CEO Message

BANDAR AL KNAWY, MD, FRCPC

Chief Executive Officer,
Ministry of National Guard - Health Affairs
President,
King Saud bin Abdulaziz University for Health Sciences

Dear Colleague,
Patients and Family Safety First is the shared commitment in the Ministry National
Guard - Health Affairs and it is within this principle that the organization continues to explore
means of advancing its services. The approach is strengthening the organization’s ability to
achieve world class outcomes in education, research and patient care through an atmosphere
of team work, trust, passion and pursuit of excellence.
In our journey to provide the best care to our patients and their families, the
MNG-HA made the decision to pursue the Joint Commission International accreditation and
successfully achieved the initial accreditation in 2006 and re-accreditation in 2009, 2012 and
2016.
This achievement was a product of the collective work of each and every one of
us and once again the opportunity calls on us as members of this great organization to im-
prove the safety and quality of care that we provide by implementing and complying with
different accreditation standards.
The re-accreditation of the organization is due by first quarter of 2019, and in order
to increase the awareness of the accreditation, your colleagues in the Department of Quality
and Patient Safety in collaboration with other departments developed this pocket guide that
outlines the most important JCI standards, safe practices as well as pertinent policies and
procedures.
I would like to thank you on behalf of patients and their families for your excellent
hard work and to congratulate you for your unwavering commitment and loyalty to this
organization in its pursuit of excellence.
 TABLE OF CONTENTS

CEO’s message
Table of content
Ministry of National Guard - Health Affairs 1
Mission, Vision, Values
The JCI Survey Overview
Tracer Methodology
2
DO’s and DON’T’s during the Hospital Onsite Survey 3
Accreditation Preparation Requirements (APR)
4
International Patient Safety Goals (IPSG)
IPSG 1: Identify Patient Correctly
5
IPSG 2: Improve Effective Communication
6
IPSG 3: Improve the Safety of High-Alert Medications 7
IPSG 4: Ensure Safe Surgery 10
IPSG 5: Reduce the Risk of Health Care- Associated Infections
12
IPSG 6: Reduce the Risk of Patient Harm Resulting from Falls 13
Access to Care and Continuity of Care (ACC)
14
Patient and Family Rights (PFR)
16
Assessment of Patients (AOP)
20
Care of patients (COP)
23
Anesthesia and Surgical Care (ASC)
26
Medication Management and Use (MMU)
27
Patient and family Education (PFE)
29
Quality Improvement and Patient Safety (QPS)
30
Prevention and Control of Infections (PCI)
33
Governance, Leadership and Direction (GLD)
36
Facility Management and Safety (FMS)
37
Staff Qualifications and Education (SQE)
41
Management of Information (MOI)
42
Medical Professional Education (MPE)
43
Human Subject Research Program (HRP)
44
 INTRODUCTION

This reference guide has been developed to provide education regarding accreditation standards,
and information about how Ministry of National Guard Health Affairs utilizes these standards to
continually improve care, treatment, and services. We ask that you review and refer back to this
document as we embark together on our journey towards another successful Joint Commission
International re-accreditation survey.
In previous surveys, our staff have stepped up to the plate and been able to demonstrate the exemplary
care it provides. It is our goal that the information contained within this document will prove useful for
survey preparation, and also serve as a guide in the quest to provide excellent patient care.

MINISTRY OF NATIONAL GUARD - HEALTH AFFAIRS

! M ISSION
Ministry of National Guard - Health Affairs (MNG-HA) provides optimum healthcare to SANG personnel,
their dependants and other eligible patients. MNG-HA also provides excellent academic opportunities
conducts research and participates in industry and community service programs in the health field

! V ISION
Ministry of National Guard-Health Affairs will be recognized as an internationally acclaimed Center of
Excellence to enhance individual and public health status

! V alues
Ministry of National Guard Health Affairs adheres to core values taken from religious,
social and professional principles, abiding by:
1. Respect of religious and social values – Respect for religious and social values of
the Saudi society, and refrain from violating the rules.
2. Patient safety and satisfaction – Focusing on patient safety, through provision of
outstanding services that guarantee patient satisfaction.
3. Quality performance – Continuously seeking improvement and development of quality
performance.
4. Respect and dignity – Valuing Patients and families and employees with respect and
dignity.
5. Transparency – Being open and direct in dealing with patients and staff.
6. Teamwork – Workplace cooperation for optimum utilization of team members and
positive performance and patient outcomes.
7. Productive work environment – Provision of work environments that encourage
productivity, efficiency and optimum utilization of resources.
8. Accountability – Building individual and team loyalty and responsibility toward work
activities.
9. Behavior and work ethic – Performing work in accordance with behavior and work
ethics which include truthfulness, sincerity and mutual respect for each other.
10. Excellence and innovation – Innovation and excellence in dealing with all health
organizational activities.

1
 INTRODUCTION
A Joint Commission International on-site accreditation survey provides an assessment of an
organization’s compliance with standards and their measurable elements of performance.

TRACER METHODOLOGY

The Joint Commission International uses the “Tracer Methodology” as a method

.of assessment

What are the primary objectives of tracer activities?

1. Follow the course of care, treatment, and services provided to the patient by and within the
hospital using current records when possible
2. Assess the interrelationships between and among disciplines and departments, programs,
services, or units
3. Evaluate the performance of relevant processes, with particular focus on the integration and
coordination of distinct but related processes
4. Identify potential concerns in the relevant processes

Who will participate during Tracer Activity?

During a tracer, the surveyor(s) will converse with

a wide variety of staff involved in the patient’s care,
treatment, and services. Staff could include nurses,
physicians, medical students, trainees, therapists,
case managers, patient care technicians, pharmacy
staff, lab personnel, and support staff

What will occur during Tracer activity?

1. Observation of direct patient care, medication processes, infection prevention and control issues,
care planning processes, impact of the environment on safety and staff roles in minimizing
environmental risk
2. Review of the record with the staff responsible for the patient’s care, treatment, and services
provided.
3. Discussion of data use in individual departments/services.
4. Review of emergency equipment, supplies, and processes.
5. Interview with the patient and/or family (if it is appropriate and permission is granted by the patient
and/or family).
6. When visiting the emergency department, the surveyor(s) will also address emergency manage -
ment and explore patient flow issues.
7. The surveyor(s) may pull and review two to three additional records to verify issues that may have
been identified. (Concurrent chart review- new approach)

2
 DURING THE HOSPITAL SURVEY

DOs DON'Ts

1. Welcome the surveyor to your area 1. Argue with the surveyor or defend your
practice
2. Allocate appropriate space for the tracer
team to do the interviews 2. Mislead the surveyor

3. Be truthful, describe your regular practice 3. Volunteer unnecessary information.

4. Be professional in your attitude and 4. Provide non requested documents

appearance
5. Use phrases such as, “most of the
5. Reply to surveyors’ questions directly time”, “we usually”, “well, sometimes
and concisely we do”.

6. If unsure of the answer, the safest 6. Talk about past surveys or the future
response is that you would check the plan of the department
policy or ask your supervisor
7. Offer gift as this may be intepreted as
7. Keep your answers focused and specific bribery, offering water will be sufficient
to their questions
8. Prompt the staff during the interview
8. Answer with confidence

9. If you don’t understand something, ask

the surveyor to clarify or explain

3
 APR ACCREDITATION PREPARATION REQUIREMENTS

To create a “safe” reporting environment, the hospital educates all staff that concerns about the safety
or quality of patient care provided in the hospital may be reported to JCI. The hospital also informs
its staff that it will take no disciplinary or punitive action because a staff member reports safety or

What to report to JCI What NOT to report to JCI

Concerns about patient safety and quality Concerns about:

of care related to: • Billing issues
• Patient rights • Payment disputes
• Care of patients • Staff conflicts
• Safety • Employee relations issues
• Infection control • Individual clinical management
• Medication use of a single patient
• Security

HOW TO REPORT TO JCI

1. Summarize your Patient Safety concerns (1-2 pages)

2. Include the Name, street address, city, and country of the health care organization
3. Name and contact information of the individual submitting the complaint (optional)
• Complaints that contain contact information will allow JCI to follow up with the submitter
if further clarification is needed or to request additional necessary information.
4. The name and contact information of the individual or individuals submitting the complaint
will be kept confidential and will not be disclosed to any other party

APR.11
The hospital also needs to inform the public about how to report concerns about patient safety and
quality of care to JCI, in particular when the hospital process has not been effective in resolving the
concern

Staff, patients and the public can contact JCI offices directly to report patient safety issues that are
not resolved by the organization

To contact JCI office visit their website

/http://www.jointcommissioninternational.org/reporting-quality-and-safety-issues
or email: jciquality@jcrinc.com

Mail
Quality and Safety Monitoring
Joint Commission International Accreditation
West 22nd Street, Suite 1300W 1515
Oak Brook, IL 60523 USA
4
 IPSG INTERNATIONAL PATIENT SAFETY GOALS

It is critical that EVERYONE be familiar with the International Patient

Safety Goals (IPSGs) and other Joint Commission patient safety-related
standards and incorporates them into your daily practice.
The purpose of the IPSG is to promote specific improvements in patient safety.
The goals highlight problematic areas in health care and describe evidence
and expert-based consensus solutions to these problems.

