompliance with Civil Defence regulations.
II. Assesses compliance with fire and building codes.
III. Includes fire and smoke separation, areas under
construction and other high-risk areas for
example stores, fuel tanks, kitchens including hoods,
generators, laundry, oxygen supply,
medical gases rooms, electrical control panels, medical
records room, garbage room, etc.
IV. Addresses the safety of all occupants including
patients, families, full time staff, part time staff,
visitors, suppliers, contractors and others.
V. Addresses evacuation for fire and non-fire
emergencies, for example, dangerous gas leakage.
VI. A special risk assessment is performed during
renovation and construction.
b) Early detection of fire and smoke system, including
the central control panel connected to all areas
in ambulatory healthcare centers according to its
functionality, and ensure continuous monitoring
24/7.
c) Fire suppression system such as water system,
automated or manual fire extinguisher.
d) Listing of firefighting and alarm systems includes
maintenance testing, inspection schedule.
e) Availability of safe, unobstructed fire exits, with clear
signage to assembly areas and emergency
light, in addition to other related signage like how to
activate the fire alarm using a fire extinguisher
and hose reel.
f) Inspection of all firefighting and alarm systems should
be in place, and results are recorded with
needed corrective actions.
g) Safe storage and handling of highly flammable
materials.

61
 h) The ambulatory healthcare center should perform
proper annual training and orientation of all staff
in a practical manner to make sure that everyone in the
ambulatory healthcare center can:
I. Demonstrate RACE and PASS.
II. Define who is responsible for medical gas valves shut
off, with alternative oxygen sources in
case of fire.
III. Safely evacuate all occupants.
IV. Provide specific training for the evacuation of high-
risk patients like (Operating theatres,
Dialysis units).
V. Ambulatory healthcare center evacuation’ pathway,
gathering areas, and assembly points.
i) Documentation of all results in a proper way and
repetition according to the training plan.
j) The plan is evaluated annually and, if needed,
according to related performance measures results
or major incidents.
comment there is plan include all items from a) to j) but there
was no diesel fire pump and there was no smoke
containment system included in plan
EOC.2 The ambulatory healthcare center fire alarm, firefighting 1
and smoke containment system are available,
functioning and comply with civil defence requirements.
comment The ambulatory healthcare center fire alarm,
firefighting are available functioning but there was no
diesel fire pump and there was no smoke containment
system and there was no fire detector in the store of
old devices and O2 cylinder
EOC.3 Inspection, testing and maintenance of fire alarm, 1
firefighting and smoke containment systems are
performed and recorded.
comment There is testing and maintenance of fire alarm,
firefighting system but there was no smoke
containment systems
EOC.4 The ambulatory healthcare center provides education 2
for fire response and evacuation to all staff at least once
annually.
comment
EOC.5 The ambulatory healthcare center guarantees safe 2
evacuation processes for all occupants in case of fire
and/or other internal emergencies.
comment
EOC.6 The fire and smoke safety plan is evaluated annually NA
and, whenever indicated, with aggregation and analysis
of necessary data.
comment First accreditation.
EFS.03 The ambulatory healthcare center clinical and non-clinical areas are Met

62
 smoking-free.
EOC.1 The ambulatory healthcare center has an approved 2
policy for a smoking-free environment.
comment
EOC.2 Staff, patients and visitors are aware of the ambulatory 2
healthcare center policy.
comment
EOC.3 Occupants, according to laws and regulations, do not 2
smoke in all areas except designated areas.
comment
EOC.4 The ambulatory healthcare center monitors compliance 2
to smoking-free policy.
comment
EFS.04 Fire drills are performed in different clinical and non-clinical areas, Met
including at least one unannounced drill annually.
NSR.14 EOC.1 Fire drills are performed based on a predefined time 2
interval.
comment
EOC.2 Staff members participate in fire drills at least once 2
annually.
comment
EOC.3 Fire drill results are recorded from a) through e) in the 2
intent.
a) Dates and timings.
b) Staff who participated in the drill.
c) Involved areas.
d) Shifts.
e) Drill evaluation and corrective action plan.
comment
EOC.4 Fire drill results evaluation is performed after 2
performing each drill.
comment
EOC.5 The ambulatory healthcare center plans a corrective 2
action, whenever indicated.
comment
EFS.05 The ambulatory healthcare center plans safe handling, storage, Met
usage and transportation of hazardous materials and waste disposal.
NSR.15 EOC.1 The ambulatory healthcare center develops hazardous 2
material and waste management plan that addresses all
elements from a) through j) in the intent.
Hazardous materials and waste management plan
includes, but is not limited to, the following:
a) A current and updated inventory of hazardous
materials used in the ambulatory healthcare center,
the inventory should include the material name, hazard
type, location, usage, consumption rate,
and responsibility.
b) Material safety data sheet (MSDS) should be available
and includes information such as physical

63
 data, hazardous material type (flammable, cytotoxic,
corrosive, carcinogenic, etc.), safe storage,
handling, spill management and exposures, first aid, and
disposal.
c) Appropriate labeling of hazardous materials.
d) Procedure for safe usage, handling, storage, and
spillage of hazardous materials.
e) Appropriate segregation, labeling, handling, storage,
transportation, and disposal of all categories
of hazardous waste.
f) Availability of required protective equipment and spill
kits.
g) Investigation and documentation of different
incidents such as spill and exposure.
h) Compliance with local laws and regulations,
availability of required licenses, and/or permits.
i) Staff training and orientation.
j) The plan is evaluated and updated annually and/or
when required.
comment
EOC.2 The ambulatory healthcare center ensures staff safety 2
when handling hazardous materials/or waste.
comment
EOC.3 Waste disposal occurs according to laws and regulations. 2
comment
EOC.4 The ambulatory healthcare center ensures safe usage, 2
handling, storage, and labeling of hazardous materials.
comment
EOC.5 The ambulatory healthcare center has an approved 2
document for spill management, Investigation, and
recording of different incidents related to hazardous
materials.
comment
EOC.6 The plan is evaluated and updated annually with NA
aggregation and analysis of necessary data.
comment First accreditation.
EFS.06 A safe work environment plan addresses high-risk areas, procedures, Met
risk mitigation requirements, tools, and responsibilities.
NSR.16 EOC.1 The ambulatory healthcare center has an approved plan 2
to ensure a safe work environment that
includes all elements from a) through g) in the intent.
The safety plan includes at least the following:
a) Proactive risk assessment.
b) Effective planning to prevent accidents and injuries
and minimize potential risks, to maintain safe
conditions for all occupants to reduce and to control
risks.
c) Processes for pest and rodent control.
d) The ambulatory healthcare center identifies potential

64
 risks because of system failure and/or staff
behavior, for example: wet floor; water leakage from the
ceiling beside electrical compartments;
improper handling of sharps; non-compliance to
personal protective equipment in case of working
at heights, cutting, and welding, dealing with high
voltage; and unsafe storage.
e) Regular inspection with documentation of results,
performing corrective actions, and appropriate
follow up.
f) Improvements for long-term upgrading or
replacement.
g) Safety training depending on job hazard analysis.
comment
EOC.2 Staff is aware of safety measure pertinent to their job. 2
comment
EOC.3 Safety measures are implemented in all areas. 2
comment
EOC.4 Safety instructions are posted in all high-risk areas. 2
comment
EOC.5 Safety management plan is evaluated and updated NA
annually with aggregation and analysis of necessary
data.
comment First accreditation.
EFS.07 The ambulatory healthcare center performs a pre-construction risk Met
assessment when planning for construction or renovation.
EOC.1 The ambulatory healthcare center performs a pre- 2
construction risk assessment before any construction or
renovation.
comment
EOC.2 All affected departments are involved in the risk 2
assessment.
comment
EOC.3 The ambulatory healthcare center plans corrective 2
actions whenever indicated.
comment
EOC.4 If a contractor is used, contractors' compliance is 2
monitored and evaluated by the ambulatory healthcare
center.
comment
EFS.08 Security plan addresses security of all occupants and properties Met
including restricted and isolated areas with risk mitigation, control
measures, tools, and responsibilities.
EOC.1 The ambulatory healthcare center has an approved 2
security plan that includes items a) through i) in the
intent.
a) Security risk assessment.
b) Ensuring the identification of patients, visitors, and
staff in the ambulatory healthcare center.

