Ocean et es ‘su con ter for ecreton tthe nn _ STANDARDS wD. Lotz Lots L26 27 Lo28 Lo29 Lo2.10 The hospital has an effective governing body. ‘There i a governing body that fulfils its main roles for mission and strategy setting as well as performance evaluation and oversight onthe hospital processes and outcomes. The governing body has its organization, membership, oles and responsibilities, meetings procedure, performance evaluation, and committees defined in a written bylaws or a similar ‘document The governing body's responsibilities reflect its ultimate accountability for the quality of ca ‘and patient safety, and include the following LD.1.3.1 Working together with the senior management and hospital leaders to crea regularly review the hospital's mission, vision, and values. LD.1.32 Appointing a qualified hospital director. D193 Evaluating on a regular basis the performance of the hospital director. D134 Ensuring that the hospital has an effective organizational structure displayed in an organizational chart that shows the titles (or names) and the reporting relationships. LD.1.35 Approving the scope of services provided by the hospital 0.1.3.6 Approving the hospital strategic and operational plans, LD.1.37 Approving the hospital-wide policies and procedures. 10.138 Monitoring, evaluating, and continuously improving the outeome of the quality and. patient safety plans and programs, LD.13.9 Approving the medical staff bylaws LD.1.3.10 Approving the annual budget of the hospital and 0.13.11 Ensuring the provision of adequate resources (e.g. manpower, financial resources and medical supplies). 0.13.12 Defining and approving delegations of authority. ‘The governing body meets regularly and adequate minutes of the proceedings are maintained. A qualified hospital director is responsible for managing the hospital. ‘The hospital director is qualified in healthcare management by education, training or experience ‘The hospital director has a good command of the English language. ‘The hospital director ensures the hospital's compliance with all relevant laws and regulations. The hospital director ensures the recruitment and selection of competent and skilled hospital stat The hospital director is accountable to the governing body for the clinical performance and Professional conduct of the hospital stat ‘The hospital director ensures the implementation of the policies set by the governing body. ‘The hospital director participates actively in supporting the safety of patients, staff and visitors (e.g. through leadership safety rounds, review of reported incidents) The hospital director identifies and works closely with other hospital leaders, collectively constituting the hospital leadership group. ‘The hospital director ensures appropriate response to reports or enquiries from relevant authori 2 including accreditation agencies. ‘The hospital director ensures the availability of adequate resources (e.g. human resources, ‘equipment, supplies, and medications) Eyer) el assOcsani ita tore Loan L212 D3 Lost Los2 Lat \o42 Lo43 Lo44 4s Lo46 Lost Los2 Los3 Loss Loss Lose L061 Le2 Les ‘The hospital director ensures all physical properties are kept in a good stat ‘operating conditions, ‘The hospital director ensures the efficient utilization ofall resources. of repair and Hospital leaders ensure the hospital is in compliance with relevant laws and regulations. Hospital leaders identity all relevant laws and regulations. Hospital leaders ensure compliance with all relevant laws and regulations (e.g, laws and regulations related to recruitment, professional staff licensure and registration, waste management, food management, infection control, medications management, patient rights, radiation safety, and physical environment) Hospital leaders work collaboratively to develop the hospital's scope of services. Hospital leaders identity the scope of services provided by the hospital ‘The scope of services includes the range of services offered by the hospital e.g. children hospital, ‘maternity hospital, or general hospital. ‘The scope of services includes the targeted age groups. ‘The scope of services includes the number of patients seen annually ‘The scope of services includes the principal diagnostics and therapeutic modalities used inthe hospital ‘The scope of services is approved by the governing body. A structure is in place for the hospital leaders to communicate and collaborate in order to fulfill the hospital's mission and plans. Hospital leaders form an executive management body (e.g, an executive management committee), led by the hospital director and includes the medical director, the nursing director, the Quality director, selected heads of the departments, and other senior staff members as required. Hospital leaders are qualified in healthcare management by education, Hospit ing, or experience, leaders have specific responsibilities as outlined in a current job description. Functions and meetings of the hospital leaders are outlined in specific terms of reference. Hospital leaders meet regularly (at least ten times per year) to evaluate the progress of the overall strategic plan , the quality and safety of care provided to patients, and all other clinical and non-clinical issues related to the hospital work. Discussions, decisions and actions taken by the hospital leaders are documented in a formal meeting minute The hospital administrative work and day to day operations are consistent and organized. The hospital work is guided by a manual that contains all important hospital-wide guiding ‘administrative policies and principles. The contents of the manual are communicated with and made accessible to the hospital staf, Contente of thie manual reflect the general organization of the hospital work and include, but are ot limited to, the following @ eh 4 3 > Ee 5 7)oO CBAHI . AiaetediaN eles goca isat wor 072 07a L075 LD.8 81 Loa2 was Las Lot Lez LD.63.1 A brief general description of the hospital. D832 Vision, mission ana values. D633 Organizational chart LD.634 Scope and organization of services. LD.635 Standing meetings and commi D636 Staff code of conduct and ethics. D637 Conflict of interest. D638 Admission/Discharge/Referral LD&39 Visiting times. LD.6.3.10 Smoking policy. LD.63.11 Parking, The hospital work, planning, and mission. The hospital has a clearly stated vision and mission statements. The vision and mission are communicated to the hospital staft. The vision and mission are displayed to patients, visitors, and the wider community. ‘The mission reflects the scope of services provided by the hospital and the health needs of the population served ‘The mission and vision are regularly reviewed and modified ind goals setting are guided by a clear vision ppropriat The hospital work, planning, and goals setting are guided by a set of values and professional code of conduct. Hospital leaders collaboratively develop the hospita' set of values and the code of conduct. ‘The professional code of conduct describes the hospital's expectations of the staff regarding their behavior and communication with each other and with their patients and other external customers, The professional code of conduct includes hospital stat The professional code of conduct includes process to resolve conflicts among staff and betw ‘process to handle inappropriate behaviors of the n staff and external customer Hospital leaders work collaboratively to establish medic: medical hospital-wide committees that support integration of services and communication amongst staff. ‘There is a policy and procedure that addresses the formation of hospital-wide committee conduct and communication amongst the committee member approval process, and annual review of accomplishments Medical committees provide oversight on specific are 10.921 Pharmacy and therapeutics. 10.922 Morbidity and mortality 10.929 Infection contol and non- committee's recommendations that include of responsibil a ef J a 5 > Es] 3 7)Ocsani places eae toes Los4 Los Lo.t0.1 1.102 10.103 Lott Lore D924 Cardio pulmonary resuscitation LD.925 Credentialing and privileging LD.926 Operating room. LD.927 Tissue review. LD.928 Blood utilization review. 0.928 Quality and patient safety LD.92.10 Medical records review. 10.92.11 Patient rights. 0.92.12 Utilization review. Each committee has terms of reference that define: LD.93.1 Committee functions. LD.932 Chairperson and members with their titles. 10.933 Quorum. 