IPSG INTERNATIONAL PATIENT SAFETY GOALS

1 The hospital develops and implements a process to improve accuracy
of patient identifications.
APP 1430-16 Patient Identification

THE INTENT OF THIS GOAL IS TWO FOLD:

• FIRST, to reliably identify the individual as the person for whom the service or treatment is
intended.
• SECOND, to match the service or treatment to that individual.
1. Patients must be identified using “two unique identifiers” i.e.FULL NAME and MEDICAL RECORD
NUMBER (MRN) throughout the organization. MUST NEVER use patient’s room or location to
identify patient.
2. Patients are identified in special circumstances, such as the comatose patient or new born who is
not immediately named.
3. Patients are identified before performing diagnostic procedures, providing treatments, and
performing other procedures (Such as administering medications, blood, or blood products;
serving a restricted diet tray; or providing radiation therapy, taking blood and other specimens for
clinical testing).
You should always check the “two identifiers” from:
• Patient’s Medical Record Card
• Patient’s Identity band
• Electronic Medical Record
ALWAYS ask the patient /guardian/parent/to verbalize patient’s name if required.

IPSG.1
• Pay attention on the process of identifying comatose, stroke, dementia & psychiatry
patients.
• Food trays, breast milk and nutritional products must be labeled with patient identifier
and same process of patient identification should be used .

5
 IPSG Improve Effective Communication
2 The hospital develops and implements a process to improve the effectiveness of verbal and/ or
telephone communication among caregivers.
APP 1435-07 Patient Care Handover & Verbal/ Telephone Communication

• Verbal/telephone orders must only be accepted from licensed authorized healthcare provider in
an urgent/emergency situation, weekends and holidays. A verbal order includes but not limited to
medications, diagnostic testing, other treatments and dietary changes.
• Complete verbal or telephone orders and reporting critical diagnostic test results received must
be documented in patient’s electronic record in the BESTCare HIS by the receiver, read-back by
another licensed healthcare provider and confirmed by the prescriber.

IPSG.2
1. The documentation of the health care providers in case of verbal and telephone order must be
according to the policy (Date , Time, and signature of the person requesting the order).

Improve Effective Communication

IPSG The hospital develops and implements a process for reporting critical results of diagnostic tests.
2.1
APP 1426-06 Reporting Critical Laboratory Values
APP 1426-09 Reporting Critical Radiological Findings

• The reporting of critical results of diagnostic tests is documented and read back by the receiver
and confirmed by the individual giving the critical results as per policy.

The Most responsible physician or his designee must be informed immediately

IPSG Improve Effective Communication

2.2 The hospital develops and implements a process for Handover communication.
APP 1435-07 Patient Care Handover and Verbal/Telephone Communication

1. Effective communication, which is timely, accurate, complete, unambiguous, and understood

by the recipient, reduces errors and results in improved patient safety. Breakdowns in
communication can occur during any handover of patient care and can result in adverse events.

2. The ISBAR technique provides a framework for communication between members of the health
care team about a patient’s condition.

6
 • (I) Identification: Identify yourself
• (S) Situation: a statement of the problem (What is happening at the present time?)

• (B) Background: sets the context by providing background information

(What are the circumstances leading to this situation?)
(A)Assessment: (What do I think the problem is?) - Based on your assessment
•
(R) Recommendation: What is the recommendation or what is the problem that needs to be
• addressed. Provides an opportunity to make a request for action – (What should we
do to correct the problem?).

Handovers of patient care within a hospital occur:

• Between health care providers and during shift changes;
• Between different levels of care in the same hospital (General ward to Critical care)
• From inpatient units to diagnostic units (endoscopy, physiotherapy, Cath. Lab. Etc.)
• When temporarily transferring nursing assignments of a patient for an extended period (greater
than 30 minutes) such as meal breaks.
• Between incoming and outgoing Nurse in Charge/Care Coordinators.

Improve the Safety of High-Alert Medications

IPSG
The hospital develops and implements a process to improve the safety of high-alert medications.
3
APP 1429-02 Look-Alike, Sound-Alike and High Alert Medications
APP 1433-36 Medication Storage and Security/Control Requirements

High Alert Medications are medications that pose an increased risk of causing significant harm to
patients if used in error.

7
 • An independent double check procedure will be performed for all High Alert Medications (APP
1429-02 Appendices B).
• Independent double check procedure must be completed without distractions or interruptions.

• Always use the 5 Rights before administration: Right Patient, Right Medication, Right Time,
Right Dose and the Right Route.
• High Alert medications within Pharmaceutical Care Services and patient care areas are stored
in RED BINS with standardized medical label.

Look-Alike and Sound-Alike Medications are medications whose names/packages, sound/look

similar to other drug names/packages

Healthcare providers will adhere to the following:

1. Use Tallman lettering on labels for Look-Alike, Sound-Alike

Medications (as applicable)

2. Look-Alike, Sound-Alike medications without approved

Tallman lettering will be labelled as ‘LASA’.

3. Utilize medication segregation for Look-Alike, Sound-Alike

Medications.

For more information on MEDICATION SAFETY please visit “ONE STOP RESOURCE “ site on
the MNG-HA intranet Homepage.

8
 IPSG Improve the Safety of High-Alert Medications
3.1 The hospital develops and implements a process to manage the safe use of concentrated
electrolytes.
APP 1433-18 Concentrated Electrolytes

Concentrated Electrolytes are High Alert Medications that must first be diluted prior to parenteral
administration, to ensure patient safety.

Concentrated electrolytes will be:

Stored and kept in a locked cabinet, with a similar sign

in/out procedure used for Narcotics and Controlled
Substances

Separated from other medications and stored in red

bins with lids

Utilized Standardized Medication Labels, which state

―High Alert Medication/ Concentrated Electrolyte
Must be Diluted

Concentrated (undiluted) electrolytes will be limited for handling by staff outside of the Pharmaceutical
Care Services Department as per policy.

Always do Independent Double Check before administration of all High Alert Medications order.

9
 Ensure Safe Surgery
IPSG The hospital develops and implements a process for the preoperative verification and surgical/ invasive
4 procedure site-marking
APP 1426-08 Surgical Safety Verification Process in the Operating Room
APP 1437-03 Procedural Safety Verification Process Outside the Operating Room

Wrong-site, wrong-procedure, wrong-patient surgery errors are the result of ineffective or

inadequate communication between members of the surgical team, lack of patient involvement
in site marking, and lack of procedures for verifying the operative site.

Preoperative Verification. This process starts in

the ward/department/ holding area.

• Ensure that documents, imaging and test

results, paperwork are properly labeled and
readily available , if required blood products,
special medical equipment and/ or implants
are present.

• Informed consents are completed and signed

by the Physician, Patient/Guardian or Parent
and the witness.
• Proper handover is done in the Holding Area
and all discrepancies should be corrected before
sending the patient into the procedural room.

Marking the Surgical site should:

• Must be made by Person Performing the

surgery/ procedure with a permanent skin
marker

• take place with the patient AWAKE and

AWARE if possible, parent/ guardian must
be involved.

• be done in all cases involving laterality (right,

left), multiple structures (fingers, toes, lesions),
or multiple levels (spine)
• be done using an instantly recognizable mark
that is consistent throughout the hospital.

10
 Ensure Safe Surgery
IPSG The hospital develops and implements a process for the time-out that is performed immediately prior
4.1 to the start of the surgical/ invasive procedure and the sign-out that is conducted after the procedure.
APP 1426-08 Surgical Safety Verification Process in the Operating Room
APP 1437-03 Procedural Safety Verification Process Outside the Operating Room

Time Out
This is the full verification that is performed immediately
prior to the induction of Anaesthesia or the start of an
invasive procedure when the entire care team actively
and verbally confirms:

• Correct Patient (two identifiers)

• Confirmed procedure to be performed
• Correct side/site/level is confirmed, if applicable
• Permission to start from Operating Team
(done inside OR)

Remember these requirements also apply for invasive

and other procedures performed outside of the OR.

Sign Out
Before the patient to leaves the Operating Room (OR)/
area where the procedure was performed.

• The Nurse confirms/ initiates with the Operating/

Procedural team.
• Correct name of the surgical/ invasive procedure
done
• Complete count ( instrument, sponge and
needles)
• Correct labeling of specimen & read aloud i
including patient’s full name & MRN
• Any equipment problems to be addressed, as
applicable

Added elements in the Surgical/Procedural Safety

Checklist
• Post-Operative Notes done and available in
electronic medical record.
• Post operative plan of care available emediately
after the surgery.

“SAFE SURGERY SAVES LIVES”

11
 IPSG Reduce the Risk of Health Care-Associated Infections
5 The hospital adopts and implements evidence-based hand-hygiene guidelines to reduce the risk of
health care –associated infections
Infection Control Manual ICM-II-04 Hand Hygiene

Clean Hands Save Lives

MNG-HA adapted the WHO Guidelines of Hand Hygiene in Health Care 2009 to reduce the risk of
health care-associated infections.