65
 c) Identification of vendors/contractors with the
restriction of their movement within the ambulatory
healthcare center.
d) Vulnerable patients such as the elderly, infants, those
with mental disorders, and handicapped
should be protected from the abuse and above-
mentioned harms.
e) Children should be protected from abduction.
f) Drill for child abduction should be performed at least
annually.
g) Monitoring of remote and isolated areas.
h) Staff training and orientation.
i) The plan is evaluated annually and, if needed,
according to related performance measures results
or major incidents.
comment
EOC.2 Security plan education is provided on at least annually 2
to all staff.
comment
EOC.3 Security measures are implemented including 1
identification of occupants.
comment There is one security member per shift , Camiras were
outside the facility but there was no Camira inside the
facility and camiras monitoring was in the central
department ( Montaz district )
EOC.4 Occupants are protected from harm, such as violence, 2
aggression, infant/child abduction.
comment
EOC.5 Restricted and isolated areas are protected and secured. 2
comment
EOC.6 Security plan is evaluated and updated annually with NA
aggregation and analysis of necessary data.
comment First accreditation.
EFS.09 Medical equipment plan ensures safe selection, inspection, testing, Met
maintenance, and safe use of medical equipment.
NSR.17 EOC.1 The ambulatory healthcare center has an approved 2
medical equipment management plan that addresses all
elements from a) through k) in the intent.
a) Developing criteria for selecting new medical
equipment.
b) Inspection and testing of new medical equipment
upon procurement and on a predefined interval
basis.
c) Training of staff on safe usage of medical equipment
upon hiring upon installation of new
equipment, and on a predefined regular basis by a
qualified person.
d) Inventory of medical equipment including availability,
criticality, and functionality.

66
 e) Identification of critical medical equipment that
should be available for the operator even through
provision of back- up such as life-saving equipment,
ventilator, DC shock.
f) Specialized and critical equipment(s) lists are
identified.
g) Periodic preventive maintenance according to the
manufacturer's recommendations which usually
recommends using tagging systems by tagging dates and
due dates of periodic preventive
maintenance or labelling malfunctioned equipment.
h) Calibration of medical equipment according to the
manufacturer's recommendations and/or its
usage.
i) Malfunction and repair of medical equipment.
j) Dealing with equipment adverse incidents, including
actions taken, backup system, and reporting.
k) Updating, retiring and/or replacing for medical
equipment in a planned and systematic way.
comment
EOC.2 The ambulatory healthcare center has qualified 2
individuals to oversee medical equipment management.
comment
EOC.3 Staff are educated on the medical equipment plan at 2
least annually.
comment
EOC.4 Records are maintained for medical equipment 1
inventory, user training, equipment identification cards,
and company emergency contact, testing on installation,
periodic preventive maintenance, calibration and
malfunction history.
comment Records maintained for medical equipment inventory,
user training, equipment identification cards, and
company emergency contact, but there was no
documentation of testing on the installation and
calibration of X-rays devices and lab devices
EOC.5 The ambulatory healthcare center ensures that only 2
trained and competent people handles the specialized
equipment(s).
comment
EOC.6 The plan is evaluated and updated annually with NA
aggregation and analysis of necessary data.
comment First accreditation.
EFS.10 The ambulatory healthcare center has an approved policy and NA
procedure for managing critical alarms. There
was no
devices
with
clinical

67
 alarm
NSR.18 EOC.1 The ambulatory healthcare center has an approved
policy that addresses all the elements mentioned in the
intent from a) through f).
a) Inventory of critical alarms and their preventive
maintenance.
b) Testing of critical alarm systems.
c) Alarms are tested and activated with appropriate
settings.
d) Priorities for competing alarms, staff members’
authorization for disabling alarms or changing their
settings, and monitoring of response to alarm activation.
e) Staff members’ responsibility, control measures,
assurance measures and remedial action.
f) Alarms are sufficiently audible with respect to
distances and competing for noise within the unit.
comment
EOC.2 All staff members using devices with critical alarms are
aware of the ambulatory healthcare center policy.
comment
EOC.3 Competent individuals are responsible for the
management and use of critical alarms.
comment
EOC.4 Management and the use of critical alarms is safe.
comment
EOC.5 Management and use of critical alarms are recorded
according to policy including evidence of responsible
staff members, responsible company, schedule, agreed
settings, evidence of function, reporting of malfunction,
and remedial action.
comment
EFS.11 Essential utilities plan addresses regular inspection, maintenance, PM
testing and repair.
NSR.19 EOC.1 There is an ambulatory healthcare center approved plan 1
for utility management that includes items a) through i)
in the intent.
a) Inventory of all utility key systems, for example,
electricity, water supply, medical gases, heating,
ventilation and air conditioning, communication
systems, sewage, fuel sources, fire alarm, and
elevators.
b) Layout of the utility system.
c) Staff training on utility plan.
d) Regular inspection, testing, and corrective
maintenance of utilities.
e) Testing of the electric generator with and without a
load on a regular basis.
f) Providing fuel required to operate the generator in
case of an emergency.

68
 g) Cleaning and disinfecting of water tanks and testing of
water quality with regular sampling for
chemical and bacteriological examination with
documentation of the results at least quarterly and/or
more frequently if required by local laws and regulations
or conditions of the source of water.
h) Preventive maintenance plan, according to the
manufacturer's recommendations.
i) The Ambulatory healthcare center performs regular,
accurate data aggregation, and analysis for
example, frequency of failure, and preventive
maintenance compliance for proper monitoring,
updating, and improvement of the different systems.
comment There is plan include items from ( a, b, c, d, h, I but
didn’t include items e, f, g and there was only external
telephone and there was no internal telephones
EOC.2 The ambulatory healthcare center has qualified staff 0
members to oversee utility systems.
comment The utility system overseen by engineer from the
directorate of health affairs but there was qualified
staff member appointed at the facility
EOC.3 Staff are educated on the utility systems plan at least 2
annually.
comment
EOC.4 Records are maintained for utility systems inventory, 2
testing, periodic preventive maintenance and
malfunction history.
comment
EOC.5 Critical utility systems are identified and back up 0
availability is ensured.
comment There was no backup for water and fire water and
electricity
EOC.6 The plan is evaluated and updated annually with NA
aggregation and analysis of necessary data.
comment First accreditation.
EFS.12 Water services are safe and effective. Met
EOC.1 The ambulatory healthcare center has an approved 2
policy that addresses all the elements mentioned in the
intent from a) through e).
a) Routine maintenance and monitoring of water
distribution and treatment systems.
b) Continuing training and education of operators of
water treatment systems.
c) Monitoring of water at all stages (feed, product and
dialysis water).
d) Methods and frequency of measuring microbiological
and chemical contaminants.
e) Maximum allowable concentrations of microbiological
contaminants.

69
 comment
EOC.2 The ambulatory healthcare center has available 2
continuous water supply.
comment
EOC.3 Regular chemical and microbiological analyses for water 2
services and dialysis water are performed and recorded.
comment
EOC.4 The ambulatory healthcare center conducts appropriate 2
corrective actions when needed.
comment
EFS.13 Emergency preparedness plan addresses responding to disasters Met
that have the potential of occurring within the geographical area of
the ambulatory healthcare center.
EOC.1 There is approved ambulatory healthcare center 2
emergency preparedness plan that includes items a)
through h) in the intent.
a) Risk assessment of potential emergencies. Internal
and external disasters, such as heavy rains,
earthquake, floods, hot weather, wars, bomb threats,
terrorist attacks, traffic accidents, power
failure, fire, gas leakage.
b) Risk assessment of potential epidemics and/or
pandemics.
c) Degree of preparedness according to the level of risk.
d) Communication strategies: Internal communication
may be in the form of Clear call tree that
includes staff titles and contact numbers, and External
communication channels may include civil
defence, ambulance center, and police.
e) Clear duties and responsibilities for ambulatory
healthcare center leaders and staff.
f) Identification of required resources such as utilities,
medical equipment, medical, and non-medical
supplies, including alternative resources.
g) Response and recovery procedures:
i. Triaging.
ii. Staff main task is maintained in case of emergencies:
management of clinical activities during a
disaster such as operating theatre and intensive care
units.
iii. Alternative care sites, and back-up utilities.
iv. Safe patient transportation in case of emergency is
arranged by the ambulatory healthcare
center.
h) Drill schedule. The ambulatory healthcare center must
have a drill schedule for emergencies at
least annually and ensure the attendance of staff; Proper
evaluation and recording of the drill
includes, but is not limited to:

70
 i. Scenario of the drill
ii. Observations on: code announcement, timing, staff
attendance, response, communication, triaging,
and clinical management.
iii. Clear corrective actions if needed.
iv. Feedback to the environmental safety committee.
v. Debriefing.
comment
EOC.2 Staff training is performed, tested, and evaluated. 2
comment
EOC.3 The ambulatory healthcare center performs at least one 2
drill annually that includes item (h) in the intent.
h) Drill schedule. The ambulatory healthcare center must
have a drill schedule for emergencies at
least annually and ensure the attendance of staff; Proper
evaluation and recording of the drill
includes, but is not limited to:
i. Scenario of the drill
ii. Observations on: code announcement, timing, staff
attendance, response, communication, triaging,
and clinical management.
iii. Clear corrective actions if needed.
iv. Feedback to the environmental safety committee.
v. Debriefing.
comment
EOC.4 The ambulatory healthcare center demonstrates 2
preparedness for identified emergencies.
comment
EOC.5 The plan is evaluated regularly (at least annually) with NA
aggregation and analysis of necessary data.
comment First accreditation.
Infection Prevention and Control (IPC)
IPC.01 Dedicated and qualified healthcare professional(s) oversees the PM
infection prevention and control activities according to applicable
laws and regulations, national and international
guidelines.
EOC.1 The ambulatory healthcare center has an assigned 2
dedicated IPC team.
comment
EOC.2 The IPC team leader and each member has a defined job 2
description.
comment
EOC.3 The IPC Team members are qualified by certification and 0
education that match their job description
requirements.
comment By related staff personnel file review, there was no
evidence.
EOC.4 The IPC team member(s) effectively communicate with 2
the top management and all other relevant

71
 departments\disciplines.
comment
IPC.02 A comprehensive infection prevention and control program is Met
developed, implemented, and monitored.
EOC.1 The ambulatory healthcare center has a program that 2
include the scope, objectives, expectations, and
surveillance methods.
comment
EOC.2 The program included all areas of the ambulatory 2
healthcare center and covers patients, staff, visitors
according to the scope of ambulatory center.
comment
EOC.3 The IPC. Program includes a training plan for all staff. 2
comment
EOC.4 The ambulatory healthcare center tracks, collects, 2
analyzes, and reports data on its infection control
program.
comment
EOC.5 The ambulatory healthcare center acts on improvement 2
opportunities identified in its infection control program
comment
IPC.03 The ambulatory healthcare center establishes a functioning Met
multidisciplinary IPC committee that meets at least monthly.
EOC.1 There are clear terms of reference for the infection 2
control committee that includes at least from (a) to (d) in
the intent.
a) Setting criteria to define ambulatory healthcare
center associated infections.
b) Surveillance methods and process.
c) Strategies to prevent infection and control risks.
d) Reporting infection prevention and control activities.
comment
EOC.2 The committee meets at least monthly. 2
comment
EOC.3 The committee meetings are recorded. 2
comment
EOC.4 Recommendations taken by the committee are 2
implemented and followed up at the end of each
meeting.
comment
IPC.04 The ambulatory healthcare center identifies the procedures and Met
processes that are associated with an increased risk of infection.
EOC.1 The ambulatory healthcare center has a process that 2
identify departments, services, procedures with
increased potential risk of infection.
comment
EOC.2 Responsible staff is aware of process implemented for 2
risk identification, mitigation and reporting.

72
 comment
EOC.3 The ambulatory healthcare center tracks, collects, 2
analyzes, and reports data of infection risk assessment
and analysis.
comment
EOC.4 The ambulatory healthcare center acts on improvement 2
opportunities identified in its infection assessment and
analysis process
comment
IPC.05 Evidence-based hand hygiene guidelines are adopted and Met
implemented throughout the ambulatory healthcare center to
prevent healthcare-associated infections.
NSR.03 EOC.1 The ambulatory healthcare center has an approved hand 2
hygiene policies and procedures based on evidence-
based guidelines.
comment
EOC.2 Healthcare professionals are trained on how to apply 2
this policy.
comment
EOC.3 Hand hygiene posters are displayed in required areas, as 2
per center policy.
comment
EOC.4 Hand hygiene facilities are available in numbers and 2
places, as per center policy.
comment
EOC.5 Compliance of healthcare professionals with hand 2
hygiene policy is monitored.
comment
EOC.6 Results of staff compliance are linked and documented 2
in staff appraisal\ evaluation process
comment
IPC.06 Standard precautions measures and the minimum infection Met
prevention practices apply in any settings where healthcare is
delivered.
EOC.1 The ambulatory healthcare center has PPE that is easily 2
accessible and available
comment
EOC.2 Selection and use of PPE are based on the risk 2
assessments that are performed at the points of care
and according to the patient’s suspected infection
comment
EOC.3 Responsible staff is aware of PPE proper use and 2
disposal
comment
IPC.07 Respiratory hygiene is implemented as an element of standard Met
precautions.
EOC.1 Respiratory hygiene /cough etiquette posters are 2
displayed at appropriate places.

73
 comment
EOC.2 Resources such as tissues and surgical masks are 2
available in numbers matching patients’ and staff
members’ needs.
comment
EOC.3 Ambulatory healthcare centers designate space for 2
patients with suspected respiratory infections to
separate them from others.
comment
EOC.4 Patients with suspected respiratory infections are 2
identified and placed in designated areas.
comment
IPC.08 The ambulatory healthcare center ensures safe injection practices. Met
EOC.1 Intravenous bottles/bags, single use fluids infusion 2
/administration sets (e.g., tubing and connections) are
disposed directly in-between patients
comment
EOC.2 Use of multi-dose vials is done in accordance to the 2
manufacturers’ recommendations to ensure that vials
are remain free from contamination.
comment
EOC.3 The ambulatory healthcare center ensures that all staff 2
has trained and aware of safe injection practices.
comment
IPC.09 Environmental cleaning activities are aligned with current evidence- PM
based guidelines.
EOC.1 Cleaning activities with determined times are listed for 1
each area and include all elements mentioned in the
intent from a) through c).
a) Activities to be done every day.
b) Activities to be done every shift.
c) Deep cleaning activities
comment By observation the required lists are posted in five out of
ten areas.
EOC.2 Responsible staff is trained on the process of 0
environmental cleaning activities that include;
availability,
accessibility, use of disinfectant, and spill kits.
comment By related document review, there was no training
evidence.
EOC.3 Disinfectants selection and cleaning methods used are 2
matched the requirements of each cleaning area.
comment
IPC.10 Current evidence-based aseptic techniques are followed during all Met
medical procedures.
EOC.1 The ambulatory healthcare center has an approved 2
policy for aseptic techniques that define items from a) to
c) in the intent.
a) Surgical asepsis is the use of a sterile technique to

74
 prevent the transfer of any organisms from
one person to another or from one body site to another.
The goal of the sterile technique is to
maintain the microbe count at an irreducible minimum.
b) Surgical aseptic technique outside of the operating
room refers to a practice in a setting
outside the operating room that may not have the
capacity to follow the same strict level of
surgical asepsis applied in the operating room. However,
the goal to avoid infection remains in
all clinical settings.
c) Medical asepsis, or clean technique refers to practice
interventions that reduce the number of
microorganisms to prevent and reduce transmission risk
from one person (or place) to another.
comment
EOC.2 Healthcare professionals are trained on how to 2
implement the aseptic techniques, as relevant to their
jobs.
comment
EOC.3 Choice of the level of antisepsis are based on the IPC. 2
Risk assessment and analysis.
comment
IPC.11 Patients with clinically suspected and/or confirmed communicable Met
diseases follow isolation precautions according to probable mode(s)
of transmission.
EOC.1 The ambulatory healthcare center has an approved 2
policy to guide transmission-based precautions.
comment
EOC.2 Healthcare professionals are trained and aware of the 2
approved policies.
comment
EOC.3 Standardized isolation room(s) and assigned areas for 2
suspected infectious patient is designated according to
the center capacity and the national laws and
regulations.
comment
EOC.4 Patients with suspected/ confirmed clinical 2
communicable diseases are identified and separated in
separate assigned areas/rooms
comment
EOC.5 Healthcare professionals caring for patients with a 2
suspected communicable disease are adherent to
suitable PPE and hand hygiene practices according to the
type of isolation.
comment
IPC.12 A safe and protective environment is provided to NA
immunocompromised hosts depending on their clinical needs.
EOC.1 The ambulatory healthcare center has an approved