0.834 How often the committee is expected to meet (at least quarterly unless otherwise ‘specified in this manual), LD.835 Mechanism of disagreement resolution including when to resort for voting and members that are not allowed to vote. 0.836 Distribution of the minutes to the executive management. ‘There is an annual review of each committee's accomplishments and non-resolved issues ‘submitted by the committee chair to the executive management, Feedback from the annual review is studied by the committee and recommendations are implemented. Hospital leaders drive effectively the quality improvement initiatives in the hospital. Hospital leaders are fami Improvement, such as: 1L0.10.1.1 Basic data analysis and interpretation of quality reports 10.10.12 Basic tools used in quality management e.., POCA cycle) 10.10.13 Root cause analysis. Hospital leaders participate actively in quality improvement plans and projects. Information about the quality and performance of the services offered including the accreditation status) are communicated to the stat, governing body, public, community, and other customers in an appropriate format i with the basic concepts and tools used in continuous quality Hospital leaders consider the community input during planning for health care needs of the population Hospital leaders identity the relevant community leaders (e.g, members of the regional council, es, patients rights advocates, civil defense, health elated commissions and councils, other society organizations and representatives) Local community leaders participate in planning for the current and future health care needs ofthe population (.g, planning for health-relevant demographic changes, public health issu ‘groups with special needs members of municipal a eI S 5 = E 3 aOcean lita Er Lo.113 borat Lo.122 Lo.123 Lo.124 0.125 10.126 L.127 D.13 Lo.13.1 Lo.132 10.133 Lo.134 Loss POET u.14.t L142 L143 L015. 1.152 1.153 L154 Hospital leaders plan with the community leaders to provid ‘and health promotion for patients and the wider community rviees related to health education Hospital leaders work collaboratively to develop an effective planning process ‘The planning process includes soliciting inputs from patients and staff eg. feedback from patient satisfaction surveys and patients/statf complaints) The planning process is consistent with the hospita's mission and strategic directions ‘The planning process considers cultural and religious needs ofthe local community. ‘The planning considers environmental and financial factors and is consistent withthe hospital's mission and strategic rection, ‘The planning process ensures coordination and integration of services throughout the hospital ‘The planning process ensures efficient use of different resources through regular evaluation by hospital leaders against plans and budgets ‘The planning process considers the upgrade or rep resources. sment of buildings, equipment, and other Hospital leaders work collaboratively to develop an effective budgeting process. ‘The hospital has a finance director who is qualified by education and experience. Hospital leaders work together to address both the capital and the operating budgets, ‘The budgeting process addresses the manpower in addition to other financial assets. ‘The budgeting process allocates resources to all patient care units based on the scope and complexity of care, aiming to ensure a safe, efficient process. ‘The hospital's budget is approved by the governing body. Hospital leaders work collaboratively to ensure the provision of a safe and quality care. Hospital leaders encourage the use of research, evidence, and best practice information to Gevelop and improve patient care services. Hospital leaders work collaboratively to develop and execute plans, policies, and procedures related to the patient care 10 solve challenges, conflicts, and problems affecting the Hospital leaders work collaboratively to develop the hospital strategic plan. Hospital leaders work together to develop a strategic plan that is guided by the mission, vision, and values, ‘The strategic plan is based on comprehensive evaluation of the intemal and external ‘environmental factors (e.g, SWOT analysis, PEST analysis) ‘The strategic plan addresses all clinical and non-clinical services and programs. ‘The strategic plan spans over a period of -§ years and is reviewed on a regular basis.Ocean slain pcan 0.155 L.156 157 10.158 10.159 10.15.10 wo.15.11 0.16.1 10.162 10.163 10.164 10.165 10.166 10.167 up.17.1 172 L018. Lo.182 Lo.183 Lo.184 Lots Lo.186 ‘The strategic plan includes the broad goals and objectives required to fulfill the hospital's mission. Goals and objectives are translated into operational plans with defined projects, clearly delineated responsibilities, and time fram« Resources required for executing the operational plans are properly allocated, Operational plans are implemented and closely monitored for progress toward achieving the goals and objectives. LD.158.1 Key performance indicators are developed for each operational plan, 0.15.82 Key performance indicators are reviewed regularly and corrective actions are taken when required. Heads of departments develop annual departmental plans in line withthe hospital's strategie plan. The strategic plan is communicated to relevant staf. ‘The strategic plan is approved by the governing body. Hospital leaders work collaboratively to plan for staffing needs, recruitment, and selection. Hospital leaders work together to develop a hospital-wide staffing plan. ‘The staffing plan defines the total number and categories of staff required by all departments and their qualifications. ‘The statfing plan ensures the services provided by stat! meet the health care needs ofthe patients The staffing plan is consistent with the hospital strategie plan, The staffing plan is reviewed at least annually. Hospital leaders ensure a uniform and fair process for recruitment and hiring of new staff members. Heads of departments participate in the selection of new stat The hospital has a process for delegation of function and authority. ‘There is a policy and procedure that guides the process for delegation of function and authority, between two qualified peers. ‘The process of delegation is consistent with other relevant hospital pol Hospital leaders ensure an effective and efficient internal and external communication. ‘The hospital implements a policy that outlines the process, including roles and responsibil for communication between the different departments, both vertical and horizontal Departmental staff meetings are held on a regular basis and minutes are documented. Hospital-wide policies are properly communicated to all relevant staf ‘The hospital utilizes one or more of professional communication tools (e.g, intra-net, bulletin boards, periodic reports, newsletters, and website) ‘The hospital implements a policy that outlines the process, roles and responsibilities for handling all incoming requests from other hospitals and external organizations, ‘The response to the incoming requests is timely and informative. a 2g > 5 b= Es] 5 ci)Ocean scone eet pani Lo.19.1 to.192 Lo.193 Lot94 Loss Lo.196 Lo.19.7 \201 \202 \203 L204 L205 L206 10207 1208 want L212 Lo21s Loe Lois. io2t6 uo2i7 Lo2ie Initiation of a new process or changing of an existing one is systematic and consistent throughout the hospital. ‘All customers of a new or modified process are identified Customers’ needs and feedback are addressed when dé Procedure, new practice guideline) or changing an existing one. Hospital leaders ensure that the initiation of a new process or the changing of an existing one is. ‘always based on evidence, research, and best practice. Hospital leaders assess new or modified processes for risk and safety issues. Whenever applicable, new or modified processes undergo pilot testing betore their routine use. Hospital leaders regularly evaluate new or modified processes through proc: Indicators to ensure an optimal performance. Hospital leaders ensure the provision of staff training on new or modified processes. ning @ new proces and outcome The hospital has a policy for controlling the development and maintenance of policies and procedures for key functions and processes. ‘There is a unique identification for each policy with title, number, and dates of issue and revision. Policies are developed, approved, revised, and terminated by authorized individuals, Policies are dated and are current. Policies are revised according to a defined revision due date (every 2-3 ye Policies are communicated to statf and are always accessible, ‘A process is in place to ensure that new or updated policies are appropriately communicated to relevant statt ‘A process isin place to ensure that policies are always