5 Moments of Hand Hygiene

40-60 seconds 20-30 seconds

• Wash hands with soap and water when hands are visibly soiled.
Limitation of Alcohol Based Hand Rub (ABHR):
• ABHR is inactive when hands are visibly dirty and when
dealing with spore forming bacteria, i.e., clostridium difficile
patients.
Using alcohol-based sanitizers
• Use alcohol-based hand rub when hands are NOT visibly
soiled.

12
 Reduce the Risk of patient Harm Resulting from Falls
IPSG
The hospital develops and implements a process to reduce the risk of patient harm resulting from
6
falls for the
INPATIENT population.

Reduce the Risk of patient Harm Resulting from Falls

IPSG
6.1 The hospital develops and implements a process to reduce the risk of patient harm resulting from
falls for the
OUTPATIENT population.

Many injuries in hospitals to both inpatients and outpatients are a result of falls. Risks associated with
patients might include patient history of falls, medications use, alcohol consumption, gait or balance
disturbances, visual impairments, altered mental status, and the like.

APP 1430-05 Fall Prevention and Management Program

The purpose of the policy is to provide a process for prevention and management of
patient fall risks reducing patient harm and to promote patient safety throughout the
Ministry of National Guard - Health Affairs (MNG-HA) and all affiliated facilities.

ALWAYS REMEMBER!

Any member of the patient care team (Nurse, Physicians and other
Healthcare Professionals) shall use their assessment and clinical judgment
to determine if a patient is at risk for falls, and shall communicate with primary
nurse to implement appropriate falls prevention.

13
 ACC ACCESS TO CARE AND CONTINUITY OF CARE

These standards address which patient needs can be met by the health care organization, the
efficient flow of services to patients, and the appropriate transfer or discharge of patients to their
home or to another care setting.

IMPROVE PATIENT FLOW

JCI requires the hospital to develop a process to manage the flow of patients throughout
the hospital.
APP 1437-01 Patient Flow and Escalation Policy & Procedure

The components of the patient flow process address the following:

a. Adequate inpatient beds.
b. Staff to support temporary allocation of patients.
c. Facility Plans : Space, Equipment Medical Technology and supplies.
d. Non clinical services e.g. housekeeping and transportation.
e. Adequate clinical services e.g. Laboratory, radiology Operating room etc.
f. Same level of care as inpatients.
g. Support services (such as social work, religious or spiritual support, and the like).

IMPROVE OUT-PATIENT PROFILE

JCI requires the records of outpatients requiring complex care or with complex diagnoses
contain profiles of the medical care and are made available to health care practitioners
providing care to those patients.

Process requires as follows:

a. Hospital identifies the types of outpatients receiving complex care and/ or with complex
diagnoses who require an outpatient profile.
b. Necessary information must be included in the outpatient profile.
c. Hospital uses a process ensure the outpatient profile is easy to retrieve and review.
d. The process is evaluated to

14
 SAFE TRANSPORTATION
The hospital’s transportation services comply with relevant laws and regulations and meet
requirements for quality and safe transport.
JCI requires the hospital’s process for referring, transferring, or discharging patients
includes an understanding of the transportation needs of patients.

Required elements as follows:

• Transportation services meets the hospital’s requirements for quality and safe transport.
• All vehicles used for transportation, contracted or hospital owned, comply with the infection
control program and have appropriate medical equipment, supplies, and medications to meet
the needs of the patients being transported.
• A process in place to monitor the quality and safety of transportation provided, including a
compliant process.
• Accompanying staff must have skills to match patient needs, could be Paramedics, nurses or
physicians – with appropriate medical equipment, medication and supplies.

LEAVE AGAINST MEDICAL ADVICE

APP- 1419- 08 Patient Informed Consent
When a patient decides to leave the hospital after an examination has been completed and a
treatment plan recommended, whether it is an inpatient or an outpatient, this is identified as “leaving
against medical advice.”

ACC
1. Triage process include signs/ symptoms of communicable diseases ( fever, cough,
diarrhea travel history to considered the required precautions during the patient’s
movement.
2. Hospital should have the process to orientate patient/family about hospital.
3. Transportation having appropriate medical equipment – monitor, defibrillator,
medications and appropriate personnel accompanied the patients.

15
 PFR PATIENT AND FAMILY RIGHTS

These standards address issues such as promoting consideration of patients’ values, recognizing the
hospital’s responsibilities under law, and informing patients of their responsibilities in the care process.
Standards regarding patient rights with respect to informed consent, resolution of complaints, and
confidentiality are also included.

Patient Relations Department

Patient Relations staff answer questions, provides information, assist with special needs and facilitate
problem solving and complaint management and ensure that all issues and complaints are handled
with sensitivity and confidentiality. They identify opportunities to improve the patient experience, assist
caregivers in meeting patients’ needs, expectations and concern, and gather data for patient
satisfaction.
Whether you have a question, concern, complaint or compliment, our Patient Relations team ensures
that you have a voice.
APP 1431-17 Patient Complaints/ Suggestions/ Compliments
APP 1433-21 Rights and Responsibilities of Patients/ Families

• The program must recognize the right of the patient to receive a high standard of care and
treatment.
• The patient/family has the RIGHT to make a complaint or suggestion when the expectations
are not met or the patient/family experiences/notices any lapse in the service rendered.
• The Program must establish and maintain an open and transparent system to respond to
complaints and suggestions of patients, their families and visitors.
• The complaints and suggestions must receive sympathetic attention and must be
investigated and resolved as expeditiously as possible, in accordance with the MNG-HA
complaint handling process.

The ―Patient’s Rights & Responsibilities‖ brochure is provided to the patient at the time
of Admission or Outpatient Visit.
APP 1433-21 Rights & Responsibilities of Patients/ Families

Privacy
The patient has the right to refuse to talk to or meet anyone who is not officially and directly involved in
the healthcare provided to him/her including visitors.
Medical assessments and examinations are to be conducted in designated
areas out of the sight and hearing of others.
Confidentiality
Only direct health care providers have access to patients’ files and details
of their condition.

16
Refusal of Treatment
When a patient refuses care or chooses to discontinue treatment, he/she will be advised of the
consequences of his/her refusal and the expected outcome of this decision.
Complaints Resolution
The Patient Relations Department and its representatives familiarize patients
and their families with valid rules and regulations and how to submit proposals,
opinions, and complaints and provide them with the required feedback.
Informed Consent
The patient (or his/her family) is entitled to have a complete explanation of the
medical procedure required for his/her treatment, including risks and benefits
of the proposed procedure, its complications, and alternative treatments.
Pain Management
Patients have the right to have his/her pain assessed and addressed as part of his/her treatment plan.

Safety
The Patient has the right to expect appropriate and reasonable provision of personal safety insofar as
MNG-HA treating/healthcare facilities, the environment, and personnel practices are concerned.
Respect, Dignity and Consideration
Patients have the right to considerate and respectful care at all times and under all circumstances with
due recognition of his/her personal dignity.
Privacy and Confidentiality
These are some best practices to maintain patient privacy & confidentiality:

Privacy and Confidentiality

These are some best practices to maintain patient privacy & confidentiality

1. Do not share computer passwords.

1. Log-out after using the computers in 2. Do not discuss patient-specific
patient care areas. information in public areas like elevators, food courts
2. Knock before entering a room. and hallways.
3. Close doors and curtains during treatment 3. Do not display patient-specific information on notice
and examination. boards accessible to the public.
4. Cover patients appropriately during 4. Do not leave medical records in public areas or
treatment and transport. unattended by staff.
5. Modulate voice volume in areas where 5. Do not give treatment or perform physical examination
privacy could be compromised. or procedures if the patient belongs to the opposite
gender, without the presence of a person/chaperone
/careprovider of the same (patient’s) gender present

17
 GENERAL CONSENT FOR TREATMENT
General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for the
first time as an outpatient, is clear in its scope and limits.
APP 1419-08 Patient Informed Consent

• General consent for treatment, if obtained when

a patient is admitted as an inpatient or is registered
for the first time as an outpatient, is clear in its scope
and limits.

• Patients and families are informed as to the

scope of a general consent, when used by the
hospital.

• The hospital has defined how a general consent,

when used, is documented in the patient record.

• Patients and families are informed about which

tests and treatments require informed consent.
(Also see PFR.5.1)

The general consent notes if it is likely that students

and trainees will participate in care processes.