75
 policy of protective environment for
immunocompromised hosts to define items from a) to c)
in the intent.
a. the protective environment shall be provided for
immunocompromised patients including positive
pressure,
high-efficiency particulate absorption-filtered air
handling as well as Legionella-free water
supply.
b. Required training of responsible staff including, taking
care of these patients, use of standard
precautions as well as transmission-based precautions
conditions\ situations.
c. Signage locations and positions, it is preferred to be
prominently outside the room of a patient in
transmission-based precautions. This is to ensure staff
and visitors do not enter without appropriate
PPE.
Comment Out of scope.
EOC.2 Responsible staff is aware and trained on transmission-
based precautions.
Comment
EOC.3 Facility design supports the provision of a safe
environment for immunocompromised hosts
comment
EOC.4 Signage is positioned prominently outside the room of a
patient in transmission-based precautions.
Comment
EOC.5 Transmission-based precautions are performed as per
center policy.
Comment
IPC.13 Patients care equipment are disinfected/sterilized based on Met
evidence-based guidelines and manufacturer recommendations.
EOC.1 The ambulatory healthcare center has an approved 2
policy to guide the process of disinfection and
sterilization that addresses all elements in the intent
from a) through g).
a. Receiving and cleaning of used items.
b. Preparation and processing.
i. Processing method to be chosen according to
Spaulding classification. Disinfection
of medical equipment and devices involves low,
intermediate, and high-level
techniques. High-level disinfection is used (if sterilization
is not possible) for only
semi-critical items that come in contact with mucous
membranes or non-intact skin
as gastrointestinal endoscopes, respiratory and
anesthesia equipment,

76
 bronchoscopes, and laryngoscopes etc. Chemical
disinfectants approved for highlevel
disinfection include glutaraldehyde, ortho-phtaldehyde
(OPA), and hydrogen
peroxide.
ii. Sterilization must be used for all critical and heat-
stable semi-critical items.
iii. Low-level disinfections (for only non-critical items)
are used for items such as
stethoscopes and other equipment that touching intact
skin. In contrast to critical and
some semi-critical items, most non-critical reusable
items may be decontaminated
where they are used and do not need to be transported
to a central processing area.
c. Labeling of sterile packs.
d. Storage of clean and sterile supplies: properly stored
in designated storage areas that are
clean, dry, and protected from dust, moisture, and
temperature extremes. Ideally, sterile
supplies are stored separately from clean supplies, and
sterile storage areas must have
limited access.
e. Logbooks are used to record the sterilization process.
f. Inventory levels.
g. Expiration dates for sterilized items.
comment
EOC.2 Healthcare professionals are trained on the approved NA
policy.
comment Out sourced service.
EOC.3 Sterilization or disinfection process is performed NA
according to the national laws and regulations, Spaulding
classification, and manufacturer’s
requirements\recommendations.
comment Out sourced service.
EOC.4 Clean and sterile supplies are properly stored in 2
designated storage areas that are clean, dry and
protected from dust, moisture, and temperature
extremes.
comment
IPC.14 A disinfection/sterilization quality control program is developed and NA
implemented
EOC.1 The ambulatory healthcare center has an approved
policy describing the quality control process of
disinfection/sterilization process addressing all elements
in the intent from a) through e).
a) Quality control elements, method and frequency
include
i.Physical parameters (temperature, time, and pressure),

77
 which are monitored every cycle.
ii. Chemical parameters (internal chemical indicator
inside the sterilization pack- external chemical
indicator on the outside of the sterilization pack), which
are monitored every pack.
iii.Biological indicator, which is done at least weekly.
iv.The test for adequate steam penetration and rapid air
removal shall be done every day before
starting to use the autoclave using Class 2 internal
chemical indicators and process challenge
devices, which is either porous challenge device or
hollow challenge device.
v. Porous challenge Pack: Bowie-Dick Sheets (class 2
indicator) inside a porous challenge pack
(every load). Hollow load challenge (Helix test): a class 2
chemical indicator (strip) inside a helix
(every load).
vi.Chemical test strips or liquid chemical monitors shall
be used for determining whether an
effective concentration of high-level disinfectants is
present despite repeated use and dilution.
The frequency of testing shall be based on how
frequently these solutions are used.
b) Quality control performance expectations and
acceptable results shall be defined and
readily available to staff so that they will recognize
unacceptable results to respond appropriately.
c) The quality control program is approved by the
designee prior to implementation.
d) Responsible authorized staff member reviews Quality
Control results at a regular interval.
e) Remedial actions taken for deficiencies identified
through quality control measures and
corrective actions taken accordingly.
Comment Out sourced service.
EOC.2 Quality of packaging material, as well as chemical and
biological indicators, are determined based on
standardized product specifications.
Comment
EOC.3 Staff who involved in sterilization/disinfection are
competent in quality control performance.
Comment
EOC.4 Quality control tests for monitoring sterilization and
high-level disinfectants are done regularly as per
center policy.
Comment
EOC.5 Corrective action is taken whenever results are not
satisfactory.
Comment

78
IPC.15 Laundry service and healthcare textile management are safe. Met
EOC.1 The ambulatory healthcare center has an approved 2
policy to guide the safe laundry and healthcare textile
services management that addresses all elements in the
intent from a) through f).
a) Processes of collection and storage of contaminated
textiles.
b) Cleaning of contaminated textiles.
c) Number of washing machines needed according to
center capacity.
d) Water temperature, detergents, and disinfectants
usage.
e) Processes of storage and distribution of clean textile.
f) Quality control program (temperature, amount of
detergents and disinfectants used, and maintenance) for
each washing machine.
comment
EOC.2 Staff members involved in laundry and health textile 2
management are aware of the approved policy.
comment
EOC.3 Contaminated textile is collected, stored, and 2
transported safely.
comment
EOC.4 There are a least three physically separated areas for NA
sorting, washing, and drying, and/or storing of laundry.
comment Out sourced service.
EOC.5 A quality control program, including water NA
temperatures, is implemented, and recorded.
comment Out sourced service.
IPC.16 Healthcare-associated infections surveillance processes and Met
outbreak investigations are implemented.
EOC.1 The ambulatory healthcare center has an approved 2
policy to guide the surveillance process.
comment
EOC.2 Responsible staff is trained on how to apply the policy. 2
comment
EOC.3 The ambulatory healthcare center has an approved 2
process for outbreak investigations.
comment
EOC.4 Outbreak management includes immediate control 2
measures, general control measures, and recovery
measures.
comment
EOC.5 Data collected from the surveillance program is 2
analyzed, investigated and acted upon
comment
IPC.17 Multi-drug resistant organisms (MDROs) are controlled. Met
EOC.1 The ambulatory healthcare center has an approved 2
policy for MDRO spread control.

79
 comment
EOC.2 Healthcare professionals are fully aware and trained on 2
the approved policy.
comment
EOC.3 Measures are taken to control MDRO infection spread 2
comment
Organization Governance and Management (OGM)
OGM.01 The ambulatory healthcare center has a governing body structure Met
with identified responsibilities.
EOC.1 The ambulatory health care center has an approved 2
policy that define the structure, responsibilities and
accountabilities of the governing body that include items
from a) to g) in the intent.
a. Developing and disseminating the mission statement
b. Developing and achieving the strategic plan
c. Developing the operational plan and budget
d. Promoting and supporting the quality management,
patient safety and risk management
programs, performance improvement plan
e. Allocating resources and effective financial planning
f. Promoting and monitoring safety culture activities and
reports.
g. Responsiveness to internal and regulatory inspection
reports.
comment
EOC.2 The ambulatory healthcare center has a vision and 2
mission statement approved by the governing body and
are visible in public areas to staff, patients and visitors.
comment
EOC.3 There is defined process of communication between the 2
governing body and the ambulatory healthcare center’
leaders and staff.
comment
EOC.4 Staff is aware of the methods for the flow of orders 2
through the approved line of authority.
comment
OGM.02 The ambulatory health care center appoints a qualified director Met
responsible to manage the center.
EOC.1 There is a qualified, trained director managing the 2
ambulatory healthcare center.
comment
EOC.2 There is a job description for the ambulatory healthcare 2
center director covering the standard requirements from
a) through h) as in the intent.
a) Providing oversight of day-to-day operations.
b) Ensuring clear and accurate posting of the ambulatory
healthcare center’s services and hours of
operation to the community.
c) Ensuring that policies and procedures are developed,

80
 implemented by leaders, and approved by
the governing body.
d) Providing oversight of human, non-human and
financial resources.
e) Annual evaluation of the performance of the
ambulatory healthcare center’s committees and
meeting minutes.
f) Ensuring appropriate response to reports from any
inspecting or regulatory agencies, including
national or international accreditation.
g) Ensuring that there is a functional, organization-wide
program for performance improvement,
patient safety, and risk management with appropriate
resources.
h) Regular reports to the governing body on how legal
requirements are being met.
comment
EOC.3 The ambulatory healthcare center has an approved 2
policy for committee types and formulation that include
elements from I) to III) in the intent.
I . Terms of references that include its membership,
duties, accountability/reporting, frequency of
meeting, quorum, and baseline agenda.
II. Meeting minutes’ documentation requirements and
responsibility.
III. Type of committee according to center scope of
services. The ambulatory healthcare center has
at least the following committees:
i. Environmental safety committee
ii. Infection control committee
iii. Pharmacy and therapeutic committee
iv. Performance improvement and patient safety
committee
v. Mortality and Morbidity Committee
comment
EOC.4 There is evidence of delegation of authority, when 2
needed.
OGM.03 The responsibilities and accountabilities of the ambulatory Met
healthcare center leaders are identified.
EOC.1 The ambulatory healthcare center leaders are identified 2
based on the service provided, and their
accountabilities are described in written documents and
includes at least items from a) through d) in the intent.
a. Sustaining firm ambulatory healthcare center
structure:
i. Planning for upgrading or replacing systems, buildings,
or components needed for
continued, safe, and effective operation.
ii. Collaboratively developing a plan for staffing the