implemented, A process is in place to ensure that only the last updated versions of polici (e.g,, organizational plans) are available for use in the hospital. ‘or when required), snd other documents Hospital leaders ensure the overseeing of contracts for clinic: administrative service: Policies and procedures are in place to ensure the quality and safety of all contracted services. Policies and procedures indicate how to track and monitor all contracted services for quality and fety (within the hospital premises and off-site) Hospital leaders ensure that the contracts clearly state the services to be provided by the ‘contracted entity Hospital leaders and other heads of departments participate in the selection, monitoring, and ‘management of contracted services, Hospital leaders ensure that contracted services and provi regulations. and rs both meet applicable laws and Hospital leaders ensure the services provided are con: ty standards. ‘The quality of services provided is always considered by hospital leaders before contract renewal The proc tent with the hospital's quality and {or contracts oversight is documented a 3 > is} > a fe aOcean Ie se 221 10222 L023 L232 L0.233 Lo234 Lo235 ae eT twas cE 0.242 L025. L252 L253 Hospital leaders ensure coordination of care during off duty hours. The hospital has a qualified duty manager with a clear job description to coordinate the care during off duty hours. ‘The duty manager has the resources required to function (e.g, efficient office epace, information fon vacant and occupied beds, authority to allocate beds between different specialties, authority to accept referrals trom other hospitals) Hospital Leaders ensure there is a system for the safe management of medical supplies and devices. Hospital leaders and relevant heads of departments identity all medical supplies and devices that are essential forthe provision of a safe quality care, ‘Suppliers of medical supplies and devices are qualified and carefully selected and evaluated. Medical supplies and devices recommendations. Medical supplies and devices are protected against theft, damage, contamination, ordeterior Hospital leaders conduct regular inspections to ensure the safety of medical supplies and devices (eg, storage conditions, integrity, contamination, expiration) Hospital leaders respond to any adverse effects resulting from the use of medical supplies and devices through prompt investigation and the use of recurrence prevention measures. Hospital leaders ensure the reporting of adverse effects resulting from the use of medical supplies ‘and devices to the relevant regulatory authorities. The hospital has @ process for safe segregation and disposal of expired, damaged, or contaminated medical supplies and devices. ‘The hospital has a proce: leve dispensed supplies and devices when recalled or discontinued by the manufacturer or relevant regulatory authorities for safety fe stored safely and in accordance with manufacturer's Hospital leaders work collaboratively to optimize the flow of patients. Hospital leaders address all variations contributing to waits, delays, and cancellations that impact smooth and timely flow of patients through hospital departments, Hospital leaders implement strategies to maximize the efficiency of the flow of patients, Each clinical and administrative department is directed by a qualified individual. Each department has an assigned department head Qualifications, experience, and training of the appointed department head match the services Provided by the department. When the department head is appointed on a part-time ba that is part of a corporate chain), the department he: L0.25.3.1 Ensures that work flow and patient safety are not compromised during his absence. 0.25.32 Ensures that the department functions are well managed through regular scheduled visits LD.253.3 Provides guidance department during his absence LD.25.34 The frequency and duration of the visits must be documented in the contract. (e.g, 2 small hospital or a hospital well as continued ssessment ofthe individual in charge of the a 4 > i=] > a ] aOcean ee oa Lo26.1 026.2 026.3 \o27.t L272 \o273 [DET 028.1 L282 1283 LD.29 L020. L292 L293 1030.1 L302 The department head develops an organizational chart for the department. Each department has an organizational chart that clearly displays all sectionsidvisions within the department, titles (or names), lines of authority, accountability, and reporting relationships. The organizational chart is signed by the department head and approved by the hospital management ‘The organizational chart is communicated to the staff working in the department. ‘The department head addresses alll issues related to the customers of the department. ‘The department head identifies all internal and external customers of the department (p families, visitors, stat, suppliers, and contractors ‘Whenever required, there is written agreement or verbal understanding between the department ‘and other clinical departments andior external customers, explaining the expectations of each party ‘The department head has a mechanism for identifying and handling customers’ needs and feedbacks (e.g, responding to complaints, satisfaction surveys) ‘The department head develops and maintains the mission of the department and its scope of services. The department head develops a written mission for the department that is consistent with the hospital's mission. The department head provides a written scope of services provided by the department that is Consistent with the hospital's scope of services, ‘The department head ensures coordination and integration of services within the department and with other departments The department head ensures the work of the department is guided by a clear set of departmental policies and procedures. The department head develops and maintains a manual for all relevant departmental policies and procedures. The department head collaborates with other department heads to develop multidisciplinary policies and procedures. The department head ensures and oversees the communication of policies and procedures to evant staff and their implementation. The department head ensures sufficient resources and staffing are available for the delivery of safe and quality service. ‘The department head defines and requests the resources required by the department for a and quality service (eg, space, equipment, supplies, statfing, and other resources) ‘The department head provides a written departmental stafing plan that defines the number, type, ‘and qualifications required for each position to fulfil the departments responsibilities. fe Tesh el AnyOcean poet 1303 10304 10305 Lostt Losi2 Losi3 Lose Loss Lose Los17 The department head defines the qualifcatior other relevant ce ion, training, experience, sation~ required by all categories of staff In the department, ‘The department head ensures the provision of orientation, raining, and continuing education for the staff working in the department. ‘The department head monitors the performance of the stat license, and any The department head ensures performance measurement and improvement of the outcomes of the department. Performance measurement and improvement are consistent with the hospital wide quality improvement, patient safety, and risk management plans. Performance measurement and improvement are based on the important processes and priorities of the department. The department head selects and monitors the appropriate performance indicators (eg, two indicators ata time Performance measurement and improvement involve regular data collection and analysi appropriate improvement actions/projects. ‘The department interacts with other departments/committees to promote the quality improvement ctfors when needed Results of performance measurement and improvement are reported periodically tothe hospital leadership (eg. the executive management committee or the quality improvement committee) ‘and shared with stat, departments, and committees as applicable. Staff members participate in quality improvement and patient safety activities and rec training on quality assessment and improvement. nd ere Leg) a = S S 4 Fe 5 cyOcean fetid See Human Resources (HR) Introduction In order for the hospital to provide a quality and safe care, improving the human resources practices and ‘management is critical. In this twenty first century, itis not acceptable any more for @ hospital to operate without an efficient human resources department directed by @ qualified director who understands the contemporary practices for managing people in a complex setting