Download “Be prepared to talk about the hospital`s `Impact Analysis` project for

REGULATORY, COMPLIANCE
AND
ACCREDITATION SERVICES
EMPLOYEE GUIDE
TO
JOINT COMMISSION
INTERNATIONAL
HOSPITAL STANDARDS 5th EDITION
Accreditation Survey Readiness
2015 – 2016
‫االلتزام والوالء‬
‫"سأفعل كل ما يلزم لجعل كل اتصال وتعامل مع مؤسسة حمد الطبية تجربة‬
... ‫مرضية و فريده‬
"‫لمرضانا وأسرهم والزوار والموظفين والشركاء‬
Commitment and loyalty
“I will do whatever it takes to make every contact with HMC
a uniquely satisfying experience for our patients, families,
visitors, employees and partners.”
1
TABLE OF CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Introduction
……………………………………………………
HMC Mission, Vision and Values
……………………………………
International Patient Safety Goals (IPSG) …………………………
Access to Care and Continuity of Care (ACC) ……………………
Patients and Family Rights (PFR)…………………………………
Assessment of Patients (AOP) ………………………………………
Care of Patients (COP) ……………………………………………….
Anesthesia and Surgical Care (ASC)………………………………
Medication Management and Use (MMU)………………………….
Patient and Family Education (PFE)………………………………...
Quality Improvement and Patient Safety (QPS)………………….
Prevention and Control of Infections (PCI)………………………
Governance Leadership and Direction (GLD)……………………
Facility Management and Safety (FMS)……………………………
Safety Management Program …………………………………………
Security Management Program …………………………………………
Fire safety Program ……………………………………………………
Hazardous Materials Management Program ……………………………
Utility System Program ……………………………………………………
Medical Technology Program ……………………………………………
Major Incident Program……………………………………
Staff Qualification and Education (SQE)……………………..
Management of Information (MOI)…………
Medical Professional Education (MPE) ……………………..
Human Subject Research Program (HRP) ……………………..
Helpful Hints for the Survey Process………………………………
2
Introduction:
The Regulatory, Accreditation and Compliance team has developed an Employee Guide for the Joint
Commission International (JCI) standards. These are based on the 5th edition manual requirements and HMC
policies and procedures to make the survey process and requirements clearer and easier for our leaders and
employees.
This booklet is intended to cover most if not all possible questions that may be asked and the scenarios that
may arise during the survey process.
Tracer Rounds are conducted by the Regulatory, Accreditation and Compliance team to monitor compliance
with JCI standards and assess reaccreditation readiness, including staff awareness of policies and procedures,
especially those required by JCI, as well as the implementation of the corporate mission, to improve the
quality of care provided to the public through the provision of health care and related services that support
performance improvement in health care organizations.
Our combined efforts will result in accreditation success. We appreciate and recognize the unique role played
by every individual at HMC during previous accreditation surveys and hope that all our staff will work together
as a team for the benefit of our patients and their families.
HMC Mission:
Our mission is to improve people’s lives by providing the highest quality multidisciplinary healthcare services
quickly, safely, effectively and efficiently to meet the needs and expectations of our patients and their
families within the community we serve.
Vision:
We aim to deliver the safest, most effective and most compassionate care to each and every one of our
patients.
Values: Our Values reflect “RESPECT”
Reliable service delivery.
Excellence is our standard.
Safe and clean environment.
Patient-centered care.
Empowerment, enabling each to be his/her best.
Concerned with community well-being.
Teamwork, which is interdisciplinary and collaborative.
3
Joint Commission International (JCI):
The Joint Commission International (JCI) is one of the largest international healthcare evaluators in the world.
Their primary focus is on improving the safety of patient care through the provision of accreditation and
certification services.
JCI provides accreditation for hospitals, ambulatory care facilities, clinical laboratories, care continuum services,
home care and long term care organizations, medical transport organizations, and primary care services, as well
as certification for 15 types of clinical care programs.
JCI is accredited by the International Society for Quality in Healthcare (ISQUA) and is a World Health
Organization (WHO) Collaborating Centre and has accredited over 450 healthcare organizations in 70 countries.
Accreditation Survey Overview:
Accreditation has gained worldwide attention as an effective quality evaluation and management tool and
surveyors are using the latest JCI Accreditation Standards as the foundation for their assessment.
During an on-site accreditation survey, a JCI survey team evaluates the performance of an organization’s
functions and processes which are aimed at continuously improving patient outcomes. This assessment is
accomplished by evaluating compliance with the applicable standards in the accreditation manual for the
relevant hospital, based on the following:




Tracing the care and services delivered to patients and the system
Verbal and written information provided to JCI
On-site observations and interviews by Joint Commission International surveyors
Documents provided by the organization, as required.
The on-site accreditation survey uses tracer methodology that is data-driven, patient-centered and focused
on evaluating actual care processes to evaluate individual components and systems of care.
The objectives of the survey are not only to evaluate the organization, but to provide education and good
practice guidance that will help staff continually improves the organization’s performance.
The on-site survey focuses on continuous operational improvement in support of safe, high quality care,
treatment and services.
JOINT COMMISSION
4
During the visit, the surveyors will:
 Hold an opening conference with HMC leaders, and others involved in the survey. Any change to the survey
agenda will be discussed in this briefing.
 Attend an orientation presentation about the hospital services and its quality improvement program.
 Attend a survey planning meeting.
 Review documents to gather evidence of compliance and to orientate the survey team about the
organizational and management structure of the hospital. These may include but is not limited to:









Required quality data.
Required organizational programs.
Required policies and procedures.
Written documents and bylaws.
An accurate list of the patients currently receiving care at the hospital.
Operative procedure schedule for the day (Main OR and Day Surgery).
Current map of the hospital campus.
Sample of all medical record forms.
List of all employees.
 Interview corporate leaders.
 Interview hospital and departmental leaders.
The surveyors may refer to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Organizational structure.
Mission Statement.
Strategic planning.
Scope of services.
Staffing plan.
Budget and resource allocation.
Information management plan.
Quality management program.
Safety culture program.
Work schedule/roster.
Applicable laws and regulations.
Approved international standards.
5
Patient care and service area visits guided by patient and system tracer activities.
Individual Patient Tracer Activity:
A tracer follows the experiences of an individual patient in order to evaluate the organization’s performance
against international standards. One approach to conducting a tracer is to sequentially follow the course of care
and services received by the patient from pre-admission through to the post-discharge phase.
During an individual tracer, the surveyors will:






Follow the course of care, treatment, or service provided to the patient by and within the organization
using current records whenever possible.
Assess the interrelationships between and among disciplines and departments, programs, services, or
units, and the important functions in the care and services being provided.
Evaluate the performance of relevant processes, with a particular focus on the integration and
coordination of distinct but related processes.
Identify potential concerns about any of the relevant processes.
Tracers can be unpredictable and can challenge even the best hospitals.
Tracers being carried out are: System Tracer for Infection Control, Medication Management, Data
Management, Facility Management and a Safety System Tracer.
Environment of Care Reviews and a Facility Tour
To address issues related to:




The physical facility
Medical and other equipment
Patient and visitor safety
Infection control
This booklet provides assistance in answering a variety of questions from surveyors from outside Hamad
Medical Corporation. Such surveys will provide us with an opportunity to demonstrate our processes and
procedures which lead to the provision of high quality of patient care.
6
The following questions were asked based on the previous accreditation survey experience. These are in
order of their appearance in the JCI 5th Edition Standards:
INTERNATIONAL PATIENT SAFETY GOALS (IPSG)
The purpose of IPSG is to promote specific improvements in patient safety and highlight problematic areas in
healthcare settings by describing evidence and expert-based solutions and recognizing that the system
delivers safe, high quality healthcare to ensure consistent practice in all situations and locations.
1. What are the International Patient Safety Goals?
Goal 1: Identify Patients Correctly.
IPSG 1: Implement a process to improve the accuracy of patient identification.
Goal 2: Improve Effective Communication.
IPSG 2: Improve the effectiveness of verbal and/ or telephone communication among caregivers.
IPSG 2.1 Implement a process for reporting critical results of diagnostic tests.
IPSG 2.2 Implement a process for handover communication.
Goal 3: Improve the Safety of High Alert Medications.
IPSG 3: Implement a process to improve the safety of High Alert Medications including lookalike and soundalike
medications.
IPSG 3.1 Implement a process to manage the safe use of concentrated electrolytes.
Goal 4: Ensure Correct Site, Correct Procedure, Correct Patient Surgery.
IPSG 4: Implement a process for ensuring correct site, correct procedure, and correct patient surgery.
IPSG 4.1 Implement a process for the time-out that is performed in the operating theatre immediately prior to the
start of surgery.
Goal 5: Reduce the Risk of Health Care Associated Infections.
IPSG 5: Adopt and implement evidence based hand hygiene guidelines
Goal 6: Reduce the Risk of Patient Harm resulting from a Fall
IPSG 6: Implement a process to reduce the risk of patient harm resulting from falls.
7
2. How do you identify your patients and when?
Patients are identified by using two patient identifiers:
 Patient’s full name and health card number.
 Qatar ID number can be used if there is no available health card.
Patients are identified before providing treatments/procedures and before any diagnostic procedures are
carried out.
Note:
Never use a room number or location as identifiers.
Policy CL # 7026 ……………Patient Identification”
3. What is the process you follow when receiving verbal / telephone orders or a critical lab/radiology result?
 Receiver should document a complete verbal / telephone order or a critical test result. This should then be
read back by the receiver, and confirmed by the individual who gave the order or test result.
 Notify the physician about the critical test results for immediate intervention.
 The telephone/verbal order should be countersigned by the physician within 24 hours
Policy CL # 6063 …………. Physicians Verbal and Telephone Orders
Policy CL# 7204 ………….. Reporting Laboratory Critical Test Results/Value
Policy CL # 6045 …………Red Flag Reporting Process in Radiology and Diagnostic Imaging Services
4. What do we mean by high-alert medications?
High Alert Medications are drugs that bear a heightened risk of causing significant patient harm when used in
error.
They are those medications involved in a high percentage of errors and/or sentinel events, the
medications that carry a higher risk of adverse outcomes, and medications with names, packaging and
labeling or clinical use, look and sound alike, such as hydralazine and hydroxyzine.
Although mistakes may or may not be common with these drugs, the consequences of an error with these
medications may be devastating to the patient.
Policy CL# 7207………. High Alert Medications
Policy CL # 6105 ……….Lookalike and Sound-Alike Medications
8
Note:
Make your self familiar with the list of High Alert medications.
5. What are the types of concentrated electrolytes that are considered as high-alert medications?