81
 ambulatory healthcare center that
identifies the numbers, types, and desired qualifications
of staff.
iii. Providing appropriate facilities and time for staff
education and training.
iv. Ensuring all required policies, procedures, and plans
have been developed and
implemented.
v. Providing adequate space, equipment, and other
resources based on strategic and
operational plans and needed services.
vi. Selecting equipment and supplies based on defined
criteria that include quality and
cost-effectiveness.
b. Running smooth directed operations:
i. Creating “Just culture” for reporting errors, near
misses, and complaints, and use the
information to improve the safety of processes and
systems.
ii. Designing and implementing processes that support
continuity, coordination of care,
and risk reduction.
iii. Ensuring that services are developed and delivered
safely according to applicable
laws and regulations and approved organization
strategic plan with input from the
users/staff.
c. Continuous monitoring and evaluation:
i. Ensuring that all quality management and patient
safety activities is implemented,
monitored, and action is taken when necessary.
ii. Ensuring the ambulatory healthcare center meets the
conditions of facility inspection
reports or citations.
iii. Annually assessing the operational plans of the
services provided to determine the
required facility and equipment needs for the next
operational cycle.
iv. Annually reporting to the ambulatory healthcare
center governing body or authority
on system or process failures and near misses, and
actions had taken to improve
safety, both proactively and in response to actual
occurrences.
d. Continuous Improvement.
Data from all over the ambulatory healthcare center
shall collected, reviewed, analyzed,
and reported to the upper management in order to
determine the opportunities of

82
 improvement through an effective data driven decision-
making.
comment
EOC.2 The ambulatory healthcare center leaders are educated 2
in the concepts of quality improvement and patient
safety plans.
comment
EOC.3 Ambulatory healthcare center leaders are fully aware of 2
their written responsibilities.
comment
OGM.04 The ambulatory health care director together with governing body PM
and leaders develop the center’s scope of services based on
community needs.
EOC.1 The ambulatory health care center has an approved 2
scope of services provided.
comment
EOC.2 Methods exist for conducting the community needs 2
assessment
comment
EOC.3 The ambulatory health care center governing body, 0
leaders perform, and update the community
needs assessment (at least annually).
comment By document review and staff interview there was no
community need assessment.
EOC.4 The ambulatory health care center scope of services is 0
matched to the current community needs assessment.
comment Based on the above.
OGM.05 A strategic plan is developed under oversight and guidance of the Met
governing body.
EOC.1 The ambulatory healthcare center has a strategic plan 2
with defined achievable timeline for each desired
goal/ outcome.
comment
EOC.2 The strategic plan includes the broad goals and 2
objectives required to fulfill the center’s mission.
comment
EOC.3 The strategic plan addresses all clinical and non-clinical 2
services and programs.
comment
EOC.4 There are progress review reports to monitor the NA
strategic plan at least annually.
comment First accreditation.
OGM.06 Operational plans are developed to achieve the strategic plan goals Met
and objectives, with inputs from staff, service providers, and other
stakeholders.
EOC.1 The ambulatory healthcare center has operational plans 2
that include a) to e) in the intent.
a) Clear goals and objectives (in line with the center’s

83
 strategic plan).
b) Specific activities and tasks for implementation.
c) Timetable for implementation.
d) Assigned responsibilities.
e) Sources of the required budget and resources.
comment
EOC.2 Staff is aware and actively participate in designing for 2
the operational plans.
comment
EOC.3 The plans are communicated throughout the ambulatory 2
healthcare center.
comment
EOC.4 The governing body approves resources that required 2
for the operational plans implementation.
comment
EOC.5 There are progress review reports to monitor the NA
operational plans at least annually.
comment first accreditation.
OGM.07 The ambulatory healthcare center has effective supply chain Met
management.
EOC.1 The ambulatory health care center has an approved 2
policy of supply chain management that addresses all
elements from a) through f).
comment
EOC.2 Supplies are monitored and evaluated to ensure 2
matching with the pre-defined acceptance criteria that
determined in center’s policy.
comment
EOC.3 Critical supplies are identified and clear processes are 2
followed in case of shortage.
comment
EOC.4 Basic information is recorded for stock items as 2
mentioned from i) through iii) of item f) in the intent.
I. Compliance with the applicable laws, regulations, and
organization policies
i. Compliance of the stocks management with the safe
storage strategies that require at least the
following records for stock items: date received, lot
number, expiration date, date of disposition,
if not used.
II. Identify and tracking the use of critical resources and
supplies.
comment
OGM.08 The ambulatory healthcare center manages the patient billing Met
system.
EOC.1 The ambulatory healthcare center has an approved 2
policy for billing patients that include items from a) to e)
in the intent.
a) Availability of an approved price list for services

84
 provided to patients and their sponsors.
b) Patients and families are informed of an initial
estimated cost of required services and any potential
cost pertinent to the planned care.
c) Process to ensure that patients and families are
obtained an accurate invoice for services
rendered.
d) Use of the approved codes for diagnoses,
interventions, and diagnostics, if applicable.
e) Payment methods. e.g. itemized bill, package deal.
comment
EOC.2 In the case of a third-party payer (or health insurance), NA
the timeliness of approval processes is monitored.
comment There was no history of a third-party payer.
EOC.3 Responsible staff is fully aware of the various health 2
insurance processes and different payment methods.
comment
OGM.09 The ambulatory healthcare center implements a process for Met
selection, evaluation, and continuously monitoring contracted
services.
EOC.1 The ambulatory care center has a documented process 2
that describe the nature and scope of the services
provided through a contractual agreement, including all
outsources clinical and non-clinical services.
comment
EOC.2 The ambulatory healthcare center has a documented 2
process for contract monitoring and evaluation.
comment
EOC.3 The performance measures for monitoring contracted 2
services are integrated into the center performance
improvement and patient safety plan.
comment
EOC.4 Significant results of contract monitoring is reported to 2
center leaders.
comment
EOC.5 If contracts are terminated, the ambulatory healthcare NA
center has a clear process to maintain the
continuity of patient care.
comment There was no history.
OGM.10 The ambulatory healthcare center leaders create and support a Met
culture of safety and quality within the ambulatory healthcare
center.
EOC.1 The ambulatory healthcare center has an approved 2
policy of safety culture that include elements from a) to
d) in the intent.
a. Identification of the high-risk activities and persistence
to achieve safe operations;
b. Deploy an environment in which staff is able to report
errors/ incidents without fear of blame

85
 or punishment
c. Encourage all disciplines and staff to highlight their
patient safety problems and trying to find
a suitable solutions for it.
d. Commitment of leaders to perform regular safety
rounds.
comment
EOC.2 Leaders provide all required resources needed to 2
promote and support the culture of safety.
comment
EOC.3 There is evidence that leaders participate in safety 2
rounds on an- ongoing basis.
comment
EOC.4 All staff is fully aware of how to apply the safety culture 2
policy.
comment
OGM.11 The ambulatory healthcare center ensures positive workplace Met
culture.
EOC.1 The ambulatory healthcare center has an approved 2
policy for positive workplace culture, addresses at
least item a) to f) in the intent.
a) Workplace cleanliness, safety and security measures
b) Management of workplace violence, discrimination,
and harassment
c) Communication channels between staff and
ambulatory healthcare center leaders
d) Staff feedback measurement
e) Planning for staff development
f) Planning to maintain the staff healthy lifestyle.
comment
EOC.2 The workplace is clean, safe, and security measures are 2
implemented.
comment
EOC.3 Measures of workplace violence, discrimination, and 2
harassment are implemented.
comment
EOC.4 Staff feedback and satisfaction are measured and 2
periodically analyzed.
comment
OGM.12 The ambulatory healthcare center establishes appropriate ethical Met
management.
EOC.1 The ambulatory healthcare center has an approved 2
policy for ethical management that addresses
at least a) to f) in the intent.
a) Developing and implementing the code of ethics
b) Developing and implementing of ambulatory
healthcare center values
c) Handling medical errors and medico-legal cases
d) Managing clinical research