like the healthcare industry Recognizing the human resources challenges and the best strategies to follow should be on the top list of the hospital management. This chapter is newly added to this manual to emphasize the importance of a successful human resources management in any hospital or healthcare organization trying to compete for a better care and ‘more market share. ‘This chapter discusses the standards related to the following functions of the human resources management. Attraction of qualified staff Orientation of new statf Ver ining and education Continuous competency evaluation and performance appraisal Job description Personnel files Staff health Staff complaints Staff satistaction ication of credentials ® M4 ES 5 4 a 5 7)Ocean ea ea ‘sua can ord octane tn _ STANDARDS HRA HRI2 R13 cae HR21 HR22 HR23 HR24 HRSA HR2 HRS3 HRS4 HAAS HAS6 HR7 HRA1 HR42 HAAS HRAe The hospital has human resources departmentsunit. ‘The human resources department is well staffed and equipped to match the size and needs of the hospital ‘The head of the human resources department is qualified in managing human resources by ‘education, training, or experience Policies and procedures manual guides the work of human resources department, HR.1.3.1 The manual includes items related to recruitment, hiring, resignation, termination, Grievance and complaints, leaves, new employee orientation, on job training, and performance appraisal. HR.1.32. The manual is made accessible and communicated to all statf members. HR.1.33 Policies and procedures contained in the manual are implemented, Heads of departments, in collaboration with the human resources department, develop, implement, and monitor departmental staffing plans. Each department nas a written stating plan, developed in collaboration with the human resources department, to fulfil its part of the hospital's mission, ‘The departmental staffing plan defines the number, type, and qualifications of staff required for ‘each department and their job responsibilities. ‘The staffing plans are reviewed and updated at least annually and as needed The staffing plans are monitored to identity deficiencies and take improvement actions accordingly. Alll categories of staff have clearly written job descriptions. ‘There is a policy that describes a standardized format for job description, ‘The job description is used when selecting employees for hire, performance evaluation, internal promotion, and transfer. Al job descriptions are revised at least every three years and as needed, The job description defines the required knowledge, skills, and attitude to perform the job responsibilities. ‘The job description clearly defines the roles and responsibilit ‘The job description specifies the reporting relationships, ‘The job description is discussed with and signed by the staff member on hiring and is kept in the personne! file The hospital maintains personnel files for all employees. ‘The hospital has a policy guiding the initiation, management, content updat ‘and disposal of personnel files, Personnel files are complete and updated. Personnel files are kept confidential and only those who ai Personnel files contain the following minimum items: HR.4.4.1 Qualifications; including current licensure, certificat HR4.42 Current job description. HR4.43.Reteren: and retention time authorized can access them. ion, i applicable. fel) fel Ans)Ocean eee ee ESR cia HAA HR.4.44 Orientation, continuing education, and training records. HR.4.45 Performance evaluations. HR.446 Records of leave and sickness, HR.4.47 Disciplinary actions, i any. HR448 Other documents required by relevant laws and regulations. ‘The hospital has a process for proper credentialing of staff members licensed to provide patient care. HRS.1 Tho hospital hae a written pol credentials. HRS2 The hospital gathers, verifes, and evaluates the credentials (license, education, training, certification and experience) of those medical staf, nursing staff, and other health professionals licensed to provide patient care HAS3 Credentials are verified from the original source. y describing the process used for the verification of HR54 Job responsibilities and clinical work assignments/ privileges ate based on the ‘evaluation of the verified credentials, HR55 The hospital ensures the registration of all healthcare professionals with the Saudi Commission for Health Specialties. HRS6 — Staff licensed to provide patient car ‘must always have and maintain a valid license to practice only within their profession, HRS7 The hospital maintains an updated record of the current professional license, certificate, or registration, when required by laws, regulations, or by the hospital for every medical staff, nursing staff and other healthcare professionals. HR.5.8 When verification of credentials is conducted through a thitd party, the hospital must request for a confirmatory documentation HAS9 Verification process applies to all clinical statf categories (ull time, part time, visitor, and locum) New employees go through a general hospital orientation program before allowed to work independently. New employees , contract workers, students, and volunteers go through a general orientation program that provides the relevant intial training and information onthe following: HR.1.1 Hospital mission, vision, values, and orga! tional chart. HR.6.12 Role of staff members in all programs related to facility management and safety (e.g fie, safety, disasters, hazardous materials, utlities, and equipment failures) HR.6.13 General information on infection control HR.6.1.4 General information on the paging and telephone system, HR.6.15 General information on staff evaluation process, HA.6.16 Definition of adverse and sentinel events along with the proc HR.6.1.7 Hospital policy on abuse and neglect of children and adults. HR.6.18 Hospital policy on credentialing and privileging HR.6.19 General information about staff health program, HR.6.1.10 General information about important local cultur of reporting and social themes. % 4 3 re > Fs 5 &Ocean pi lreauanee HRe2 HR6S HRes Gia HATA HRT.2 HATS HRT.4 Cie HRB HR82 HRaS HRs al HR HR92 HARES HRO4 HR.6.1.11 General information about the hospital-wide quality, patient safety, and risk management plans. HR.6.1.12 Ethical conduct and expected professional communication with patients and colleagues. HR.6.1.19 Patient rights, The hospital provides all new employees with an “Employee Manual” or equivalent that contains ‘a summary of the general orientation program as well as other relevant important information. ‘The general orientation program is conducted before working independently ‘The general orientation program is documented in the employee's personnel fie. New employees go through a departmental and job orientation program before allowed to work independently. ‘The departmental and job orientation program is defined in a departmental policy and includes the following: HR.7.1.1 Departmental policies and procedures. HR.7.1.2. Specific job responsibilities within the department as outlined in the job description HR7.13. Safe operation of equipment and medical devices including troubleshooting and ‘matfunctions reporting, HR7.14 Clarification on all topics provided in the general orientation as needed. ‘Additional orientation is provided upon changing the job description or introducing a new technology or equipment. ‘The departmental orientation is conducted by the head of the department or the immediate ‘supervisor. ‘An evidence of attending the departmental and job orientation program i ‘employee and documented in the personnel file ned by the new The hospital has a process for i conduct of the new employees. ‘The hospital has @ process described in a policy or other document for initial evaluation of the competency of the new employees. All new employees go through a probationary period tor competency evaluation. During this Period, clinical staff can only work under direct supervision Competency evaluation during the probationary period is a structured process that aims to assess and review the employee's knowledge, performance, capabilty, conduct, and suitability forthe role. ‘The competency evaluation is documented in the personnel fle, itial evaluation of the competency and The hospital has a process for the regular evaluation of staff performance. ‘There is a policy describing the process used in the regular evaluation of staff performance. ‘The performance evaluation is based on objective criteria and is linked with the job description. ‘The performance evaluation is a two-way process conducted at least annually. ‘The outcome of the performance evaluation is used to set objectives for performance improvement ‘and professional development. a | PS S > Fs] 5 CyOcean sleet HROS rien HR.10.1 HA.102 RAIL HR112 HRI HR HRL121 HA122 uation is signed by both the employee and the supervisor and is documented in the personnel file. The hospital identifies the staff training and educational needs. ‘The hospital has a process in place for identification ofthe training and educational needs of the different categories of hospital stat ‘The training and educational needs are identified based on objective criteria that include, but are ‘ot limited to, the following: HR.10.2.1 The hospital mission, vision and scope of services. HR.10.22 Individual staff member's education and training history. HR.10.23 Information trom quality, }essment and improvement activi HR.10.24 Needs generated by advancements made folds. HA.10.25 Findings from department performance app HR.10.26 Findings from peer review activities. HR.10.27 Findings from the hospital's technology and safety management programs, HR.10.28 Findings from infection control activities. 