APP 1419-08 Patient Informed Consent

The purpose of the policy is to provide a process relating to patient informed consent for diagnosis,
treatment and surgical/procedural intervention at the Ministry of National Guard-Health Affairs
(MNG-HA) and its affiliated facilities

The patient/family should be provided with the

following information prior to sign the informed
consent
a) The patient’s condition;
b) The proposed treatment(s);
c) The name of the person providing the treatment;
d) Potential benefits and drawbacks;
e) Possible alternatives;
f) The likelihood of success;
g) Possible problems related to recovery;

18
 VALIDITY PERIOD FOR OTHER CONSENTS

Surgery/ Procedure/ Anaesthesia and Sedation/Blood and

Blood Products/ Instrumental delivery/ Manual removal
of placenta/ Termination of pregnancy/ DNA banking and 90 days
genetic studies / Photography/ Elective Caesarian Section /
Sterilization

Consent for General Treatment Outpatient: all subsequent visits

Inpatient : On admission day

Consent for Imaging of Pregnant Patients’ Abdomen or 30 days

Pelvis
Consent for Cryopreservation of Embryos & of Sperm One Session only ( Preservation is
valid for two years)
Consent for IVF Treatment One year

Consent for Chemotherapy Onecycle

All year

Consent for Hemodialysis, Plasmopheresis One year

THINGS TO REMEMBER ABOUT THE INFORMED CONSENT FROM THE HOSPITAL POLICY

1. The legal age to give consent is 18 HEGIRA years for both males and females.

2. Consent must be obtained by the attending physician or designee (R3 or above) who is going to
perform the treatment, procedure/ intervention from the patient, legal guardian.

3. The attending physician or designee will write in full on the respective consent form (no
abbreviations will be accepted), the name of the procedure, the site, side, and level (if applicable)
of the procedure to be performed.

4. The consent form shall be completed in English for non-Arabic speaking patients and in both
English and Arabic for Arabic speaking patients.

5. Consent must be obtained from a patient or legal representative on behalf of the patient (should
the patient be unable to give consent) for all treatments, procedures.

Consent must be obtained by the attending physician or designee

(Resident 3 or above) as per policy.

19
 AOP ASSESSMENT OF PATIENTS

APP 1430-27 Patient Admission (H&P) Assessment & Reassessment

The Medical Initial Admission Assessment will include at a minimum, an evaluation of patient’s:

• Presenting illness.
• Medical, Surgical and Family History;
• Psychosocial and Economic Assessment.
• Nutritional and Functional Screening.
• All medications being taken at admission.
• Allergies.
• A complete Review of Systems.
• Pain Screening.
• A Complete Physical Exam.
• Initial Assessment Impression.
• Initial Care Plan
• Educational and Discharge planning needs.

A detailed History and Physical examination MUST be completed and documented in

the clinical record (Physician Admission Assessment) within 24HRS of admission

Nursing Initial Assessment:

• Emergency patients are based on their needs and conditions.
• Is performed and documented within 24 hours of admission as an inpatient or sooner as
required by the patient condition.
• Results in a list of specific patient nursing needs or conditions that require nursing care,
interventions, or monitoring.
Nursing assessment and reassessment must be related to the specific area of practice
– e.g. Pediatric, Adult, Critical Care, L&D, Outpatient and Emergency Room (ER).

APP 1430-32 Patient Assessment & Reassessment by Allied Health Professionals

20
Pain Screening and Assessment
APP1430-07 Pain Management
The pain management standards address the assessment and management of pain. The standards
require organizations to:
1. Recognize the right of patients to appropriate assessment and management of pain.
2. Screen patients for pain during their initial assessment and, when clinically required, during
ongoing, periodic re-assessments.
3. Educate patients suffering from pain and their families about pain management.
Pain Assessment Tools for Different Age Groups
Patient Tools
Neonate - 3 months Cries
Infant 3 months – 1 yr. & FLACC
Toddlers 1 yr. – 3
Developmentally delayed child FLACC
3 yrs. – 14 years old Wong - baker 0 - 10 Numeric
Verbal Adult Wong - baker 0 - 10 Numeric
Non-verbal Adult FLACC

Effectiveness of pharmacologic and non-pharmacologic interventions will be assessed and

documented at the following intervals:
1. Thirty (30) minutes post IV administration of analgesia.
2. Sixty (60) minutes post oral, per rectum or intramuscular analgesia.
3. Immediately after non-pharmacologic interventions.

DISCHARGE PLANNING
General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for
the first time as an outpatient, is clear in its scope and limits.
APP 1430-27 Patient Admission (H&P) Assessment and Reassessment
APP 1430-32 Patient Assessment and Reassessment by Allied Professionals

The Standard requires:

• Discharge planning process early in the assessment to identify those patients for whom
discharge planning is critical.
• Discharge planning includes identifying special needs and developing and implementing a plan
to address those needs.
• Patients, family as appropriate, and staff involved in the patient’s care participate in the
discharge planning process.

LABORATORY SERVICES
A qualified individual is responsible for the oversight and supervision of the Point-of-Care Testing (POCT)
program.
APP 1433-29 Point of Care Testing

21
 The Standard requires:
Point - of- Care Testing (POCT) program requiring:
• Person responsible for managing, provide oversight and supervision.
• Staff performing required qualifications, training and competent.
• Defined a process for reporting abnormal/ critical test results.
• Quality control performance, documentation and evaluation.
• Monitoring and evaluated in quality improvement activities.

NEW JCI STANDARD

RADIOLOGY & DIAGNOSTIC IMAGING SERVICES

Radiology and diagnostic imaging services are

available to meet patient needs, and all such
services meet applicable local and national
standards, laws, and regulations.

All requirement used to conduct radiology and

diagnostic imaging is regularly inspected, main-
tained, and calibrated, and appropriate records
are maintained for these activities.

Radiation Safety program includes education

about dosing of radiation.

Dying patient and their family are Assessed and

Reassessed according to their individual needs,
if applicable:

• For spiritual
• Psychosocial
• Support services
• Individualized needs & cultural
preferences.

22
 COP CARE OF PATIENTS

This chapter discusses activities basic to patient care, including processes for planning and coordinating
care, monitoring results, modifying care, and conducting follow-ups. The chapter also includes high-risk
care services, food & nutrition therapy, pain management, end-of-life care and organ and / or transplant.
CARE OF HIGH-RISK PATIENTS &
PROVISION OF HIGH-RISK SERVICES

List of high-risk patients to provide high-risk Interventions of Care for High-Risk Patients,
services. refer to the following policy and procedures:
1. Emergency patients 1. APP 1430-39 Care of Vulnerable High
2. Comatose patients Risk patients
3. Patients on life support 2. APP 1438-05 Determination of Goals
4. Care of patients with communicable of Care
disease 3. APP 1428-22 Management of Suspected
5. Care of immunosuppressed patients Child Abuse & Neglect (SCAN) cases.
6. Care of patient receiving dialysis 4. APP 1430-06 Palliative and End-of-Life
7. Care of patients with restraints Care
8. Care of patients receiving 5. APP 1430-21 Physical Restraints
chemotherapy 6. APP 1430-07 Pain Management
9. Care of vulnerable patient 7. Infection Control Manual
populations a. Immuno-Compromised Patient
( frail elderly, dependent child, risk b. Hematopoietic Stem Cell
for abuse and/ or neglect) Transplantation (HSCT)
10. Care of patients at risk for suicide c. Prevention of transmission of Infection
among Chronic Dialysis patients.

CODE BLUE
APP 1430-41 Code Blue Activation- Cardiopulmonary Resuscitation

JCI Requirements
1. Resuscitation services are available and provided to all
patients 24 hours a day, every day, throughout all areas
of the hospital.
2. Medical technology for resuscitation and medications for
basic and advanced life support are standardized and
available for use based on the needs of the population
served.
3. In all areas of the hospital, basic life support is
implemented immediately upon recognition of cardiac or
respiratory arrest, and advanced life support is
implemented in fewer than 5 minutes.

23
 CRITICAL CARE RESPONSE TEAM CALLING CRITERIA
APP 1429-34 Critical Care Response Team (CCRT) Activation
Critical Care Response Team is a formally designated multidisciplinary critical care team that assess-
es and manages a patient demonstrating the early signs of deterioration in clinical status, prior to the
development of progressive and irreversible deterioration.

ACTIVATION SYSTEM FOR THE CCRT: “THE AFFERENT ARM”

1. Initiation of the CCRT is at the discretion of the bedside healthcare provider(s) including the
primary nurse, respiratory therapist, physician or other healthcare workers.
2. Activation of the CCRT does not require a prior order or an explanatory progress note.
3. CCRT will NOT be activated for patients who are labeled with either ―”Support Care or
Comfort Care” status.
The CCRT will be activated when a patient meets any of the following criteria (unless they are
labeled ―Support Care or Comfort Care).