86
 e) Identifying conflict of interest
f) Gender equality
comment
EOC.2 All Staff is aware of how to apply the policy. 2
comment
EOC.3 The ambulatory healthcare center has a process for 2
addressing ethical concerns that may arise,
within a pre-determined time-frame as per center’s
policy.
comment
OGM.13 The ambulatory healthcare center has an effective staff health Met
program in accordance with the applicable laws and regulations.
EOC.1 There is an approved ambulatory healthcare center’s 2
staff health program that cover a) through j) in the
intent.
a) Pre-employment medical evaluation of new staff
b) Periodic medical evaluation of staff members
c) Screening for exposure and/or immunity to infectious
diseases.
d) Exposure control and management to work-related
hazards
I. Ergonomic hazards that arise from the lifting and
transfer of patients or equipment, strain,
repetitive movements, and poor posture
II. Physical hazards such as lighting, noise, ventilation,
electrical and others
III. Biological hazards from blood borne and airborne
pathogens and others
e) Staff education on the risks within the ambulatory
healthcare center environment as well as on their
specific job-related hazards.
f) Staff preventive immunizations.
g) Recording and management of staff incidents (e.g.,
injuries or illnesses, taking corrective actions,
and setting measures in place to prevent recurrences).
h) A pre-employment medical examination is required
for all employees’ categories to evaluate their
appropriateness for safe performance, and staff that is
exposed to certain hazards, as radiation
should have periodic specific medical evaluation (tests
and examinations). The situational
examination may be required in case of exposure to
specific substances. Results of the medical
evaluation are documented in staff health records, and
action is taken when there are positive
results, including employee awareness of these results
and provision of counseling and
interventions as might be needed.
i) Infection control staff shall be involved in the

87
 development and implementation of the staff health
program as the transmission of infection is a common
and serious risk for both staff and patients in
healthcare facilities.
j) All staff occupational health program-related results
(medical evaluation, immunization, work
injuries) shall be documented and kept according to laws
and regulation
comment
EOC.2 There is an occupational health risk assessment that 2
defines occupational risks within the ambulatory
healthcare center.
comment
EOC.3 Staff members are educated about the risks within the 2
ambulatory healthcare center environment, their
specific job-related hazards, and periodic medical
examination.
comment
EOC.4 All staff members are subjected to the immunization 2
program and to work restrictions according to the
approved ambulatory healthcare center guidelines.
comment
EOC.5 All test results, immunizations, post-exposure 2
prophylaxis and interventions are recorded in the staff’s
health record.
comment
EOC.6 There is evidence of taking action and informing NA
employees in case of positive results.
comment There was no history.
OGM.14 Ambulatory health care services are planned in line with Met
international, national, regional, or local community initiatives.
EOC.1 All ambulatory health care center plans reflect alignment 2
with international, regional, and/or national community
initiatives.
comment
EOC.2 All staff is aware of the community involvement plan and 2
initiatives.
comment
EOC.3 Community involvement plan is updated periodically to 2
meet the needs of the community.
comment
WorkForce Management (WFM)
WFM.01 Workforce recruitment, education, training, and appraisal processes Met
comply with laws and regulations.
EOC.1 The ambulatory healthcare center has an approved 2
policy for staff files that addresses at least elements
from a) through f) in the intent.
a) Staff file initiation
b) Standardized contents such as;

88
 I. Verified certification, license, education, training and
work history,
II. Current job description,
III. Recorded general orientation to the ambulatory
healthcare center, the assigned
department, and the specific job orientation,
IV. Evidence of initial (pre-employment) evaluation, to
ensure that the staff member able to
perform the assigned job,
V. Ongoing In-service education received,
VI. Copies of the first three months’ evaluations and
copies of annual evaluations
VII. Any required health information.
c) Update of file contents
d) Storage
e) Retention time
f) Disposal
comment
EOC.2 Staff files are standardized, current, maintained and kept 2
confidential according to ambulatory healthcare center
policy.
comment
EOC.3 Staff files contains all elements listed in the point (b) 2
from the intent.
I. Verified certification, license, education, training and
work history,
II. Current job description,
III. Recorded general orientation to the ambulatory
healthcare center, the assigned
department, and the specific job orientation,
IV. Evidence of initial (pre-employment) evaluation, to
ensure that the staff member able to
perform the assigned job,
V. Ongoing In-service education received,
VI. Copies of the first three months’ evaluations and
copies of annual evaluations
VII. Any required health information.
comment
EOC.4 Responsible staff is aware of the staff file management 2
policy and procedures.
comment
WFM.02 Ambulatory healthcare center develops a staffing plan to ensure that Met
provided services meet the needs of safe patient care.
EOC.1 Staffing plan matches the mission, strategic and 1
operational plans
comment Staffing plan matches the mission, strategic and
operational plans, but there was shortage in three
physicians, one radiology technician, and adminstartive
staff

89
 EOC.2 Staffing plan complies with recommendations of 2
professional practices
comment
EOC.3 Staffing plan identifies the estimated needed staff 2
numbers including independent practitioners and skills
with staff assignments to meet the ambulatory
healthcare center needs.
comment
EOC.4 The staffing plan is reviewed at least annually. NA
comment First accreditation.
WFM.03 Ambulatory healthcare center develops job descriptions to address Met
each position requirements and responsibilities.
EOC.1 There is current job description for every position and 2
recorded in the staff’s file.
comment
EOC.2 Job descriptions include the all-necessary requirements 2
as described by the ambulatory healthcare center.
comment
EOC.3 All staff is aware of their job description specifications 2
and requirements.
comment
WFM.04 The ambulatory healthcare center implements an effective process PM
to verify credentials of all staff members.
EOC.1 There is a process for verifying credentials of all staff in 2
the ambulatory healthcare center.
comment
EOC.2 Required credentials for each position are identified and 0
available in each staff file (including independent
practitioners’ files).
comment Credentials of pharmacists but physicians, and nursing
was in process
EOC.3 Actions are taken and documented when credentials 2
cannot be verified.
comment
WFM.05 Appointed, contracted, and outsourced staff undergo a formal Met
orientation program.
EOC.1 General orientation program is performed and it 2
includes at least the elements from a) through c).
comment
EOC.2 Department orientation program is performed and it 2
includes at least the elements from d) through f).
comment
EOC.3 Job specific orientation program is performed and it 2
includes at least the elements from g) through i).
comment
EOC.4 Any staff member attends orientation program 2
regardless of employment terms.
comment

90
 EOC.5 Orientation completion is recorded in the staff file. 2
comment
WFM.06 A continuing education and training program is developed and Met
implemented.
EOC.1 There is a continuing education and training program for 2
all staff categories that may include elements
in the intent from a) through m).
a) Patient assessment
b) Infection control policy and procedures, needle stick
injuries and exposures
c) Environment safety plans
d) Occupational health hazards and safety procedures,
including the use of personal protective
equipment
e) Information management, including patient’s medical
record requirements as appropriate to
responsibilities or job description
f) Pain assessment and treatment
g) Clinical guidelines used in the ambulatory healthcare
center
h) Valid Basic cardiopulmonary resuscitation training for
all staff that provides direct patient care
i) Quality concept, performance improvement, patient
safety, and risk management.
j) Patient rights, Patient satisfaction, and the complaint/
suggestion process.
k) Provision of integrated care, shared decision making,
informed consent, interpersonal
communication between patients and other staff
cultural beliefs, needs and activities of different
groups served
l) Defined abuse and neglect criteria
m) Medical equipment and utility systems operations
and maintenance
comment
EOC.2 Resources needed to deliver the program are identified 2
in the education and training program.
comment
EOC.3 The program is based on needs assessment of all staff. 2
comment
EOC.4 Results of a performance review are integrated into 2
program design.
comment
WFM.07 Staff performance and competency are regularly evaluated. Met
EOC.1 Performance evaluation is performed at least annually 2
for each staff member and linked to the education and
training provided.
comment
EOC.2 Performance evaluation records for medical staff 0

91
 members include at least all elements from a) through e)
in the intent
a. Patient’s medical record review for completeness and
timeliness.
b. Utilization practice and medication use.
c. Compliance with approved clinical guideline
d. Complications, outcomes of care, mortality, and
morbidity
e. Professional development
comment By for medical staff members files review, the evaluation
form didn’t include items from a) to e)
EOC.3 Performance evaluation is performed based on the 2
current job description.
comment
EOC.4 Clear procedures for the effective management of 2
underperformance.
comment
EOC.5 There is evidence of employee feedback on performance 2
and competency evaluation
comment
EOC.6 Performance and competency evaluation is recorded in 2
staff members’ files.
comment
WFM.08 An organized medical staff structure is developed to provide PM
oversight on quality of care, treatment, and services.
EOC.1 The ambulatory healthcare center has a medical staff 2
structure that is developed according to the
ambulatory healthcare center’s mission, scope of
services and recommendations of professional
practices to meet patient needs.
comment
EOC.2 Medical staff structure is approved by the governing 2
body.
comment
EOC.3 Medical staff structure clearly defines lines of authorities 2
during working hours and after hours.
comment
EOC.4 Medical staff bylaws are developed and approved by the 1
governing body.
comment Medical staff bylaws are developed but signed by the
facility director
WFM.09 Appointment of medical staff members is performed according to Met
applicable laws and regulations and approved medical staff bylaws.
EOC.1 There is a uniform process for the initial appointment of 2
medical staff members.
comment
EOC.2 Medical staff appointments are made according to the 2
ambulatory healthcare center medical staff
bylaws.