8 the medical and healthcare management of individuals The hospital supports continuing education for all staff members. ‘There isa policy describing the structure and the process used inthe continuing education of all categories of stat ‘The hospital grants financi ‘Support and time of for staff to attend educational activities ‘The hospital has an educational program with an ongoing schedule of educational activities and training based on the hospital needs, The department head recommends and evaluates the educational and training activities required to maintain statt competencies to provide care. This process Is linked to performance improvement and documented in the personnel file. ‘Staff members providing direct patient care are trained on cardiopulmonary resuscitation. Allstaff members who provided profes Is renewed every two years. ‘The hospital identifies and provides training for other staff categories in areas related to advanced ‘cardiac lite support (ACLS), neonatal resuscitation program (NRP), pediatric advanced life support (PALS), and advanced trauma life support (ATLS). Examples include, but are not limited to: HR.12.2.1 Physicians and nurses working in criti certification in ACLS, PALS and NAP. HR.12.22 Internal medicine physicians must m HA.12.2.9 Emergency department phy PALS and ATLS. HA.12.24 Pediatricians must maintain additional certifcation in PALS and NAP. ct patient care (medical staff, nursing staff, and other healthcare ionals) maintain a valid certifcation in basic cardiac life support (BCLS) and certification | care areas must maintain additional propriate to the patients’ age groups. tain additional certification in ACLS. ians must maintain additional certifcation in ACLS, ny I = S > a S cr)Ocean en HR.13.1 HR.13.2 HR.133 HR.134 HRA HA142 HR143 R153 HAI54 HR.16.1 HR.162 HR.163 Saud con onl or Actas eects The hospital has a program that addresses staff health and safety. ‘The hospital has a statf health and safety program that is consistent with laws and regulations and covers all staff members. ‘The program is based on assessment and where necessary, reduction of occupational he and safety risks th The program is coordinated with the hospital's quality, safety, risk management, and infection Control programs, ‘The program includes, but is not limited to, the following: HR.13.41 Pre-employment medical evaluation of new employees, HR.13.42 Response to the health problems of the employees through staff clinic) or referral HA.13.43. Periodic medical evaluation of staff members, HR.13.44 Screening for exposure and/or immunity to infectious diseases, HR.13.45 Staff preventive immunizations. HR.13.46 Management of exposure to blood borne pathogens and other work-related conditions. HR.1347 Measures to reduce occupational exposures and hazards, including the use of protective equipment and clothing, stress management, and ergonomics. HR.13.48 Staff education on the risks within the hospital environment as well as on their specific job-related hazards (e.g, lifting techniques, safe use of medical devices, and detecting, assessing, and reporting risks). HR.1349 Documentation and management of staff incidents (e..,injuties or ilinesses, taking corrective actions, and setting measures in place to prevent recurrences). HR.13.4.10 There is appropriate record keeping and management (.g., employee health records that are filed separately. The hospital hasa process for handling staff complaints and dissati ‘The hospital has a policy for handling stat! complaints and dissatisfaction. Staff members are aware of the procedure to be followed to bring forward a complaint or a dissatisfaction issue. faction. ‘The hospital takes actions for addressing the complaints and dissatistaction in a fair, objective, and timely manner. The hospital develops and implements strategies for retaining qualified staff ‘The hospital has a process for recognition and reward of distinguished stat. The hospital provides opportu ‘The hospital carries out human resources policies in a ies for professional development and promotion, ir and consistent way without discrimination ‘The hospital carries out exit interviews for resigning statf and uses the resulting information to ‘make decisions about improving human resources processes. The hospital conducts staff satisfaction surveys on an ongoing basis ‘Ataf satisfaction survey s conducted at least once per year. Data are aggregated and analyzed for improvement a = 2 5 > Fa 5 i)Ocean eee ee Medical Staff (MS) Introduction A hospital's medical stat, the group of physicians and dentists licensed to practice medicine and prescribe ‘medications, plays a critical role in assuring quality care and improving patients’ outcomes in the hospital. The standards in this chapter define the medical staff leaders’ roles and responsibilities in credentialing, privileging, bylaws development, committees and departments: performance improvement. ‘A good hospital should always have a cle: including departments, divisions, and ‘medical committees. The medical director is responsible for the organization and conduct of the medical staff, and is viewed as the critical link between the governing board, the hospital director, and the medical staff. The medical irector must be a physician and must have his or her duties clearly defined in writing. vanagement, as well ‘structure of its medical Important processes and activiti addressed in this chapter include the following: Medical staff leaders’ roles and responsibilities Medical staff evaluation, credentialing and privileging Medical staff committees Medical staff bylaws Medical staff collaboration with other disciplines Medical statt competency assessment @ 9 > 3 > Es 5 7)Ocsani eee STANDARDS The organization, functions, and responsibilities of the medical staff aro MS.1.1 Ms.12 MS.13 Ms.14 MS.15 Ms.16 Ms.17 Ms.1.8 s21 Ms22 Ms23 Ms24 documented and communicated to all medical staff members. ‘The hospital has medical staff bylaws that govern the organization, functions, and responsibilities of the medical statt Medical staff bylaws are approved by the governing body. Medical staff bylaws are consistent with acceptable medical staff practices and laws and regulations. Medical staff bylaws describe the organizational structure of the medical staff and the reporting relationships, including all medical departments and committees, Medical staff bylaws address: MS.15.1. The medical staff ranking and the qualifications required for each rank. MS.1.52 Categories of the medical staff membership e.g, full time, parttime, and locum. MS.153 Roles and responsibilities of the medical staff members MS.1.5.4 Appointment, promotion, and reappointment of medical staff members. MS.1.5.5. The process for verification of the medical staff credentials. MS.1.5.6 Granting and maintaining clinical privileges, including temporary privileges (eg, for locums and emergency situations) MS.1.57 Disciplinary procedures for medical staff members, including corrective actions and appeals. Medical staff bylaws describe the acceptable standards of patient care and prot including: MS.1.6.1. Admission, referral, transfer, and discharge processt MS.1.62 Documentation in medical records ional conduct, MS.1.63 The conduct of care expected forall levels of medical staff (e.g, daily rounds), MS.1.6.4 The professional conduct (e.g, handling ethical issues) of the medical staft, ‘The medical director and heads of medical departments ensure the medical staff bylaws are made