Potassium chloride, equal or greater than 2 meq/ml.
Potassium phosphate, equal or greater than 3 mmol/ml.
Sodium chloride, greater than 0.9% concentrated.
Magnesium sulfate, equal or greater than 50% concentrated.
6. How do you ensure the safety of high-alert medications?
 Ensure it is clearly and properly labeled utilizing Tall Man lettering for LASA medications and physically separate
from their LASA name pair.
 A red entitled “High Alert” label for high alert medications.
 Utilize an independent double check during the dispensing and administration of the medication.
 The storage of concentrated electrolytes shall not be allowed in clinical areas in hospitals where the
pharmacy based intravenous (IV) Admixture Unit is operating (24 /7).
Policy CL # 7207…………High Alert Medications
Policy CL# 6105 …………. Look-Alike and Sound-Alike Medications
7. What extra precautions are taken with the High Alert Medications?
High Alert Medications are double checked by two nurses to visually and verbally verify the accuracy of the
dose and the route prior to administration. Both nurses should then document verification in the patient
record.
8. How do you ensure a correct site, correct patient, correct procedure / surgery?
 Surgical Sites should be clearly marked by the performing surgeon when the pre-operative verification
process is conducted and then documented on the checklist.
 Time out is held immediately before the start of any procedure/surgery to ensure a correct site, the correct
patient, and the correct procedure / surgery.
Policy CL# 6044 ……….. Correct Patient, Correct Site, Correct Procedure
9
9. What is “time out” and when it is conducted?
 Time out is a pause when all members of the surgical/ procedure team participate in the positive
identification of the patient, the intended procedure, and the visualization of the marked site for the
procedure.
 Time out is held immediately before the start of the procedure with all team members present.
10.How do you reduce health care associated infections?
Through proper hand hygiene practices and strict compliance with infection control practices.
Policy CL # 7241…………..Hand Hygiene
11. What is your hand hygiene compliance rate?
Show your department/unit specific data on QPS notice board
12. How do you protect patients from a fall?
 All inpatients and out patients are assessed to identify fall risks using specific assessment tools.
 Fall prevention measures are implemented for patients assessed to be at risk and ongoing reassessments
are done and documented.
 Patient/family education.
Policy CL # 6027..............Falls Prevention
13. What is the process when a patient has a fall?
 Attend to the patient, if unhurt assist them to their bed. If they are hurt, call for help to safely move the
patient.
 Inform the physician so the patient can be assessed; complete a vital signs check.
 Inform the nurse supervisor or in-charge/department head.
 Apply fall prevention protocol if not already in place.
 Document the actions and patient status in the medical record.
 Report the incident through the Electronic Incident Report System as per OVA reporting policy.
Policy CL # 6027......................Falls Prevention
10
14. What is SBAR/ISBAR?
It is a standardized tool to aid the safe transfer of patient information during a clinical handover.
SBAR - Is an acronym for Situation, Background, Assessment, and Recommendations.
ISBAR - Is an acronym for Identification, Situation, Background, Assessment and Recommendations.
15. Why do we need a tool for handover communication?
 Breakdowns in communication can occur during any handover of patient care because of background
noises, interruptions and other distractions from unit activities. These can result in adverse events.
 Standardized, critical content for communication between the patient, family, caregiver, and health
care providers can significantly improve outcomes related to the handover of patient care.
Policy CL # 6102 ………………Handover Communication
11
ACCESS TO CARE AND CONTINUITY OF CARE (ACC)
1. What do you mean by Triage?
The process, by which patients are classified, evaluated, and/or directed to the most appropriate area of
the emergency department according to their medical needs based on the severity of their injuries and
illnesses.
Policy CL# 7266 ………… Triage Process in Emergency Department
2. Whatis your Triage Process in the Emergency Department?
Patients are triaged using the Canadian Triage and Acuity System “CTAS” for both adult and pediatric
patients.
Policy CL# 7266……………….. Triage Process in the Emergency Department
Policy CL # 7266 PEC …………Triage Process in the PEC Emergency Department
3. Specify the triage levels in the CTAS Triage System within the Adult Emergency Department?





Level 1 – Resuscitation (Blue)
Level 2 – Emergent
(Red)
Level 3 – Urgent
(Yellow)
Level 4 - Less Urgent (Green)
Level 5 - Non Urgent (White)
Policy CL# 7266………… Triage Process in the Emergency Department
4. Do you have admission, transfer and discharge criteria for your unit? Could you show it?
Yes, we have admission, transfer and discharge criteria for my unit.
Policy CL# 6085 ……….………Admission Process
5. Do you inform patients and family if there are any delays for diagnosis, treatment or services?
12
Yes, and it will be documented in the medical records of both outpatients and Inpatients.
Policy CL # 6085 …………. Admission Process
6. What information should the patient/legal representative receive upon admission?
Patients/legal representatives should receive information on the proposed care, the expected outcomes of
care, and any expected costs for the care which will help them to make knowledgeable decisions.
Policy CL # 6085 …………. Admission Process
7. What are the areas involved in the process of Continuity of Care?





Emergency Care Services and Inpatient Admission.
Diagnostic Services and Treatment Services.
Surgical and Nonsurgical Treatment Services.
Outpatient Care Programs.
Other Organization and Health Care Settings.
8. What is your process if your patient is found to be missing/ absconded?
If a patient is believed to have absconded or is missing, the following individuals should be informed
immediately:







Immediate Supervisor
Security
Physician In-Charge of the Unit or the Doctor On-Call
Social Worker, if needed.
Nursing Supervisor/Director of Nursing/Assistant Executive Director of Nursing
Administrative Director On-Call, if needed.
Infectious Disease Team; if applicable
Policy CL # 7031 …………..Absconding or Missing Patient
9. Do you initiate OVA if a patient is missing/ absconded?
Yes, electronic OVA shall be initiated.
10. Do you make a Transfer Summary when patients are transferred within the same hospital?
When the patients are transferred within the same hospital, there should be a documented summary in the
Progress Note which includes:




Reason for Admission.
Significant Findings.
Diagnosis.
Performed Procedures.
13
 Any Medications and Other Treatments.
 Patient’s Condition at Transfer.
Policy CL # 6102 ……………Handover Communication
11. What education should be provided to patient and family?
Patient and family are educated about:
 Safe and effective use of all medications taken by the patient (not just discharge ,edication),
including potential medication side effects, and the prevention of potential interactions with overthe-counter medications and/ or food.
 Safe and effective use of medical technology
 Proper diet and nutrition.
 Pain management.
 Rehabilitative techniques.
Policy CL# 6090 …………..Patient and Family Education
12. What are the contents of a Discharge Summary?
The Discharge Summary should include:






Reason for Admission, Diagnoses, and Comorbidities.
Significant Physical and Other Findings.
Diagnostic and Therapeutic Procedures Performed.
Significant Medications, including Discharge Medications.
Patient’s Condition/Status at the time of discharge.
Follow-up Instructions.
Policy CL# 6037……………Discharge Summary Completion
13. When is an Outpatient Profile required in an Outpatient Department?
An outpatient profile is required for outpatients with complex diagnoses and/or who need complex care/
services.
Policy CL# 6036…………. Outpatients Profile
14. What is “Discharge against Medical Advice”?
It is those situations when a patient, legal representative / legal guardian refuses medical care contrary to
the judgment of the health care personnel and that care is recommended and felt to be necessary for an
inpatient, outpatient, or Emergency Department.
14
Policy CL# 7070…………..Discharge Against Medical Advice
15. What is Discharge Planning?
Discharge Planning is an interdisciplinary process involving the patient, legal representative/ guardian and
healthcare providers that starts on admission and considers the patient’s needs for discharge throughout
hospitalization.
Policy CL# 7028……………..Discharge Planning
16. When does discharge planning occur?
Discharge Planning begins upon admission and continues post-discharge; with referrals for community
assistance when required.
Policy CL# 7028…………. Discharge Planning
17. What is the referral process?
The process of directing or redirecting an individual from one physician to another physician.
The referral process constitutes a complete handover of care and treatment to another physician.
Policy CL# 7210………………. Referral Process
18. How are referrals prioritized and the time frames stated?
Referrals are prioritized as follows:
 For ambulatory care:
 Regular referral – next available appointment.
 Urgent referral – within seven (7) days.
 Emergency referral – immediate referral to the nearest emergency department.
 For the In-Patient Units;
 Regular referral – within (24) hours.
 Urgent referral – within (12) hours.
 Emergency referral – within one (1) hour.
19. How are patients transferred to another organization?
15
Transfer is based on the patient’s status and the need for continuing health care services.
Policy CL# 7030…………Transfer of Patients Between Facilities
20. What does the Transfer Process address?
The Transfer Process addresses the following:







How responsibility is transferred between practitioners and settings.
The criteria for when transfer is necessary to meet the patient’s needs.
The individual responsible for the patient during their transfer.
When medication, supplies and medical technology are required during transfer.
A follow-up mechanism that provides the condition of the patient during transfer and upon arrival at
the recognized organization.
What is done when transfer to another source of care is not possible?
Evaluation of the quality and safety of the transfer patient.
Policy CL# 7030…………..Transfer of Patients Between Facilities
21. What are the needs that are assessed when any patient is referred, transferred or ready to go home
following an inpatient admission or OPD visit?
The patient is assessed for transportation needs.
Policy CL# 7030…………..Transfer of Patients Between Facilities
22. What are the laws that need to be met by the transport vehicles owned by the hospital?
Transport vehicles owned by the hospital need to meet relevant laws and regulations related to their
operations, condition, and maintenance.
23. What are the other requirements that need to be met by the transport vehicles (contracted or owned) by
the hospital?
They need to comply with the Infection Control Program and need to have appropriate medical technology,
supplies, and medications to meet the needs of the patient being transported.
16
PATIENTS AND FAMILY RIGHTS “PFR”
1.
What are patient/family rights?
Requirements
Patient rights
Access to Care.
Respect and Dignity
Privacy and Confidentiality
Impartial access to treatment
Considerate, respectful care at all times
Physical privacy during treatment and examination
Confidentiality of medical record information
Personal Safety
Safety related to hospital practices and environment
Identity
Professional status of those caring for the patient and which
provider is directly responsible for the patient care
Information
Complete and current information concerning diagnosis,
treatment, and prognosis.
Communication
Receive information in an understandable manner
Be informed of the process to receive complaints, conflicts and
differences of opinion related to patient care
Consent
Informed participation in decisions related to care
Consultation
To seek a second opinion without fear of compromise to their
care, to be able to change physician and transfer to another
hospital as long as medically appropriate.
Refusal of Treatment
To the extent permitted by law and HMC policy.
Transfer and Continuity of Care
The patient may not be transferred to another facility unless
they have received a complete explanation and alternatives.
Special Needs (Dying Patient, Ethical Issues) Every attempt will be made to meet the individual patient’s
care needs.
Hospital Charges
To be informed accordingly per hospital policies
17
Patient Family Education
Receive education that is appropriate to the patient’s age,
cognitive level and patient care needs.
2. What are the patient /family responsibilities?
Information
Report
Respect
Financial Obligation
Responsibility
Provide accurate information about the patient’s condition and
medical history.
Unexpected changes in the patient’s condition.
HMC rules and regulations, property and personnel, treatment
plan recommended, and follow up for appointments.
Fulfill financial obligations as promptly as possible.
Accept the consequences of decisions made.
Not to leave the hospital without being officially discharged.
 Booklet/Brochures of “Patient/Family Rights and Responsibilities” are available for patients,
families and staff throughout HMC.
 Posters of Patient Rights and Responsibilities are posted in patient care areas.
 Educated all Staff are knowledgeable about patient/family rights and responsibilities.
3. How does HMC staff ensure that patients and families know their rights and responsibilities?
 All patients are given written information about patient rights/responsibilities upon entry to the
hospital.
 Patient/family booklet and posters of patient rights and responsibilities are posted at visible areas
throughout the hospital.
 If the patient is unable to understand his/her rights (i.e. deemed incompetent, medically unable to
understand treatment, or unable to communicate their wishes), the information about patient
rights /responsibilities should be provided to the patient's designated legal representative/
guardian.
Policy CL # 7225 ……………..Patient /Family Bill of Rights
4. Who is responsible for ensuring that Patients and Family Rights are respected and maintained at all
times?
It is the responsibility of every health care provider.
5. How do you maintain the patient's privacy and confidentiality?
 Provide privacy during care, examinations, and procedures, by closing doors or pulling curtains.
 Ensure privacy during care and discussions.
18