92
 comment
EOC.3 Medical staff appointments are consistent with the 2
ambulatory healthcare center’s mission, patient
population, and services provided to meet patient
needs.
comment
WFM.10 Medical staff members have current and specific delineated clinical Met
privileges
EOC.1 The ambulatory healthcare center has an approved 2
policy that addresses at least all elements from
(a) through(f) in the intent
a) Medical staff members and independent practitioners
with clinical privileges are subject to bylaws
b) Privileges indicate if the medical staff can admit,
consult, and treat patients.
c) Privileges define the scope of patient care services and
types of procedures they may provide in
the ambulatory healthcare center.
d) Privileges are determined based on documented
evidence of competency (experience qualifications
– certifications-skills) that are reviewed and renewed at
least every three years
e) Privileges are available in areas where medical staff
provides services pertinent to granted
privileges
f) Medical staff members with privileges do not practice
outside the scope of their privileges.
comment
EOC.2 Medical staff members are aware of the process of 2
clinical privileges delineation and what to do when
they need to work outside their approved clinical
privileges
comment
EOC.3 Clinical privileges are delineated to medical staff 2
members based on defined criteria
comment
EOC.4 Clinical privileges are accessible to and used by staff 2
involved in booking of surgery and invasive
procedures
comment
EOC.5 Physicians and dentists' files contain personalized 2
recorded clinical privileges, including renewal when
applicable.
comment
EOC.6 Physicians and dentists comply with their clinical 2
privileges.
comment
WFM.11 The ambulatory healthcare center has a staff burnout and turnover Met
preventive measures and strategies.

93
 EOC.1 The ambulatory healthcare center has an approved 2
policy and procedures that clearly describe the
process to ensure safe and efficient working hours, the
policies address a) to d) in the intent.
a) Measures to avoid staff burnout.
b) Planned rest times.
c) Maternity protection and arrangements for breast-
feeding.
d) Setting staff working hours according to the national
laws and regulations
comment
EOC.2 The staff schedules ensure suitable working hours 2
planned rest times.
comment
EOC.3 Staff is aware of how to apply the policy. 2
comment
WFM.12 The ambulatory healthcare center has a defined nursing structure Met
that is led by a qualified nurse director.
EOC.1 There is a current, approved job description for the 2
nursing director describing responsibilities as
addressed in the intent from item a) to d).
a) Responsible for developing and implementing written
nursing standards of practice and recording
for nursing assessment, nursing care plan, nursing
reassessment, and treatments
b) Responsible for evaluating the effectiveness of
nursing treatments
c) Member of the senior leadership team of the
ambulatory healthcare center and attending the senior
leadership staff meetings
d) Ensuring that schedules and assigned tasks to the staff
are completed
Comment
EOC.2 The nursing director file fulfills the licensure, 2
qualification, and expertise as required by the job
description.
comment
EOC.3 The ambulatory healthcare center defines trainee nurses NA
and the duration of working under training
comment There was no nursing trainee
EOC.4 Trainee nurses' practice under supervision through their NA
job description and their performance is monitored and
evaluated.
comment There was no nursing trainee
EOC.5 Nursing standards of practice are adopted and 2
implemented.
comment
Information Management and Technology (IMT)
IMT.01 Documentation management system is developed for all the Met

94
 ambulatory healthcare documents.
EOC.1 The ambulatory healthcare center has an approved 2
policy that clearly describe the process of the
documentation management including elements in the
intent from a) to f).
a) Standardized formatting
b) Tracking system and tracking of any changes
c) The document control system (document to be
identified by title, date of issue, edition and/or current
revision date, the number of pages, who authorized
issue and/or reviewed the document and
identification of changes of version).
d) Obsolete controlled documents are dated and marked
as obsolete
e) Required policies are available and disseminated to
relevant staff
f) Policies revisions and update
comment
EOC.2 Staff is fully aware and trained for the documentation 2
management system and using of patient
unique identifier.
comment
EOC.3 There are standardized formats for all similar documents 2
throughout the ambulatory healthcare
center.
comment
EOC.4 The implementation documentation management policy 2
is continuously monitored, any concerns
may arise is identified and corrected on time.
comment
IMT.02 The ambulatory healthcare center defines standardized diagnosis PM
codes, procedure codes, definitions, symbols, and abbreviations.
NSR.22 EOC.1 The ambulatory healthcare center has an approved 2
policy for abbreviations that includes all the
elements in the intent from a) through b).
a) Not-to- use symbols/abbreviations list. For example;
adopt “do-not-use abbreviation list” for
medication from reliable references, e.g., The Institute
for Safe Medication Practices (ISMP) list
and includes at least the following:
§ U/IU
§ Q.D.,
§ QD,
§ q. o. d
§ q.o.d
§ MS
§ MSO4
§ MgSO4
§ Trailing Zero

95
 § No leading Zero
b) Situations where Symbols and abbreviations (even the
approved list) are not allowed; such as
informed consent and patient rights documents,
discharge/home instructions, and discharge
summaries and any record that patients and families
receive from the ambulatory healthcare center
about the patient’s care.
comment
EOC.2 Staff who records in the patient’s medical record are 2
educated and trained on the process of the
standardization and uniform use of the center’s codes,
symbols, and abbreviations.
comment
EOC.3 There is a uniform use of standardized diagnosis and 0
procedure codes across the center.
comment By medical records review there was no diagnoses
coding
EOC.4 Approved codes are matched to those provided by 0
health authorities and/or 3rd party payers.
comment Related to EOC.3
IMT.03 the ambulatory healthcare center ensures data and information Met
confidentiality, security and integrity.
EOC.1 The ambulatory healthcare center has an approved 2
policy that includes all the points in the intent
from a) through d).
a. Determination of who can access (list of authorized
individuals).
b. The circumstances under which access is granted.
c. Confidentiality agreements with all those who have
access to patient data.
d. Procedures to follow if confidentiality or security of
information has been breached
comment
EOC.2 All staff are aware of the policy requirements. 2
comment
EOC.3 Only authorized individuals have access to patient’s 2
medical records.
comment
EOC.4 Procedures are followed if confidentiality or security of 2
information has been violated.
comment
EOC.5 The medical records department storage area has 2
measures to ensure medical records and
information protection.
comment
IMT.04 The ambulatory care center determines the retention time of Met
records, data, and information.
EOC.1 The ambulatory healthcare center has an approved 2

96
 policy that includes all the items in the intent from a)
through d).
a. Retention time for each type of documents.
b. Measures to maintain information confidentiality
during the retention time.
c. Retention conditions, archival rules, and permissible
means of storage, access, and encryption.
d. Data destruction methods that respect the security
and confidentiality measures.
comment
EOC.2 Responsible staff are aware of the policy requirements. 2
comment
EOC.3 The information confidentiality is maintained during the 2
retention time in accordance to the center’s policy.
comment
EOC.4 Destruction and/ or removal of records, data, and 2
information are done as per policy.
comment
IMT.05 Patient’s medical record is managed effectively. Met
EOC.1 The ambulatory healthcare center has an approved 2
policy that includes all the items in the intent
from a) through e)
a) Availability of medical records within a pre-
determined timeframe.
b) Medical record contents and order uniformity.
c) Medical record standardized use and storage
methods.
d) Patient’s medical record release.
e) Management of voluminous patient’s medical record.
comment
EOC.2 Responsible staff is aware of the policy requirements. 2
comment
EOC.3 The patient’s medical record contents, format, and 2
location of entries are standardized.
comment
EOC.4 The patient’s medical record is available when needed 2
by a healthcare provider within a timeframe
matched to centers’ policy.
comment
EOC.5 A patient medical record is initiated for every patient 2
receiving care.
comment
IMT.06 Patient’s medical record is reviewed effectively. NM
EOC.1 The ambulatory healthcare center has a process of 2
tracking and monitoring data that collected and analyzed
from medical record review process.
comment
EOC.2 An authorized responsible staff performs the medical 0
record review focusing on timeliness, accuracy,