accessible and communicated to all members of the medical statt ‘The medical director and heads of medical departments enforce the medical staff bylaws along 1nd regulations. al director is responsible for managing the medical staff and medical services. ‘The medical director is a board certified physician or equivalent, qualified management by education, raining or experience. ‘The medical director is responsible and accountable for the clinical performance of the medical staff, the quality of care they provide, as well as their professional conduct ‘The medical director recommends to the hospital director the appointment of the heads of clinical departments, healthcare ‘The medical director has a current written job description that clearly describes his managerial roles and responsibilities, e o z 6 > Ey 3 &Ocean pal ae ec ss. Ms32 Ms33 Mss4 EE Ms4.1 ws42 Ms43 ws44 Ms5.1 Ms52 Ms53 The hospital has an effective process that supports the professional communication and coordination of care amongst medical staff. ‘There is a medical executive committee or equivalent, chaired by medical director and includes the heads of clinical departments, to ensure that they work together to coordinate the provision of care. ‘The medical executive committee holds regular formal meetings (at least month) ‘The medical executive committee reviews and approves policies and procedures related to clinical departments ‘The medical executive committee reviews all relevant reports of other hospital committees for prioritizing the services needed and guiding the credentialing and privileging process. Each clinical department is directed by a qualified individual. ‘The department head is board certified or equivalent in his field and qualified in healthcare management by education, training or experience. ‘The department head has a written job description that clearly describes his role and responsibiliti Responsibilities of the department head include: MS.43.1 Defining medical statf qualifications required for the provision of effective and safe Patient care MS.43.2 Recommending the need for further training/certifcation of a medical staff member. MS.4.3.3. Monitoring admissions to ensure that the diagnostic and therapeutic intervention within the staff capabilities and the available hospital resources. MS.43.4 Ensuring that medical staff members work within the clinical privileges granted to them MS.435 Developing a written scope of services for the department. ‘The department head has an ongoing method of peer review (e.g., peer review committee) to ‘evaluate care provided as well as the performance of the medical staf, MS.44.1 The department head regularly assesses important functions that include appropriaten ipPropriateness and effectiveness of care, training ‘and educational needs, length of stay, and appropriate utilization of resources, MS.442 The department head defines criteria or indicators for selecting cases that must be referred for peer review. MS443 The activities of the peer review process are u performance evaluation, MS.44.4. The department head shares the findings of the peer review with the medical director and works closely to improve and correct any deficiencies. of adm ized as part of the physician's The credentialing and privileging of the medical staff is based on an informed group decision. The hospital has a credentialing and privileging committee chaired by the medical director or a designee. The credentialing and privileging committee provides oversight on the credentialing and privileging processes. ‘The credentialing and privileging commitige ensures that only qualited physicians and dentists appointed and granted privileges, a ey Ps S > Fa fe] 7)Ocsani pa eee Mss4 sé. Ms.62 Ms63 Ms64 Mss Ms.e1 Applicants for initial appointment submit a complete set of documents required for the Credentialing and privileging process , including: MS.5.4.1 Curriculum vitae, detailing the professional history of the applicant. MS.5.4.2 Education, training, certifcates, courses, experience, published research, and other relevant credentials MS.5.43 List of references. MS.5.4.4_ List ofthe privileges requested for approval. The hospital has clearly defined and documented processes used to credential, appoint, and grant clinical privileges to medical staff. All members of the medical staff must be registered with the Saudi Commission for Health Specialties before allowed to work independently. The hospital has a documented process for appointment, reappointment and granting of elnical privileges to all categories of medical stat. Medical statf appointment, reappointment and granting of privileg relevant laws and regulations. Medical stat appointment, reappointment and granting of privileges are based on MS.6.4.1. Evaluation of the verifed credentials license, education, training, and experience). MS.6.42 Evaluation of the mental and physical health and capabilites MS.64.3 Competency, actual performance and outcomes of care. MS.6.44 Category ofthe medical staff as stated inthe professional registration with the Saud Commission for Health Specialties (e.g, consultant, specialist, ‘Appointment, reappointment and granting of privileges are recommended by the medical staff leaders medical director, heads of clinical departments, credentialing and privileging committee, And senior medical stat! members) and approved by the governing body, either directly or by appropriate delegation ‘The hospital has a process in place for appeal in accordance with .gainst credentialing or leging decisions. Medical staff members have current delineated clinical privileges. MS.7.1_ Medical statf members are allowed to pra the credentialing and px MS7.2 Clinical privileges are reviewed and updated every two years and as needed. MS7.3 The hospital identifies the circumstances under which temporary or emergency Privileges are granted. MS.7.4 Temporary or emergency privilege: renewable, 1 only within the privileges granted by MS.7.5_ When a new privilege is requested by a medical staff member, the relevant credentials. are verified and evaluated prior to approval. ‘The performance of the medical staff members is evaluated on an ongoing basis to ensure competency. The department head together withthe medical director evaluate the performance and competency of medical staff members at least annually and when indicated by the findings of performance Improvement activities, a g > 3 S > 5 5 7)Ocsani Siaetiad sated gnc it Ms82 Ms83 wso2 s.102 Ms.103, ‘The hospital identifies the circumstances under which an unplanned review of the performance of a medical staff member may be initiated ‘The performance evaluation includes, but is not limited to, the following: MS.83.1 Assesement of patients, MS832 Adverse events MS83.3. Moderate and deep sedation MS83.4 Quality of medical records. MS83.5 Medication errors MS83.6 Sentinel events. MS.83.7 Outcome of high-risk procedures and surgeries. MS83.8 Morbidities and mortalities. MS.8.3.9. Blood and blood product usage. MS.8.3.10 Discrepan MS.83.11 Appropr between pre and post-operative pathological diagnoses, teness of admissions from the emergency room and outpatient department. Medical staff leaders make use of the data and information resulting from the medical staff performance review. ‘The data and information resulting from the medical stat performance review are used to MS.9.1.1. Provide feedback and counseling to the medical statf regarding their performance, M8912 Recommend plans for improvement. MS9.1.3 Amend clinical privileges as ne ry, by expansion or limitation, a period of counseling and oversight, or other appropriate action, MS.9.1.4 Make informed decisions regarding reappointment. MS9.1.5 Recommend training and continuous education as needed ‘The outcomes of the medical staff performance evaluation and actions taken are documented in the physician's credentials fie. Medical staff leaders support the hospital-wide quality improvement, patient safety, and risk management plans. Heads of clinical departments together withthe medical director work closely with other hospital leaders through formal meetings to support the implementation of the hospital-wide quality improvement, patient safety, and isk management plans. Data and information resulting rom the medical stat! performance review are used to continuously improve the quality and safety by MS.10.2.1 Studying and minimizing variances in the processes. 