CRITICAL CARE RESPONSE TEAM CALLING CRITERIA

Airway Threatened Stridor Excessive Secretions
Respiratory rate less Saturation less than 90%
BREATHING Distressed Breathing than 8/minute or greater or greater or equal to 50%
than 30/min Oxygen or 6L/minute
• Heart rate is lesser or equal to 40 beats/min or greater or equal to 130beats/min
• SBP is lesser or equal to 90mmHg or SBP greater or equal to 200mmHg
CIRCULATION
• Onset of chest pain
• Bleeding with Hypotension
• GCS decrease by 2 or more points over 24Hrs
DISABILITY • Repeated or extended seizures
• Onset of confusional state
Urine Output is lesser or equal to 100ml over 4 Hrs. for patient with Foleys Catheter.
OTHERS
If you have serious concern about your patient

Food and Nutrition Therapy

Appropriate food and nutrition are important to patients’ well-being and recovery. Food choices take
into consideration the patient’s age, cultural and dietary preferences, and planned care, which include
special dietary needs.
The patient participates in planning and selecting foods. The patient’s family may, when appropriate,
participate in providing food, consistent with cultural, religious, traditions and practices compatible with
patient’s diagnosis.
When patient’s family provide food to the patient, they are EDUCATED about patients’ diet limitations:
1. Foods that are contraindicated to the patient’s care needs and plans
2. Medications associated with food interactions
3. Food storage to prevent contamination.

24
 End-of-Life Care
APP 1430-06 Palliative and End-of-Life Care

Patients who are dying have unique needs for respectful, compassionate care. To accomplish this, all
staff are made aware of the unique needs of patients at the end of life.
Joint Commission Standard recommends that End-of-life care provided by the hospital
includes:
a) Providing appropriate treatment for any symptoms
according to the wishes of the patient and family;

b) Sensitively addressing such issues as autopsy and organ

donation;
c) Respecting the patient’s values, religion, and cultural
preferences;

d) Involving the patient and family in all aspects of care

e) Responding to the psychological, emotional, spiritual,

and cultural concerns of the patient and family.

Hospitals Providing Organ and/or Tissue Transplant Services

APP 1433-11 Brain-Dead Organ Donation, Procurement and Transplantation

Leadership’s commitment to creating a culture conducive to organ and tissue donation can
have significant impact on the overall success of the hospital’s organ and tissue procurement
efforts. These standards address the hospital’s

• The Program recognizes the major contribution of organ

transplantation for the good of human health and relief of
human suffering.
• The human organ procurement and transplantation process
must conform to the SCOT (Saudi Center for Organ
Transplantation) policies and regulations.
• Respect and full support must be offered to patients and
families regarding their choices to donate human organs
and other tissues.
• The provisions of this APP apply to all medical, clinical and
administrative staff involved in organ procurement and
transplantation at MNG-HA or any affiliated facility.

25
 ASC ANESTHESIA AND SURGICAL CARE

This chapter addresses sedation and anesthesia use and surgical care. Topics include procedures
for preparing, monitoring, and planning for aftercare for patients who received sedation or anesthesia
and/or who had surgery.

APP 1433-31 Sedation by Non Anesthesiologists

1. PRE –SEDATION ASSESSSMENT- Pre-Procedure Preparation: An appropriate

pre-procedure evaluation of the patient will be undertaken and documented on the
sedation form.
2. INTRA-SEDATION ASSESSMENT: All patients will have the indicated minimum
parameters monitored and documented at least every five (5) minutes during the
procedure.
3. POST-SEDATION ASSESSMENT- All monitored vital signs will be recorded at least
every five (5) minutes until the patient has achieved the criteria for discharge from the
recovery area.

STAFF CREDENTIALING:
• Current BLS, ACLS or PALS certificate
• Proof of attendance for Sedation by Non Anesthesiologist Course every 2 years.

NEW JCI STANDARD REQUIREMENT

Many surgical procedures involve the implantation of prosthesis, such as a hip, or a medical device
such as a pacemaker, insulin pump, or remote monitoring device. These types of surgical procedures
require that routine surgical care must be modified to consider special factors such as:

a. Selection of device based on available

science and research;
b. Modifications to the surgical checklist to
ensure that implants are present in the
operating theatre an special considerations
in marking the surgical site;
c. The qualifications and training of any
outside technical staff required during the
implant procedure;
d. An understanding of and reporting process
for device-related adverse events;
e. Unique infection control considerations;
f. Any special discharge instructions to the
patient; and
g. The traceability of devices in the event of
a recall.

26
 MMU MEDICATION MANAGEMENT AND USE

This chapter addresses systems and processes for selecting, procuring, storing, ordering/prescribing,
transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring medica-
tion therapies.
Antibiotic Stewardship Program
APP 1438-06 Antimicrobial Stewardship Program
The overuse and misuse of antibiotics has resulted in the growth of super-bugs that are increasingly
resistant to available antibiotics.
In addition to resistant and the growth of super-bugs, there are often side effects and/or complications
to antibiotic treatment, including acquiring Clostridium difficile, kidney or liver damage, hearing loss,
hemolytic anemia, & other such complications.

Implementation of an Antibiotic Stewardship Program will help hospitals reach the goal of
providing patients requiring antibiotic treatment with:
• The right antibiotics
• At the right time
• At the right dose
• For the right duration

STORAGE & HANDLING of MEDICATIONS

• Medications should be properly & safely stored as per manufacture recommendations
• Temperature and Humidity must be continuously monitored in all areas storing Medications
• Medications & nutritional products require special handling & labeling
• Emergency medications are available, uniformly stored & secure when stored out of the
pharmacy
COMPLETE ORDER & PRESCRIPTION of MEDICATION
APP 1429-03 Prescribing and Dispensing Medication Guidelines
The require elements of a complete order and prescription addressed include at least the following
when appropriate:

1. Accurately identify the patient.

2. Essential elements of all orders or prescriptions.
3. When generic or brand name are acceptable or required.
4. Whether or when indications for use are required on medication orders – including PRN
(pro re nata), or “ as needed”.
5. Types of orders that are weight based or otherwise adjusted – for children, frail elderly &
other similar population.
6. Rates of administration when intravenous infusion are ordered – not Saline 1 liter.
7. Other special orders such as titrating, tapering, or range orders.

27
 MEDICATION ADMINISTRATION

The safe administration of medications includes verifying the:

1. Medication with the prescription or order;
2. Identity of the patient;
3. Time and frequency of administration with the prescription
or order;
4. Dosage/amount with the prescription or order;
5. Route of administration with the prescription or order.

Monitoring the patient during the medication adminstration

The purposes of monitoring are to evaluate the medication’s effect on the patient’s symptomsor illness,
as well as blood count, renal function, liver function, and other monitoring with select medications, and
to evaluate the patient for adverse effects. Based on monitoring, the dosage or type of medication can
be adjusted when needed.

1. Medication effects on patients are monitored.

2. Medication adverse effects on patients are monitored and documented.
3. The hospital establishes and implements a process that
identifies those adverse effects that are to be recorded in the patient’s
record and those that must be reported to the hospital.
4. Adverse effects are documented in the patient’s record as identified.
5. Adverse effects are reported as identified by the process in the time frame
required.

EMERGENCY MEDICATIONS
APP 1430-41 Code Blue Activation: Cardiopulmonary Resuscitation
Emergency medications are available, monitored, and safe when stored out of the pharmacy. When
patient emergencies occur, quick access to appropriate emergency medications is critical. Each
hospital plans the location of emergency medications and the medications to be supplied in these
locations.

Anaphylactic Kit Crash Cart Medication Antidotes

28
 PFE PATIENT AND FAMILY EDUCATION

This chapter contains standards that address the effectiveness of education that is provided to patients
and families and the modalities employed to successfully educate these individuals. This chapter also
examines patients’ readiness to learn by considering their language needs and learning preferences.

APP 1426-18 Patient & Family Education

A patient/family’s educational needs assessment includes

an assessment of their preferences or barriers to learning,
such as sensory impairment, language barriers, as well as,
cultural and religious beliefs.

• Learning preferences and barriers are documented

in the Interdisciplinary Patient / Family Education
Record (IPER).

• The Patient Educators complete the initial

educational needs assessment within 48 hours of

All health care providers are responsible to provide patient education to meet their health needs or
to achieve their health goal. All activities or any actions relating to patient / family education will be
documented on the Interdisciplinary Patient / Family Education Record.

Patient education is the most vital step toward making the

patient independent in his own care.

29
 QPS QUALITY IMPROVEMENT AND PATIENT SAFETY

The standards in this chapter identify the structure, leadership, and activities to support the data
collection, analysis and improvement for the identified priorities—hospital wide and department- and
service-specific. This includes the collection and analysis of data on, and response to, hospital wide
sentinel events, adverse events, and near-miss events.
MNG-HA approach to quality and patient safety improvement is planned, systematic, collaborative,
and interdisciplinary based on the strategic direction of the organization.

Quality Improvement Methodologies

I. Rapid Cycle Model for Improvement
Was developed by the Associates in Process Improvement, and has been endorsed by the Institute
for Healthcare Improvement. The model begins with three fundamental questions, followed by the
Plan-Do-Check-Act cycles of improvement:

• Three Fundamental Questions:

• Setting Aims: What are we trying to accomplish?
• Establishing Measures: How will we know that a change is an improvement?
• Selecting Changes: What changes can we make that will result in improvement?
• Plan-Do-Check-Act (PDSA) Cycles:
PLAN – Identify the specific tasks that must be accomplished prior to testing a change,
which includes selection and scope of the pilot test.
DO – Test the change on a small scale over a brief period of time and collect the
minimum amount of data to determine the effectiveness of the test.
STUDY – Review and analyze the data from the test and feedback from the participants
involved.
ACT – Determine the effectiveness of the change, based on data analysis.
II. Robust Process Improvement
• Change Management
Change Management is a set of principles designed to increase the success and
accelerate the implementation of organizational change efforts.
• Lean
Lean is a well-defined set of tools that increase customer value by eliminating waste
(muda) and creating flow throughout the value stream.