97
 completeness, and legibility of the medical record.
comment There were no related documents of medical records
review focusing on timeliness, accuracy, and legibility
there was only KPIs for completeness medical records
completeness of 100%
EOC.3 Significant medical review’ results are reported to the 0
ambulatory healthcare center leader(s).
comment Related to EOC.2
EOC.4 Corrective interventions are taken by the ambulatory 0
healthcare center leader(s) when needed.
comment Related to EOC.2
IMT.07 The use of health information technology systems is safe and NA
efficient.
EOC.1 The ambulatory healthcare center health information
technology’ systems are selected, implemented in
collaboration to center’s leaders and stakeholders.
comment There was no health information system
EOC.2 The ambulatory healthcare center has an approved
policy for downtime including the recovery process.
comment
EOC.3 The staff is aware of the health information technology’
system.
comment
EOC.4 Data backup process and frequency of backup is
identified according to center policy.
comment
Quality and Performance Improvement (QPI)
QPI.01 Ambulatory healthcare center leaders plan, document, implement, Met
and monitor an organizational- wide quality management program.
EOC.1 The ambulatory healthcare center leaders participate in 2
planning a program for quality management
comment
EOC.2 The ambulatory healthcare center has a documented, 2
updated and approved quality management
program containing the items in intent from a) to f)
a) The commitment to regulatory requirements and
accreditation standards.
b) The goals of the quality management program
c) The quality measures (clinical and managerial)
d) The quality management activities
e) The quality tools
f) Periodic review and update (at least annually)
comment
EOC.3 An individual with knowledge, skills and experienced in 2
quality management ,related tools and activities
is assigned to oversight the quality management
program
comment
EOC.4 All staff is aware of the quality management program 2

98
 comment
EOC.5 The quality management program is updated at least NA
annually
comment First accreditation.
QPI.02 Performance measures are identified and monitored for all Met
significant processes.
EOC.1 There is an approved identification card for each 2
selected performance measure ,standardized
template is preferred, that include all elements
mentioned in the intent from a) through f)
a) Definition
b) Defined data source
c) Specified frequency
d) Sampling techniques
e) Formula
f) Methodology of data collection and analysis
comment
EOC.2 There is list of ambulatory healthcare center measures 2
including both clinical and managerial processes
comment
EOC.3 Staff responsible for the collection, interpretation and/or 2
use of performance measurement are aware
of identification card contents.
comment
EOC.4 The ambulatory healthcare center makes its NA
performance results/data publicly available at least
annually
comment First accreditation.
EOC.5 Results of measures analysis are regularly (at least 2
quarterly) reported to the governing body
comment
QPI.03 A risk management plan/program is developed. Met
EOC.1 The ambulatory healthcare center has a risk 2
management plan/ program that includes all the
elements
from a) to h) in the intent
a) Scope, objective, and criteria for assessing risks
b) Risk management assigned responsibilities
c) Risk identification (risk register)
d) Risk policies and procedures that support the risk
management framework.
e) Risk prioritization
f) Risk categorization (i.e. strategic, operational,
reputational, financial, other)
g) Risk reporting and communication with stakeholders
h) Risk reduction plans and tools with priority given to
high risks processes.
comment
EOC.2 High risk processes are re- designed based on the result 2

99
 of the analysis.
comment
EOC.3 The ambulatory healthcare center has an approved 2
proactive risk reduction tool for at least one high risk
process, updated annually.
comment
EOC.4 The risk management plan/program and the risk register NA
is updated at least annually
comment First accreditation.
QPI.04 An effective incident-reporting system is developed. Met
EOC.1 The ambulatory healthcare center has an approved 2
policy defines the incident-type and reporting
a) Definition and classification of incidents
b) Incident management process includes how, when,
and by whom incidents are reported and
investigated.
c) Identify incidents requiring immediate notification to
the management
d) Incident analysis tools, and results reporting
e) Indication for performing intensive analysis and its
process
f) Procedures of managing adverse events consequences
including the first and second victims
affected.system that include a) through f) in the intent
comment
EOC.2 All staff are aware of the incident-reporting system, 2
including contracted and outsourced staff members
comment
EOC.3 Ambulatory healthcare center communicates with 2
patient’s/services users about adverse events they
are affected by
comment
EOC.4 Corrective actions are taken in a timely manner, when 2
gaps are detected
comment
QPI.05 Significant process variation are easily detected, investigated, Met
corrected using evidence based methodology.
EOC.1 The ambulatory healthcare center has a policy that 2
describe the significant events and its intensive
analysis process that include items from a) to c) in the
intent
a) List of Significant unexpected/near misses’ events that
can happen, such as:
I. Confirmed transfusion reactions
II. Significant anesthesia and sedation events that cause
harm or have the potential to cause harm
to a patient
III. Significant differences between pre- and post-
operative diagnoses, including surgical pathology

100
 findings
IV. Significant adverse drug reactions that cause harm or
have the potential to cause harm to a patient
V. Significant medication errors that cause harm or have
the potential to cause harm to a patient
VI. Pulmonary Embolism or Deep Venous Thrombosis
developed due to missing appropriate
thromboprophylaxis
treatment and improper VTE assessment risk
VII. Patient escape or attempted escape
b) The criteria and procedures for intensive analysis
when significant unexpected events occur
c) The time required to complete the investigation and
execute the required action plan.
comment
EOC.2 All significant events (unexpected variations) are timely 2
investigated, analyzed and reported
comment
EOC.3 Corrective actions are taken with clear time- frame, 2
when gaps are detected
comment
QPI.06 The ambulatory care center has a defined process for the Met
identification and analysis of near miss events
EOC.1 The ambulatory care organization has a process for 2
identification and reporting of near misses
comment
EOC.2 All staff is aware of near miss identification and 2
reporting process
comment
EOC.3 Near miss events are analyzed, and actions are taken to NA
reduce re-occurrence
comment There was no history.
QPI.07 The ambulatory healthcare center defines investigates, analyzes and Met
reports sentinel events, and takes corrective actions to prevent harm
and recurrence
EOC.1 The ambulatory healthcare center has a sentinel events 2
management policy covering the intent from
a) through f) and leaders are aware of the policy
requirements
a) Definition of sentinel events such as:
a. Unexpected mortality or major permanent loss of
function not related to the natural course
of the patient’ illness or underlying condition
b. Wrong patient, wrong site, wrong procedure events
c. Patient suicide, attempted suicide or violence leading
to death or permanent loss of function
d. Unintended retention of a foreign object events in a
patient after surgery or invasive
procedure

101
 e. transmission of a chronic or fatal disease or illness as a
result of infusing blood or blood
products or
f. Transplanting contaminated organs or tissues;
comment
EOC.2 All sentinel events are analyzed and communicated to NA
the direct upper management by a root cause analysis in
a time period specified by leadership as per center’s
policy
comment There was no history.
EOC.3 All sentinel events are reported to GAHAR within seven NA
days of the event or becoming aware of the
event
comment There was no history.
EOC.4 The root cause analysis identifies the main reason(s) NA
behind the event and the leaders take corrective
action plans to prevent recurrence in the future
comment There was no history.
QPI.08 There is an ambulatory healthcare center-wide performance Met
improvement, and patient safety plan
EOC.1 There is a current and approved performance 2
improvement, patient safety plan that defines at least
items from a) to i) in the intent
a-The goal(s) (clinical and operational goals) that fulfill
the center’s mission.
b-Defined responsibilities of improvement activities and
reporting channels.
c-Define ambulatory healthcare center priorities.
d-Data collection, data analysis tools, and validation
process.
e-Defined criteria for prioritization and selection of
performance improvement projects.
f-Quality improvement model(s) used.
g-Information flow and reporting frequency.
h-Training on quality improvement and risk
management approaches.
i-Regular evaluation of the plan (at least annually).
comment
EOC.2 The ambulatory healthcare center director actively 2
participates in the planning, supporting, and
monitoring of performance improvement, patient safety
plan
comment
EOC.3 The plan is communicated to all relevant stakeholders 2
comment
EOC.4 The plan is implemented facility-wide, according 2
to the timetable and plan of improvement
comment
EOC.5 The plan is reviewed, evaluated and updated annually NA

102
 comment First accreditation.
QPI.09 An appropriate and sustained improvement activities are performed Met
within approved time frame.
EOC.1 There is a written process of the methodology and tools 2
used for improvement
comment
EOC.2 Actions to correct problems is taken timely and 2
appropriately
comment
EOC.3 Improvement activities were tested and the results were 2
recorded and implemented
comment
EOC.4 There is evidence that patient safety processes are 2
improved and controlled
comment
EOC.5 Quality improvement activities are monitored and 2
results are reported to the governing body
Comment

103