8.10.22 Taking actions to avoid preventable medical errors and adverse events. MS 10.23 Recommending equipment needed in specified are Heads of clinical departments together with the medical director work closely with the quality ‘management drectortsk manager in handling Incidents including neat misses and sentinel events. MS.10.3.1 Root cause analysis ie properly conducted. MS 10.32 Emphasis ison improving systems. MS.10.3.3 Corrective actions are documented. @ MI > 5 = Fs 5 cyOcean het Aothe tias MS.11.4 s.11.2 Ms.11.3 weit watts ws.121 ws 122 was28 waes Ms.126 Ms.134 Stic Dende Acedia eth atts Heads of clinical departments review mortality and morbidity cases. Heads of clinical departments conduct mortality and morbidity meetings on a monthly basis to review all cases of morality and significant morbidity. ‘Mortality and morbidity meetings are documented and attendance is considered essential ‘The departmental mortality and morbidity meetings should focus on scientific discussion, improvement and prevention, with a non-punitive intent Heads of clinical departments work with the medical director to select c hospital mortality and morbidity committee. Heads of clinical departments send regularly mortality and morbidity findings to the medi director and the quality director. to be referred to the The hospital has a mortality and morbidity committee. ‘There is a mortality and morbidity committee that is chaired by the medical director or a designee. ‘The mortality and morbidity committee reviews mortalities in the hospital and the unusual of unexpected adverse outcomes of care The mortality and morbidity committ receives cases for review trom various sources (e.g., referral from the clinical departments, patient complaints, and the medical director), The mortality and morbidity committee evaluates cases for effectiveness, timeliness and appropriateness of care. ‘The mortality and morbidity findings are regularly forwarded to the medical director and the quality director. ‘The mortality and morbidity committee recommends actions for improvement and evaluates their effectiveness. The hospital has a medical records review committee. ‘There is a medical records review committee with members representing the medical statf, the ‘nursing staff and other professionals privileged to write in the medical record ‘The medical records review committee oversees and monitors the documentation in medi records for quality, completeness, and timelines ‘The medical records review committee regularly reviews a sample (e.g, 5% on a quarterly basis) of the medical records of discharged and in-patients for: MS.13.3.1 History and physical examination MS.13.32 Assessment upon admission Ms.13.3.3 Progress notes, Ms.18.3.4 Plan of care. MS.13.3.5 Operative reports. (MS.13.3.6 Histopathology reports. MS.13.3,7 Laboratory results. MS.13.38 Radiology reports MS.13.39 Discharge summary. ‘The medical records review committee recommends actions for improvement and evaluates their effectiveness. ® 4 z 5 Fs EA 5 i)Ocsan a 8.14.1 Ms.142 8.143 Ms.154 MS.155 MS.156 Ms.16.1 Ms.162 Ms.163, The hospital has a utilization review committee. There isa representatives from relevant services such as medical staff, nursing staff, admission office and social services. ‘The utilization review committee assesses the medical necessity of the services furnished by the hospital and the medical staff members to patients. This includes, but is not limited to, the following: MS.14.2.1 Appropriateness of admissions. MS.142.2 Appropriateness and quality of care MS.1423 Length of stay, MS.14.2.4 Drug usage. MS.14.25 Efficiency in using various hospital resources (e.g, overutilization or underutlization) ‘The utilization review committee recommends actions for improvement and evaluates their effectiveness. lization review committee that is chaired by the medical director or a designee with The hospital has a blood utilization committee. ‘There is a blood utilization committee that is chaired by the medical director or a designee with representatives from relevant services such as medical staff, nursing staff and blood bank. ‘The blood utilization committee ensures the optimal use of blood and blood products by establishing Indications/riggers forthe transtusion of blood, blood components and blood derivatives. The blood ulti approves all policies and procedures that involve the ordering and administration of blood and blood products, including MS.15.3.1 Handling of blood outside the laboratory. MS.15.3.2 Use of blood warmers and infusion devices. MS.15.33 Venous access. MS.15.3.4 Addition of fuids and drugs other than 0.9%NaCL. MS.15.35 Bedside Identification of the blood product and the intended recipient. MS.15.3.6 Monitoring of patient during and after blood administration The blood utilization committee ensures the optimal utilization of therapeutic phlebotomy and apheresis services. The biood utilization committee monitors practices related to blood ordering and blood ‘administration, ation commit The blood utilization committee recommends actions for improvement and evaluates their effectiveness The hospital has a tissue review committee. ‘There isa tissue review committee that conducts analysis and review of tissues removed during surgeries and procedures. The tissue review committee ensures there is a hospital policy that governs how to obtain and handle specime! ‘The tissue review committee monitors the following MS.16.3.1 The collection and transportation of specimens tothe laboratory MS.16.2.2 The accuracy and come of histopathology forme (e.g, ite of biopsy, number of biopsies, clinical history, previous biopsies) nd tissu Te he Aes}‘Swale Bnet for Acta aston Ocsani ee, s.164 Ms.165 Ms.166 MS.17.1 Ms.17.2 Ms.173 Ms.17.4 Ms.184 MS.185 s.192 Ms.19.3 Ms.19.4 MS.16.3.3 The accuracy of fine needle aspirations, MS.16.3.4 The accuracy of frozen section specimens. The tissue review committee defines and approves the list of specimens exempted from ‘submission to surgical pathology or microscopic examination. ‘The tissue review committee reviews the appropriateness of all surgical procedures performed in the hospital, correlating pre- and post-operative surgical diagnoses with pathological findings. ‘The tissue review committee recommends actions for improvement and evaluates their effectiveness The hospital has an operating room committee. There is an operating room committee with representatives from relevant services such as ‘medical stat, nursing stat, operating room stat, infection control, and safely personnel ‘The operating room committee approves all policies required for proper conduct ofthe work in ‘the operating room including, but are not limited to, the following: MS.172.1 Infection control measures. MS.17.22 Supply of equipment and disposables. The ope protect patient privacy and dignity “The operating room committee monitors performance inthe operating room including cancellation rate and makes improvements accordingly. ing room committee develops a code of ethical conduct in the operating room to The hospital has a cardiopulmonary resuscitation committee. There such as medical statt, nursing staf, intensive care staff and emergency staff. ‘The cardiopulmonary resuscitation committee ensures there is an effective system to handle all cases requiring cardiopulmonary resuscitation at all times. ‘The cardiopulmonary resuscitation committee ensures that the cardiopulmonary resuscitation team members have cardiac life support training as appropriate to the patient population served by the hospital ‘The cardiopulmonary resuscitation committee discusses all codes in the hospital, recommends ‘actions for improvement, and evaluates those actions for effectiveness. ‘A summary of the cardiopulmonary resuscitation committee's discussions is forwarded to the ‘medical director and the quality director. ives from relevant services cardiopulmonary resuscitation committee with represents a pharmacy and therapeutics committee. Pharmacy and therapeutics committee with representatives from relevant services involved in drug prescribing, ordering, diepensing, administering, as well as patient monitoring processes, ‘The pharmacy and therapeutics committee provides oversight of the hospital formulary and ‘medications use The pharmacy and therapeutics committee maets on a regular basis (atleast quarterly) ‘The pharmacy and therapeutics committee recommends actions for improvement and e their etfectiveness, a | Ps S > 5 3 7)Ocean scons tthe Provision of Care (PC) Introduction Hospitals vary in the scope of services they provide and thus the types of patients they may eectively serve. The hospital should accept patients for care according to its capability to provide the services that meet the identified pationt's needs, Providing optimum care