•
Six Sigma
Six Sigma is a statistical model that measures a process in terms of defects. Six Sigma
enables an organization to achieve quality by using a set of strategies, tools, and methods
designed to improve processes that near to perfect as possible.

30
Measure Selection and Data Collection
APP 1440-01: Data Governance

The purpose of the policy is to set a strategy and process related to management of MNG-HA
data assets aimimg to achieve level of excellence through supporting quality performance,
enhancing data driven culture, promoting transparency, accountability and innovations.

Data analysis and validation

There is a systematic process, relevant to both quality and patient safety improvement activity
projects and performance measurement to aggregate and analyze collected data.
This assessment process includes using statistical quality process control techniques, as appropriate
and comparing data about processes and outcomes over time. Performance is also compared to
relevant scientific, clinical and management literature, relevant practice guidelines/parameters and to
similar organizations as appropriate.
The reliability and validity of measurements are at the core of all improvements. To ensure that good,
useful data have been collected.
Sentinel Event & Root Cause Analysis
APP 1423-05: Sentinel Events and Root Cause Analysis

The purpose of the policy is to provide a process to direct an immediate and thorough Root
Cause Analysis (RCA) following a sentinel event, increase employees’ knowledge about senti-
nel events, assist in understanding their cause and prevention strategies as well as provide a
structured and process-focused framework with which to approach sentinel event analysis.

Sentinel Event refers to an unanticipated occurrence involving death or serious physical (specifically
includes loss of limb or function) or psychological injury that require intensive assessment and prompt
response.
Sentinel event includes:
a. An unanticipated death, including, but not limited to:
• Death that is unrelated to the natural course of the patient’s illness or underlying condition
(for example, death from a postoperative infection or a hospital-acquired pulmonary
embolism)
• Death of a full-term infant
• Suicide
b. Major permanent loss of function unrelated to the patient’s natural course of illness or
underlying condition;
c. Wrong-site, wrong-procedure, wrong-patient surgery;
d. Transmission of a chronic or fatal disease or illness as a result of infusing blood or blood
products or transplanting contaminated organs or tissues;
e. Infant abduction or an infant sent home with the wrong parents and;
f. Rape, workplace violence such as assault (leading to death or permanent loss of function)
or homicide (willful killing) of a patient, staff member, practitioner, medical student, trainee,
visitor, or vendor while on hospital property.

31
 Root Cause Analysis (RCA) refers to a process for identifying the basic or causal factor(s) that underlies
variation in performance, including the occurrence or possible occurrence of a sentinel event.

Root Cause Analysis (RCA) is a structured method used to analyze serious adverse events. a complete
Root Cause analysis should be done for all sentinel events within 30 days from the date of the event or
when made aware of the event; and take action on the results of the root cause analysis.

Formulating Action Plan

Multidisciplinary Team Conducting Root cause Analysis
(within 30 days)

Failure Mode & Effect Analysis (FMEA)

Failure mode and effects analysis is a proactive analysis of the consequences of an event that could
occur in a critical, high-risk process.

SAFETY REPORTING SYSTEM (SRS)

APP 1435-08: Safety Reporting System

The purpose of the policy is To provide a process that governs identification, reporting,
reviewing, evaluation, analysis and management of safety incidents affecting patients,
visitors, staff or program facilities, reported via the electronic Safety Reporting System
(SRS), whereby the main objective is to assess processes/system failures to improve
quality of care and safety initiatives at the Ministry of National Guard - Health Affairs
(MNG-HA) and all affiliated facilities

The MNG-HA use Electronic Safety Reporting system (SRS) which is a non-punitive system and
is not a method of blaming any particular individual/service. The emphasis is on the prevention of
recurrence and on communication with all affected departments and units in a context of a ”JUST
CULTURE:Staff involved in a serious event shall be offered appropriate support, which may
involve psychological first aid, or other support.

32
 PCI PREVENTION AND CONTROL OF INFECTION

These standards address the methods a hospital uses to design and implement a program to identify and
reduce the risk of patients and staff acquiring and transmitting infections. Areas covered in this chapter include
the process for reporting infections and the types of ongoing surveillance activities that are in place.

EMERGENCY PREPAREDNESS to RESPOND to the presentation of GLOBAL COMMUNICABLE DISEASES

To respond effectively, the hospital develops a program to manage these potential emergencies. The program
provides process for:
1. Communication with organizations participating worldwide surveillance activities.
2. Development & implementation of segregation & isolation strategies.
3. Training, including demonstration, on the use of PPE appropriate to infectious disease
4. Development & implementation of communicable strategies, and
5. Identification & assignment to staff roles & responsibilities
The program is tested ANNUALLY to ensure proper response when an actual event occurs. Action plan
identified from testing and debriefing.

Standard Precautions is the key to prevent infection transmission

Foundation for preventing transmission of infectious agents during interactions between healthcare
personnel and patients are the work practices in having basic level of infection control to reduce the risk
of transmission. These infection control practices should be applied to all body fluids, non-intact skin,
and mucous membranes; and, should be used for all patients regardless of their diagnosis or presumed
infectious status

Use of PPEs (Personal Protective Equipment)

ICM-11-03 Standard Precautions

Put on in this order: Hand hygiene, gown, mask,

(goggles or face shield), gloves.
Remove in this order: Gloves, gown, hand hygiene,
mask or respirator.
Note: if goggles or face shield are worn, they should
be removed after the gloves because they are more
cumbersome and would interfere with removal of
other PPEs. (Gloves, HH, goggles or face shield,
gown, HH, surgical mask or respirator).
• Use of aseptic techniques for all invasive procedures
and any procedure requiring asepsis.
• Safe handling and disposal of sharps.
• Proper handling of contaminated items.
• Collection and handling of lab specimens (these are
considered infectious at all times).

33
 What to do if you have an occupational exposure to blood and/body fluid?

1. In case of exposure to blood and/body fluids

a. For the percutaneous injuries(sharp injury)
• Wash needle sticks and cuts with soap and water
• Apply isopropyl alcohol 70%
• Place a bandage appropriately
b. For the Mucutaneous and non-intact skin exposure
• Flush splashes to the nose, mouth, or non-intact skin with water.
• Irrigate eyes with clean or sterile water or saline.
• Flush site for 10 minutes. APP 1430-31 Management of Spills of Hazardous Materials
2. Report the Injury to the immediate supervisor and through Safety Reporting System (SRS)
The report will include the following information :
• The source patient’s Medical Record Number (MRN), if known

Proper Cleaning, Disinfection, and Sterilization processes.

Shelf life of patient care items and supplies sterilized by CSSD.
ICM-1X-01 Sterile Supplies and Equipment Management (Preparation, Storage and Shelf Life)

1. The shelf life for all items processed in CSSD is ―”eventrelated”

and are issued with a sterilization date.
2. Sterile packages processed by CSSD that are not used within 4
years must be returned to CSSD for resterilization.

These items or supplies are considered sterile only if integrity of sterile

packs was inspected regularly especially prior to use; and found that
the packages possess no tears, compressions, abrasions, punctures,
moisture, dirt, bending, or damage in any way.

Disinfection of medical equipment and devices involves both:

1. Low-level techniques – for items such as stethoscopes, blood glucose machine, computer keyboards,
telephone and monitors.
2. High-level techniques – is used if sterilization is not possible , as the case with flexible endoscopes
and laryngoscopes.
Safe Food storage

Improperly stored and prepared food can

cause illness, such as food poisoning or
food infections.
Safe FOOD storage principles:
FIFO – First in, First out
ICM-VIII-08 Nutrition Services
EHOHS-VI-04 Food Hygiene

34
APP 1425-05: Infection & Control Procedure during Healthcare acility Construction, Renovation or
Maintenance

The purpose of the policy is To provide a process governing regulatory and preventive measures
required during all aspects of construction, renovations or maintenance within the Ministry of National
Guard - Health Affairs (MNG-HA) and affiliated facilities in order to provide a safe facility and secure
environment based on health and safety risk assessments for patients, healthcare workers and visitors

APP 1430-46: Hazardous Materials & Waste Management

The purpose of the policy is to provide a process governing the management of hazardous medical
and non-medical materials and waste including the monitoring and control methods for purchasing,
receiving, safe handling, storage, labeling, segregation, reporting, transportation, safe disposal,
treatment processing, incineration and licensure in accordance with health and safety guidelines, laws
and regulations at the Ministry of National Guard - Health Affairs (MNGHA) and affiliated facilities.