requires careful planning, coordination, and communication. The hospital must provide fan appropriate and thorough assessment of each patient, and patient care must be planned and implemented to ‘ensure the best possible outcome, To support the continuity of care, patient assessment and care process must ‘be documented in @ completed medical record that is unique for each and every patient. As the care process may ‘need to be provided by multiple providers, a collaborative process should be in place to promote continuity and Coordination of care when the patient is referred, transferred, or discharged. Important processes and activities addressed in this chapter include the following ‘Screening of patients before acceptance for care Access to care Registration and admission processes ‘Scope and content of patient assessment and reassessment Plans of care Continuity and coordi Consultations High risk and vulnerable patients Psychiatric patients Patient discharge, ion of care insfer and referral within or outside the organization Exel) fel) ARS)Ocean Pa ‘asco aad or Acetate tons STANDARDS x Pott Po.12 P13 Po2t Poze Po23 Po24 Post Pos2 Poss Pos Poss Pose Po42 The hospital provides patients with information on care and services provided. ‘The hospital clearly defines the services it provide: The hospital provides patients, families, and the wider community with information on the Services it provides using an appropriate format and language (e.g, displayed posters, brochures, handouts, websites, and news media), ‘The hospital provides patients with information on how to access its services. Patients are screened before accepted for care in the hospital. ‘The hospital implements a policy that defines screening methods and tests required before ‘accepting patients for care. Screening i resources. In outpatient settings, screening is performed betore registration Screening of patients in the emergency room is performed during triage process or before deciding for admission to inpatient areas, ‘aimed to identify and match patient needs with hospital's mission and available The hospital has a consistent process for registration and admission of patients, A policy and procedure defin for a day procedure. A policy and procedure defines the process used for admission of emergency patients. A policy and procedure defines the process used for registration of outpatients, The hospital has a process for managing patients requiring admission when no bed is available. ‘The hospital has a process for managing patients under observation in the emergency room Statf members are aware of and implement a consistent process for regi of patients in different service settings. the process used for elective admissions and patients admitted tion and admission The hospital ensures a uniform standard of care. ‘The hospital implements policies and procedures to ensure that a uniform standard of care is Provided to all patients PC.4.1.1 All patients receive the same standard of care acr departments. PC.4.1.2 All patients receive the same standard of care at all times (e.g, during working hours, after working hours, during weekends and holidays). PC.4.1.3 All patients receive the same standard of care regardless of race, gender, or religion PC.4.1.4 All patients receive the same standard of care regardless of their ability to pay or ‘source of payment. Patient care regulations, 8 all hospital settings and vices are in accordance with professional standards and applicable laws and SQUVGNV.LSOca scons eattraanemcaans Pos.t Pose Poss Pos4 Pose Pces Poss Poss Po72 Po7.3 Por Po7s The hospital ensures easy accessibility to care and services. Hospital departments and services are physically accessible to all patients. The hospital adopts an efficient appointment system. ‘The hospital has a process to minimize language barriers by communicating with patients in their Primary language or have interpreter services provided at all times, ‘The hospital ensures effective communication with patients having special communication ‘needs (¢.,, sign language for the hearing impaired patients, and assistance modalities for sight impaired patients) The hospital has a systematic process for the initial assessment of patients. ‘The hospital implements a policy and procedure that defines the assessment process and its ‘Scope and content for all care settings (inpatients, outpatients, critical care and emergency room), ‘The hospital implements a policy and procedure that defines the assessment process and its ‘scope and content for all categories of patients (adults, geriatrics, pedi ‘trauma patients and others) The hospital implements a policy and procedure that defines the assessment process and its scope and content for all disciplines (physicians, nurses, physiotherapists, social service and others). ‘The policy defines the staff categories qualified by license, certification, and experience to sess patients, The initial assessment aims to identity the general patient's medical and nursing needs and a provisional diagnosis so that care and treatment can be initiated, 8, pregnant women, The initial assessment includes screening patients for pain, functional limitations, and mainutrition. ‘The hospital implements a policy that defines the criteria and process for screening patients for pain, functional limitations including risk for fall, and malnutrition. Screening criteria are developed by qualified individuals. When pain is present from the initial screening, the patient assessment Patients with functional impairment are referred for functional assessment. Patients identified as malnourished or at risk for malnutrition are referred for a nutritional assessment. seeives a comprehensive pain The initial assessment includes the need for discharge planning. ‘The hospital has criteria to identity patients requiring discharge planning before or upon ‘admission, A proposed discharge date is set soon after admission, Staff members are aware of the discharge planning process particularly for common cases with predictable outcome. a Me > ie] > Es] 5 Cr)Ocean recs asec xd Post Poor Poss Pos Peas Poss PC.10.1 Po.102 Po.103 Po.10.4 Initial assessment of patients is completed and documented in the medical record on a timely manner. ‘The hospital implements a policy that defines the time frame for completing the medical, nursing, and other assessments required for different care settings and services. Medical and nursing assessments are completed and documented within the frst 24 hours of ‘admission for routine elective cases. Medical and nursing assessments are completed and documented earlier whenever indicated by the patient's condition and the hospital policy. ‘Assessments completed within 30 days prior to admission or an outpatient visit can be used with ‘a documented update of any significant changes. ‘Assessments completed more than 30 days prior to admission or an outpatient visit must be repeated Medical and nursing assessments are completed and documented for all patients prior to surgery, anesthesia or invasive procedures. Medical assessment is completed and documented for each patient. Each patient undergoes an initial medical assessment that includes a health history and physical ‘examination, covering the following: PC.10.1.1 Main complaint. PC. 10.1.2 Details of the present iliness, PC.10.1.8 Systems review. PC.10.1.4 Past history including previous admissions and surgeries PC.10.1.5 Allergies and prior adverse drug reactions. PC.10.1.6 Drug history PO.10.1.7 Family history PC.10.1,8 Psycho-social history PC.10.19 Economic factors PO.10.1.10 Pain (screening followed by assessment if required). PC.10.1.11 Risk for fall (screening followed by assessment if required) PC.10.1.12 Physical status and functionality (screening followed by assessment if required), PC.10.1.13 Complete physical examination, PC.10.1.14 Diagnostic testis) as indicated by the patient's condition. PC.10.1.1 Need for additional or specialized assessment as indicated by the patient's ‘condition, PC.10.1.16 Need for discharge planning as indicated by the patient's condition PC.10.1.17 Provisional diagnosi ‘The most responsible physician ensures all patients under his care have a complete medical ‘assessment with all diagnostic tests and refer required to reach a final diagnosis. Medical assessment is performed by the most responsible physician or a member of the who is qualified by license, certification, and experience. Diagnostic tests e.g, laboratory and radiology) are available as indicated by the hospital's scope of service and the professional standards of care. a et J 3 > Ea 5 a