Paper, paper towel, diaper, cups, white pad, blue pad,

soiled fast food containers, remaining food ,napkins
and kitchen towels.
Black Bags
Polystyrene example: (hard plastic, kidney basin or plastic
container).
polythene example: ( plastic bags, plastic films especially
yellow bag).

• Stocks and cultures of infectious agents.

• Blood containers, IV tubing without needles, suction
canisters, pleurovacs, evacuated containers,
hemovacs etc.
Yellow Bags • All kind of Personal Protective Equipment PPE,
(Gloves, Gown, Mask, Goggles, etc).
• Items contaminated with blood: If saturated and/or
dripping, not saturated and/or dried.
• Gauze, disposable

Tissues, organs, other body parts, specimens of body

Red Bags
fluids and their containers (stored in lab for burial).

• Bulk chemicals and sharps.

Yellow Containers • Contaminated needles, syringes, scalpel blades
Razors, Pasteur pipettes, tubes, medication bottle
and broken glass.

APP 1430-31 Management of Spills of Hazardous Materials

The purpose of the policy is to provide a process governing the management of hazardous chemical
or biological releases and spills

35
 GLD GOVERNANCE, LEADERSHIP, AND DIRECTION

Providing excellent patient care requires effective leadership. Effective leadership begins with understanding the
various responsibilities and authority of individuals in the organization and how these individuals work together.
Those who govern, manage, and lead an organization have both authority and responsibility.

Standards in this chapter are grouped using the following leadership hierarchy (and illustrated below

LEADERSHIP STRUCTURE AND RESPONSIBILITIES

Level I- Governance
1. The governance structure he governance structure approves or provides
Level II: GLD.2 for all of the hospital’s programs and policies and allocates resources to
meet the hospital’s mission.
Hospital Leadership
2. Those responsible for governance approve the hospital’s program for
quality and patient safety and regularly receive and act on reports of the
quality and patient safety program.

Level II - CHIEF EXECUTIVE OFFICER (CEO)

Level II: GLD.2 The chief executive cooperates with hospital leadership to define the hospital’s
mission and to plan the policies, procedures, and clinical services related to
Hospital Leadership
that mission. The chief executive is responsible for the hospital’s overall,
day-to-day operations.

Level III: Hospital Leadership

Level III: GLD.3 – Gld.7.1 1. Plans for the type of clinical services required to meet the needs of the
Hospital Leadership patients.
2. Ensures effective communication throughout the hospital.
Medical Operation Administration Others 3. Plans, develops, and implements a quality improvement and patient safety
program.
4. Prioritizes which hospital wide processes will be measured.

Level IV: GLD.8 – GLD.11.2 Level IV: Department / Service Leadership

Department/Service Leaders 1. Provides direction for each department or service
Ancillary 2. Plan and implement professional structure
Clinical Nursing Pharmacy Services 3. Identifies the services provided by the department and implement clinical
Departments
practice guidelines.
4. Participate in hospitalwide improvement priorities and provide support to
Managers of Clinical and
staff in quality and patient safety.
Non-Clinical Services

GLD.12 – GLD.19 Hospital leadership establishes a framework for ethical management that
Culture of Safety promotes a culture of ethical practices and decision making to ensure that
Ethics patient care is provided withinbusiness, financial, ethical, and legal norms and
Health Care Professional Education protects patients and their rights.
Clinical Research

36
 FMS FACILITY MANAGEMENT AND SAFETY

These standards measure the hospital’s maintenance of a safe, functional, and effective environment for
patients, staff members, and other individuals. Areas addressed include emergency preparedness, security,
safety, life safety, medical equipment, utility systems, hazardous materials, and waste management.
JCI NEW STANDARD
Pre-Construction Risk Assessment (PCRA)– the organization conducts when planning for demolition,
construction, or renovation. A multidisciplinary department involvement to comprehensively evaluate risk in
order to develop plans that will minimize the impact construction will have on the quality and safety of
patient care.
Required areas of the PCRA include:
1. Air quality
2. Infection control
3. Utilities
4. Noise
5. Vibration
6. Hazardous materials
7. Emergency services, such as response to codes
8. Other hazards that affect care, treatment, and services
JCI NEW STANDARD
The hospital develops and maintains a written program(s) describing the processes to manage risks to
patients, families, visitors, and staff.

1) Safety and Security Program oversight includes the following:

2) Hazardous materials • Planning all aspects of the program
3) Emergencies • Implementing the program
4) Fire safety • Educating staff
• Testing and monitoring the program
5) Medical technology
• Periodically reviewing and revising the program
6) Utility systems • Providing annual reports to the governing
Needs Safety Program/ Plan body on the effectiveness of the program.

SAFETY and SECURITY

Safety and Security program to provide:
1. Safe physical facility through inspection and planning to reduce risk
2. A secure environment for patients, families, staff, and visitors.

Departmental staff involved in patient care and those APP 1429-08 Safety and Security
affected by absconded, presumed kidnapped, kidnapped or System for Newborns
missing patients within the Ministry of National Guard-
The purpose is to identify areas and
Health Affairs and all affiliated facilities will activate
conditions where newborns are
CODE YELLOW exposed to the risk of abduction, and
APP 1428-19 Management of Missing or Absconded implement security measures that
Patient prevent abduction of newborns

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 Infant Protection System

1. The Program endeavors to provide preventive and security measures that shall be
implemented 24 hours/7 days to protect newborns from abduction.
2. All staff in the clinical areas must be aware and uphold the provisions for visitors, that is,
allowing two visitors at one time.
3. Abduction Prevention Team shall be established in each facility to develop, implement and
evaluate all quality improvement strategies, including education on neonatal / infant abduction.
i. Education programs shall be provided for patients and employees.
ii. All women in the Obstetrics and Neonatal areas will receive education on risk
reduction strategies, which include patients in the Obstetrics Clinic.
. iii. All babies shall be transported in the Hospital and discharged by a Nurse.
iv. Military Police / Security personnel shall guarantee the function of the security
system implemented and assure the presence and quality of work of the required
security system and military personnel around the clock.
4. RFID (Radio Frequency Identification) system will be implemented in all the areas where
medical care is provided to in-patient newborns and babies born in the Emergency Care
Centre at any hospital/healthcare facilities of MNG-HA.

HAZARDOUS MATERIALS
APP 1430-46 Hazardous Materials & Waste Management
APP 1434-05 Disposal of Chemical Waste
APP 1431-31 Hazardous Industrial Chemical Leaks, Spills or Releases: Reporting and
Emergency Response
APP 1430-31 Management of Spills of Hazardous Materials
APP 1433-03 Safe Disposal of Sharps

The hospital has the program for the inventory, handling, storage, use, control and disposal of
hazardous materials and waste. Includes identifying and safely controlling throughout the facility.
The World Health Organization (WHO) identifies hazardous materials and waste by the following
categories:
What is MSDS?
1. Infectious
• A document that provides healthcare
2. Pathological & anatomical
staff with procedures for safely
3. Chemical handling or working with a particular
4. Heavy metals substance/chemical.
5. Pressurized containers
• Includes instructions regarding
6. Sharps
necessary protective equipment, how
7. Genotoxic/ Cytotoxic to handle spills, first aid suggestions,
8. Radioactive storage and disposal, and the general
health effects.

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DISASTER PREPAREDNESS
The hospital develops a program that identified the major internal and external disaster, such as
community emergencies, and natural or other disasters that pose significant riks of occuring, taking
into consideration the hospital’s geographical location.
The disaster preparedness program is tested by an annual test of the full program internally or as
part of a communitywide test.
Disaster Plan
APP 1430-29 Activation of Code Black – Disaster
FIRE SAFETY
APP 1428-21 Hospital Fire Safety Program
Fire Safety Management Plan

When you discover Fire

REMEMBER…

CODE RED PROCEDURE FIRE EXTINGUISHER PROCEDURE

R Rescue patient in area of immediate hazard P Pull out the safety pin

A Activate the Alarm – alert others A Aim nozzle at the base of the fire

C Contain fire and smoke, ClOSE all doors S Squeeze the operating lever and handle

E Extinguish the fire if you can without S Sweep over the fire

endangering yourself

Remember: Always use proper type extinguisher to fight fire

HALON & DRY POWDER : CLASS “A”,”B” & “C” Class A: Solid or ordinary combustible materials

CO2 : CLASS “A” & “B” Class B: Flammable liquids and gases

WATER : CLASS “A” ONLY Class C: Involving energized electrical equipmentY

Observe effective Fire safety and Fire prevention measures:

• Ensure that your department/ward practices good housekeeping.

• Report any faulty equipment.
• Store flammable/combustible items properly.
• Ensure that staff are aware of the procedures for safe handling of such items.
• Ensure that staff are aware of the evacuation route(s) and assembly point of the department / ward.
• Know where your fire extinguishers are and how to operate them.
• Familiarize yourself with the safety manual and attend regularly Fire safety drills & Fire safety
in-service training.
• Always treat a spilled substance as hazardous until identified as non-hazardous by proper authority.
• Hazardous material spill procedure (by Fire Department).

39
 UTILITY SYSTEMS
JCI New Requirements
APP 1426-15 Water Quality Monitoring Program
Utilities Management Plan – KAMC & KASCH
Water quality is also a critical factor in clinical care processes, such as renal dialysis. This the hospital
establishes a process to monitor water quality and implements actions when water quality is found to be
unsafe.
Quality of potable (drinking) water is tested at least quarterly, for non-potable water is tested at least every
6 months or more frequently based on local laws & regulations, conditions of the sources for water.
The testing results are measures and documented, actions are taken when water quality id found to be
unsafe.
Utility systems are inspected, maintained and improved.
• Preventive maintenance (PPM) • Effective
• Tested and monitored • Efficient

MEDICAL EQUIPMENT
APP 1429-05 Management of Healthcare Technology
Healtcare Technology Management Plan-KAMC & KASCH
The hospital establishes and implemet a program for inspecting, testing and maitaining medical equipment
and documenting the results.
Medical equipment is available for use and functioning prporly, the hospital performs and
documents:
• Inventory of medical equipment
• Regular inspection
• Testing according to its use and manufacturers’ requirements
• Performance of preventive maintenance (PPM)

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 SQE STAFF QUALIFICATION and EDUCATION

This chapter includes sections on human resources planning; staff orientation, training, and
education; staff competence assessments; handling staff requests; and credentialing and privileging
of licensed independent practitioners, nurses, and other practitioners

APP 1427-02 Employee Personnel File

JCI REQUIREMENTS FOR SQE

1. Personnel files must:
• Contain the qualifications of the staff member.
• Contain the job description of the staff member when applicable.
• Contain the work history of the staff member.
• Contain the results of evaluations (Probation and Annual Evaluation).
• Contain a record of in-service education/ training attended by the staff member.
• Contain a proof of cardiac life support training for those staff who provide patient
care.
• Contain a proof of education, licensure/registration, and other credentials issued by
recognized education entities and verified from the original source that issued the
credential.(PSV)
• Health information ( New required standard).
• Standardized and current and maintained according to hospital policy.

JCI New Standard

The hospital provides a staff health and safety program that addresses staff physical and mental
health and safe working conditions, and identifies staff who are at risk for exposure to and possible
transmission of vaccine-preventable diseases and implements a staff vaccination and immunization
program.
1. Initial employment health screening
2. Measures to control harmful occupational exposures (toxic drugs & harmful noise level)
3. Periodic preventive immunizations & examinations
4. Education, training & interventions on safe patient handling
5. Education, training & interventions on managing workplace violence
6. Education, trianing & interventions for staff who may be second victim of adverse or sentinel
events
7. Treatment for common work-related (back injuries or urgent injuries)

The hospital identifies areas for potential workplace violence and

implements measures to reduce the risk.

The hospital provides evaluation, counseling, and follow-up treatment of

staff who are injured as a result of workplace violence.

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 MOI MANAGEMENT OF INFORMATION

Providing patient care is a complex endeavor that is

highly dependent on the communication of information. This
communication is to and with patients and their families, other
health care practitioners, and the community. Failures in
communication are one of the most common root causes of
patient safety incidents.

Often, these communication failures result from illegible

handwriting, and the non-uniform or nonstandardized use of
abbreviations, symbols, and codes across an organization. The
standards in this chapter address the documentation of the
health care providers in the patient’s medical Records .

APP 1430-10: Clinical Record Content and Documentation Standards

The purpose of the policy is to provide a process to guide the content and documentation standards
in relation to Ministry of National Guard - Health Affairs (MNG-HA) patient clinical records.

APP 1433-30: Release Of Patient And Hospital Information

The purpose of the policy is to ensure privacy, confidentiality, security and data integrity are
maintained regarding the release of verbal and/or written statements in relation to patients and/or
the hospital information to the press, radio, television and/or families and friends by authorized staff.

APP 1431-24: Control And Release Of Patient Clinical Records

The purpose of the policy is to ensure the safeguard and release of Ministry of National Guard - Health
Affairs (MNG-HA) patient clinical records, and provide the healthcare provider’s role in maintaining the
privacy, confidentiality and security of patient clinical records.

APP 1427-16: Error-Prone Abbreviations, Symbols and Dose Designations

The purpose of the policy is to facilitate patient safety by establishing safe practices for the use of
abbreviations, symbols and dose designations in medication related documentation and communication
as well as to reduce and eliminate medication errors as a result of misinterpretation of error-prone
abbreviations, symbols and dose designations within the Ministry of National Guard - Health Affairs
(MNG-HA) and all its affiliated facilities.

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 MPE MEDICAL PROFESSIONAL EDUCATION

These standards address how the academic medical center hospital educates, supervises, grants
privileges, and otherwise incorporates its medical students and trainees into its care processes and
other daily operations.

SAUDI COUNCIL RESIDENCY TRAINING PROGRAM

Residency Training Programs are designed to provide residents with an opportunity for the
incremental acquisition of knowledge, skills and responsibilities which will enable them
proficiently to practice medicine in their given specialties. KSAU-HS Residency Programs
enjoy a reputation among the local community for having outstanding training programs,
because it starts with outstanding individuals, who are driven to success and eventually
become Saudi Board and/or Arab Board Certified.

The chapter is addressing the following elements

1. Those responsible for governance and leadership of the hospital approve and monitor the
participation of the hospital in providing medical education.
2. The hospital’s clinical staff, patient population, technology, and facility are consistent with
the goals and objectives of the education program.
3. Clinical teaching staff are identified, and each staff member’s role and relationship to the
academic institution is defined.
4. The hospital understands and provides the required frequency and intensity of medical
supervision for each type and level of medical student and trainee.
5. Medical students and trainees comply with all hospital policies and procedures, and all
care is provided within the quality and patient safety parameters of the hospital.
6. Medical trainees who provide care or services within the hospital -outside of the parameters
of their academic program—are granted permission to provide those services through the
hospital’s established credentialing, privileging, job specification, or other relevant
processes.

Orientation for Medical Students must include the following:

a) Hospital quality and patient safety program
b) Infection control program
c) Medication safety program
d) International Patient Safety Goals
e) All other required hospital orientation, including at the
department and unit level.
f) Any ongoing required education

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 HRP HUMAN SUBJECT RESEARCH PROGRAM

The standards in this Chapter applicable only when the organization categorized as an Academic
Medical Center Hospital

The standards in this chapter addressing the hospital’s processes to oversee research involving
hospital staff conducting the research and all research subjects, regardless of who or what entity
sponsors the research. All hospital patients and their families are informed of ongoing studies and
their right to participate if they meet study criteria. Study subjects give informed consent to participate
in research protocols only after a defined process that explains potential risks and benefits (and other
required elements) has been conducted by the principal investigator or authorized designee.

Mission:
To generate cutting-edge scientific research that helps improve the health of the population.
Vision:
To be a leading international institution in biomedical and clinical research.

APP 1419-05: Preparation of Research Proposal, Processing and Approval

The purpose of the policy is to provide a process for the submission, processing and approval of
research proposals for clinical and non-clinical research studies at Ministry of National Guard Health
Affairs (MNG-HA) and all affiliated facilities

APP 1426-02: Institutional Review Board (IRB)

The purpose of the policy is to provide a process for reviewing ethical research involving human
subjects. It specifically aims to protect the rights and health of human subjects used in research
investigations whilst promoting free inquiry and research and to assure compliance with relevant rules
and regulations.

APP 1432-04: Appeal Process for Rejected Research Proposal or Suspended Ongoing Research Study

The purpose of this APP is to define the policy and procedure which govern the process of appealing
against a decision made by the Institutional Review Board (IRB), the Research Committee (RC), the
Retrospective Research Sub-Committee (RRSC) or the Research Funding Committee (RFC) to:
• Reject the research proposal or
• Suspend an ongoing research study

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APP 1432-04: Appeal Process for Rejected Research Proposal or Suspended Ongoing
Research Study

The purpose of this APP is to define the policy and procedure which govern the process of
appealing against a decision made by the Institutional Review Board (IRB), the Research
Committee (RC), the Retrospective Research Sub-Committee (RRSC) or the Research
Funding Committee (RFC) to:
• Reject the research proposal or
• Suspend an ongoing research study

APP 1432-20: Monitoring Research Studies

This APP describes the policy and applicable procedures for monitoring approved research
studies to ensure that they have been executed in compliance with the approved study pro-
posal, ICH/GCP guidelines, King Abdullah International Medical Research Center (KAIMRC)
and other requirements from the regulatory authorities.

What will happen in Academic Medical Center Hospitals where patient tracers will include patients
on a research protocol

The discussion for Research may include the following:

1. How staff were trained on the protocol.

2. How patients on research protocols were
identified.
3. What staff understand about the informed
consent process. Review HRP
4. What happens when a patient asks to leave Standards
the study. and
5. The process when a protocol has changed. Policies
6. If a protocol changes, how patients are
re-enrolled and
sign another consent.
7. The process when an adverse event occurs.

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 King Abdulaziz Medical City
Ministry of National Guard- Health Affairs