Introduce yourself and state your job title. Wear your HMC ID card at all times
Get permission from a patient or their family before allowing a visitor or any staff to interview them.
Knock on patient’s door and wait for a response before entering the room.
Always keep medical records secure.
Log off computer terminals; ensure that the computer screen is not visible to those who do not have a
need to know the information, and don’t share your access codes and log-in details.
Accommodate a patient’s request for a room transfer if medically feasible.
Never discuss patient information in the hallways, elevators, or elsewhere in public.
Any forms or patient information should not be placed in public areas.
Full patient names and/or diagnosis/procedures should not be written on bulletin boards, patient
rooms or any visible areas.
6. What do you do if a patient has a language barrier?
Each facility has a process to overcome or limit the barriers which can impact the delivery of health care
services.
7. What is General Consent?
 It is consent by a patient, their legal representative/guardian or responsible family member to allow
healthcare staff to give routine care and/or treatment to the patient in their home and/or in-patient
facility.
 It is an agreement that home visit schedules and facility regulations will be kept and staff will be treated
respectfully in a safe environment.
8. Who will obtain General Consent?
Home Healthcare Services do not have procedures that require separate consent; however general consent
for a patient is required. General consent should be obtained by the Case Manager/designee when the
eligibility assessment is successful and the patient, legal guardian or responsible family member should be
given an information booklet.
Rumailah Hospital (Al Enaya, RCC, and Adult and the Older Adult Outreach Program of CMHS in the
Psychiatry Dept.)
General Consent should be obtained and witnessed by a Staff Nurse / Case Manager. However, in Al Enaya
and RCC, general consent is obtained after a successful eligibility assessment and before the nursing
assessment is carried out.
Policy CL# 6109 ……………………. General Consent
9. What is Informed Consent?
19
Informed consent is a process in which the physician/dentist or his/her designee, or other health care
providers, qualified and credentialed, performing a high risk treatment or procedure, provide information to
the patient, and/or his/her legal guardian, in a language that the patient/ legal guardian can understand and
use it to make a decision on the proposed treatment, surgery, anesthesia, sedation, and other procedures
which may put the patient at increased risk.
Informed consent is required but not limited to for the following:









Anesthesia and moderate sedation.
Blood and blood products administration.
Any surgical procedure.
Invasive/high risk procedure/treatment.
Clinical research, investigation, and trial consent.
Organ donation, procurement, organ transplant and live donor
Assisted conception procedures.
Photography, videotaping and other imaging of patients.
Release of patient Information.
10. Who shall obtain the informed consent?
The treating physician (consultant or specialist) shall obtain the consent through a signature from the
patient/legal guardian on the informed consent form, after counseling and discussing medical risks,
benefits, potential complications and alternative therapies.
Policy CL# 7226 ………….. Informed Consent
11. If an ethical concern arises during the course of treatment, what process would you use to resolve this
concern?
Initially, the ethical concern would be discussed by the healthcare providers involved at a Medical Ethics
facility level. If the problem cannot be resolved, the corporate Medical Ethics Committee should be and
consulted to review and provide guidance and recommendations on ethical issues.
Policy OP # 4110 ……………… Ethics Committee Regulations
12. When patients or family members express dissatisfaction, how are issues resolved?
The patient /family member concerned should address their concern/comment/complement to any
employee who should then forward it to the Patient and Visitor Service Center (PVSC).
If a complaint is lodged, the Complaint Resolution Officer coordinates the management of complaints
Policy CL# 7222…………. Patient and Complaint Management Policy
13. How do you meet the spiritual needs of your patients?
20
Patients have the right to participate in spiritual/religious care activities within the applicable HMC
regulations as long as it does not interfere with diagnostic procedures or medical treatment. Patients are
assessed for any spiritual/religious care needs during their initial admission assessment.
Policy CL # 7229 …………Spiritual / Religious Care
ASSESSMENT OF PATIENTS “AOP”
1. What is the minimum content required for a patient’s initial assessment?
Each patient’s initial assessment should include an evaluation of physical, psychological, social, and economic
factors, including a physical examination and health history.
Policy CL # 7063………….. Assessment and Reassessment by Physicians
Policy CL # 7059…………. Assessment and Reassessment by Nursing Staff
2. When is the initial assessment conducted and completed?
The initial assessment should be conducted when a patient is registered or admitted to HMC:





On arrival at the Emergency Department.
During regular OPD visits.
Ad an Inpatient.
Before anesthesia.
Before a surgical procedure / invasive procedure/treatment.
The initial assessment should be completed within:
 Inpatient: An initial assessment is completed within the first 24 hours of admission
(physicians and nursing staff).
 Outpatient: Nursing initial assessment is completed prior to being seen by the physician, and
the physician assessment is completed when the patient is discharge from their visit.
21
 Emergency patients: Are assessed immediately and completed according to triage policy.
Policy CL# 7063...............Assessment and Reassessment by Physicians
Policy CL #7059……………Assessment and Reassessment by Nursing Staff
3. Does each patient receive an initial psychological, social, and economic assessment?
Yes, each patient receives an initial psychological, social, and economic assessment as indicated by his/her
needs and is documented in the initial assessment.
4. Do you have any screening process for nutritional and functional needs?
All patients are screened for nutritional and functional needs and are referred for further specialized
assessment and management when necessary.
Policy CL # 6091……Assessment and Reassessment by Other Health Care Professionals
5. When do you initially screen pain? How do you assess/reassess pain?
 Pain screening is performed upon admission/visit and is documented in the initial assessment.
 If pain is present, the physician is informed, the pain is assessed and it is documented in the nursing pain
management flow sheet (pain scale used, intensity, character, frequency, location and duration) and
other elements.
Policy CL# 7059………. Assessment and Reassessment by Nursing Staff
Policy CL# 6078………..Pain Screening, Assessment and Management
6. Who is your patient population?
 Children (neonates and pediatrics)
 Adolescents
 Adults
 Frail elderly
 Terminally ill
 Patients with intense or chronic pain
 Women in labor
 Patients with emotional or psychiatric disorders
 Patients with infectious or communicable diseases
 Patients receiving chemo or radiation therapy
 Patients whose immune systems are compromised
Policy CL # 7221………… Care of Vulnerable Patient Population
22
7. In which circumstances are patients reassessed?
 To determine their response to treatment.
 To plan for continued treatment or discharge.
 When there are significant changes to the patient’s condition or plan of care.
 Prior to being transferred to another unit, hospital or facility.
 Pain reassessment and intervention.
 Prior to, during, and post procedure or intervention.
Policy CL # 7063………Assessment and Reassessment by Physicians
Policy CL # 7059……… Assessment and Reassessment by Nursing Staff
8. How often do you reassess patients?
Acute phase:
 Physicians: at least daily.
 Nurses: at least every shift.
 As per the patient’s condition.
Non Acute / Long Term
 Physicians:
 More than 30 days and less than 90 days, at least every 10 days
 More than 90 days, at least every month
 Neonates who require growth maintenance and palliative care.
 Patients awaiting placement in an external care facility.
 Patients hospitalized for social reasons.
 Patients with long term rehabilitation therapy needs.
 Nurses:
 Every shift and as needed according to the patient’s condition.
 Once daily and as needed according to the patient’s condition.
 Other Health Care Professionals
The frequency of reassessment should be determined by the appropriate discipline providing
the care and may be based on the patient’s diagnosis, care setting, the patient’s changing
condition and their response to the ongoing care and treatments.
Policy CL # 7063……Assessment and Reassessment by Physicians
Policy CL # 7059…Assessment and Reassessment by Nursing Staff
Policy CL # 6091…… Assessment and Reassessment by Other Healthcare Professionals
9. Do you have a process to assess and reassess dying patients and liaise with their families?
23
Assessment and reassessment will be individualized to meet patient and family needs when patients are at
the end of their life. Assessment and reassessment should be performed for evaluation purposes, as
indicated by the patient’s condition.
Policy CL # 6077…………..End of Life Care
10. Do you have a laboratory safety program?
Yes, there is a laboratory safety program to promote safe work practices in the laboratory and other areas
outside the laboratory, where laboratory services are provided.
Policy CL # 7051………. Laboratory Health and Safety
11. How are new staff oriented to the Laboratory Department?
The Laboratory Department has a process for the orientation and education of newly hired staff to the
organization, the work setting and job-specific competencies, before the employee commences his or her
duties.
 Staff Orientation:
 HMC Corporate Orientation.
 Department Orientation.
 Section Orientation.
 Personnel Training
Policy CL # 6068 ………Orientation Program for Newly Employed Staff in the Department of
Laboratory Medicine and Pathology
12. How do you reduce the risk of infection in the laboratory?
 Protective environment
 Personal protective equipment (PPE)
 Universal or standard precautions
Policy CL # 7051…….. Laboratory Health and Safety
13. Do you have a process in place to report laboratory test results?
24
 STAT test results should be available within the timeframe specified in the referred policy (15
minutes, 30 minutes, 1 hour, 2 hours)
 When a critical result is identified, confirmed and validated, laboratory staff should enter the
laboratory critical result in the Laboratory Information System (LIS), and start the calling sequence,
as specified in the policy within 10 minutes of validating the critical result. The entire reporting
process should be completed within 30 minutes.
Policy CL # 7208 …………Stat Test
Policy CL # 7204 …………Reporting Laboratory Critical Test Results / Values
14. What is your process for specimen management?
The process of specimen management includes:









Collecting
Handling
Transporting
Receiving
Recording
Reporting
Storage
Disposal
Referral
Policy CL # 7067 ………Management of Laboratory Specimen
15. Do you send specimens to any other laboratories?
Yes, for example the Mayo clinic, Heidelberg.
Policy CL # 7034…….Referring Laboratory Specimens to an External Laboratory or Expert
16. What is your process for proficiency testing?
The Laboratory Department uses Proficiency Testing as a quality improvement tool that evaluates the
laboratory’s performance in comparison to its peers, reference standards and/or reference laboratories.
Policy CL # 7033…………Proficiency Testing
17. What are the requirements for staff that perform point of care testing?
25
Staffs are required to have specific training and orientation, as well as documented competency to
perform testing which is overseen by the laboratory.
Policy CL # 7211…………….Point of Care Testing
18. Do you have a Radiology safety program?
Yes, the radiation safety program aims to establish adequate safety procedures and protective
measures against exposure from all sources of radiation within the HMC facilities.
Policy SA # 1066………..Radiology Safety Program
19. How do you reduce the risk of infection within the Clinical Imaging Service (Radiology)?
 Protective environment.
 Personal protective equipment. (PPE)
 Universal or standard precautions.
Policy CL # 7258……….Infection Control in the Radiology Department
20. Do you have a process in place to report radiology test results?
Reports of radiological investigations are delivered within timeframes dictated by the urgency of the case,
as per policy.
 For most procedures, a provisional report within 2 hours.
 For extensive imaging studies such as polytrauma CT, a provisional report within 3 hours.
 Final Reports within forty eight (48) hours.
Radiological investigation having a critical finding is communicated reliably, by the radiologist, in the
appropriate time frame as per policy.
Policy CL # 6045………Reporting of Critical Results of Radiological Diagnostic Tests
Policy CL # 7073………Scheduling and Reporting Radiological Test Results
21. Do you use outside sources of radiology and diagnostic imaging services?
No.
22. What is the process for the orientation of new staff about the Clinical Imaging Service (Radiology)?
26
The Clinical Imaging Service has a process for the orientation and education of newly hired staff to learn
about the organization, the work setting and job-specific competencies, before the employee commences
his or her duties.
 Staff Orientation:
 HMC Corporate Orientation
 Radiology Department General Orientation
 Section Specific Orientation
 Personnel Training:
 Radiation Safety Program Certification
 Radiation License
Policy CL # 7032……….Orientation and Training Program for Newly Employed Staff in the Clinical
Imaging Service
CARE OF PATIENTS (COP)
1.
When do you plan the care of your patient?
Care for each patient is planned within 24 hours of admission as an inpatient.
Policy CL # 7038………..Interdisciplinary Plan of Care
2.
Who are the high-risk patients and what are the services that considered as high- risk in your facility?
The below mentioned patients/services are identified as a high risk group in HMC:
a) Emergency patients
b) Comatose patients
c) Patients on life support
27
d) Patients with communicable diseases
e) Immunosuppressed patients
f) Patients receiving dialysis
g) Patients in restraints
h) Patients receiving chemotherapy
i) Vulnerable patient population:
 frail elderly
 dependent children
 patients at risk of abuse and neglect
3. Who is authorized to discharge a patient from the Emergency Department (ED)?
Patients shall be discharged from the Emergency Department only by an order from the assigned ED
Physician.
Policy CL # 6003 …….Care of Emergency Patients
4. How do you ensure patients coming to ED are managed in the most appropriate part of the ED?
Patients coming to ED are managed according to the Clinical Model of Care (resuscitation, critical care
areas, urgent areas and low acuity areas) by following Canadian Triage & Acuity System (CTAS).
5. What are the special needs of a comatose patient?
Special needs of a comatose patient include:






Safety
Maintenance of physiological functioning
Prevention of complications
Receipt of respectful care in a dignified manner
Ongoing communication, and
Family and/or family representatives’ supportive needs.
Policy CL # 6012 …….Care of Comatose Patients
6. How did you receive training to care for a patient on life support?
I was assessed and validated on competencies related to the care of patients on life support, during my
departmental competency assessment process.
Policy CL # 6011 …….Care of Mechanically Ventilated Patients
28
7. How do you report communicable diseases?
Notification shall be done by completing a Notification of Infectious Disease official form and sending
it to the Department of Public Health and Health Protection, Center for Disease Control (CDC) and the
Infection Control Office.
Policy CL # 6013 …….Care of Communicable Disease Patients
8. What type of isolation is used for immunosuppressed patients?
Immuno-suppressed patients should be placed in a private room with positive pressure, and a “Protective
Precautions” sign should be placed outside their room.
Policy CL # 6014 …….Care of Immunosuppressed Patients
9. How do you plan the care of a dialysis patient?
Assessments and evaluations are conducted by a multidisciplinary team and involves elements such as
blood tests, review of medications, nutritional assessments and vascular access evaluations.
Policy CL # 6021 …….Care of Hemodialysis Patients
10. Are you trained to administer or assist in the administration of chemotherapy drugs?
Yes. I have valid certification in chemotherapy administration and have validated competencies for the
medications used for non-cancerous conditions.
Policy CL # 7215 …….Care of Patients Receiving Chemotherapy
11. What is the specific age group of the pediatric population in your facility?
0 – 14 years of age
Policy CL # 7203 ……. Care of the Pediatric patient Population
12. Who are considered as elderly patients in your facility?
A group of individuals, 60 years and above with different degrees of illnesses and disabilities are
considered as elderly patients.
Policy CL # 7212 ……. Care of Elderly Patients
13.
How do you manage a patient with suspected abuse and neglect?
29
All patients will have received an initial screening for abuse, neglect, maltreatment or domestic violence
on admission. All suspected abuse or neglect will be directed for the attention of the attending physician
and referred to a social worker. Hospital Administration will be informed and an OVA report must be
initiated.
Policy CL # 7217 ……. Abuse and Neglect of Children and Adults
14.
Do you use restraints for patients and when do you use restraints?
Restraints are used based on the assessed need. Medical and surgical indications include but are not
limited to:




Extreme agitation – at high risk of harm to self or others
Cognitive impairment (confusion)
Lack of insight and judgment and unable to follow commands.
Interference with/or removal of medical devices.
Intentional or uncontrolled movements or actions that place the patient at risk of a fall or other injuries in
a psychiatric setting, as indications.
Policy CL# 6025…………Restraint of Patients
15.
16.
What type of restraints do you use in your facility?
 Mechanical.
 Chemical.
 Physical hold.
How do you monitor a restrained patient?
Color, Sensation and Movement (CSM) are monitored regularly.
Mention the frequency of monitoring as per your setting as mentioned in the policy.
Policy CL # 6025……… Restraint and Seclusion of Patients
17.
How did you receive training in the use of restraints?
I was validated to use of restraints during my departmental competency assessment process.
18.
How do you recognize and respond to changes in your patient’s condition?
 When physiological signs that are outside the normal range, indicate a potential deterioration in the
patient’s condition, seek additional assistance based on the hospital’s early warning criteria.
 Patient assessments are documented on the Standard General Observation Charts.
30
 When the observation falls in the Yellow Zone, patients are managed based on the Clinical
Response Algorithm.
 When the observation falls in the Red Zone, patients are managed based on the Rapid Response
Algorithm.
19.
Did you receive any training for the recognition and response to clinically deteriorating patients?
Yes. I have received the three levels of Early Warning System education.
 Level 1 – Awareness Training.
 Level 2 – Recognition and Response Training.
 Level 3 – Advanced clinical and resuscitation skills.
20. How do you ensure the safety of a patient during the process of blood administration?
Describe the process for:
a)
b)
c)
d)
e)
Procurement of blood from the blood bank or blood storage area.
Patient identification.
Blood administration.
Monitoring of the patient.
Identification and response to signs of potential transfusion reactions.
Policy CL # 6010…………Administration of Blood and Blood Products
21. How do you identify patients with pain?
Patients experiencing pain are identified during their initial assessment and reassessment using
standardized pain scales.
Policy CL # 6078…………Pain Screening, Assessment and Management, Addendum B, Pain Assessment
Tools Used in HMC
22. How do you manage pain appropriately?
a) Identify patients with pain during their initial assessment and reassessment
b) Communicate with and educate patients and families about pain and symptom management.
c) Management of pain according to clinical guidelines or protocol
Policy CL # 6078……….Pain Screening, Assessment and Management
23. Do you have a process to manage end-of-life care?
31
Yes. End of life care is provided based on a patient’s unique needs.
Policy CL # 6077………End-of-Life Care
24. Are Organ and Tissue Transplant Services available in your facility?
 Currently living and deceased kidney transplantation and deceased liver transplantation services
are available (only in HGH).
 Corneal Transplantation is done in RH.
The care of each patient is planned within 24 hours of admission as an inpatient.
Policy CL # 7038……….. Interdisciplinary Plan of Care
ANAESTHIA AND SURGICAL CARE “ASC”
1. What must be documented in a patient’s medical record prior to the performance of a surgical
procedure?




Pre-operative history and physical diagnosis.
Informed consent.
Planned procedure.
Pain management plan post operatively.
Policy CL # 6040……General Preoperative Care
Policy CL # 6039……Peri-operative/Peri- Procedure Care
32
2. Is a pre-anesthesia assessment performed for each patient before anesthesia induction?
Yes, pre-anesthesia assessment is essential to carefully plan the administration of anesthesia as the
administration of anesthesia carries a high level of risk. Anesthesia care is planned, the patient/family educated
and this is documented. Pre-anesthesia assessment is also performed as it is the basis for postoperative
analgesia. Risks, benefits, alternatives, post-surgery/post-procedure and pain management is also explained to
the patient and family by the anesthetist/physician. The assessment is documented prior to receiving
anesthesia in the operating room, and the other assessment is immediately before the induction of anesthesia
takes place.
Policy CL # 6030……Preoperative Assessment – The role of the Anesthesiologist
3. In which of your facilities is sedation performed?
Hamad General Hospital “HGH”
Rumailah Hospital “RH”
Women’s Hospital “WH”
Al Khor Hospital“AKH”
National Center for Cancer Care and
Research “NCCCR”
Heart Hospital “HH”
Al Wakra Hospital “AWH”
Cuban Hospital “TCH”
Sedation is performed in the ER, OR, Day Care Unit, Endoscopies,
Cath Lab., ICU, Lithotripsy.
PS, Psych, ENT, OPHTH, Dental, MRI, Radiology.
OR, LR, NICU, C2, C4, ACU, Inpatient Units, (E2, E3, E4, E6, W2, W3,
W4, W5, W6).
Premedication, OR, Induction Area, LR, A&E, Endoscopy, Day Care
Inpatient (Ward 1 and Ward 2) and Day Care Unit.
Sedation is performed in the ER, OR, Day Care Unit, Cath Lab., ICU.
Sedation is performed in the ER, OR, Day Care Unit, Endoscopies,
ICU.
Sedation is performed in the ER, OR, Day Care Unit, Endoscopies,
ICU.
4. Who can provide moderate sedation and analgesia?
Privileged physicians, dentists, or other qualified individuals, who are competent and qualified by education
and training, shall practice and supervise the administration of sedation/analgesia. He/she has to have
satisfactorily completed the training program (ILS or APLS or NRP) as appropriate to his/her specialty.
Policy CL # 6029…Moderate Sedation and Analgesia by a Non-Anesthesiologist
5. Who should monitor the patient during sedation?
Qualified care givers should be distinct from the person performing the diagnostic or therapeutic procedure
and should not be given any other responsibility which would take them away from monitoring the patient.
He/she should have valid competency and a certificate in:
 A sedation/analgesia course and/or should have passed written exams.
 Sedation and analgesic medication administration.
33





Techniques of various modes of sedation.
Appropriate monitoring.
Response to complications.
Use of reversal agents.
Certified with at least basic life support.
6. What are the parameters should be monitored during moderate sedation?
The following parameters should be monitored during moderate sedation:
1. Level of Consciousness
2. Pulmonary Ventilation
3. Oxygenation
4. Hemodynamic
Availability of Emergency
5. Equipment During the
Administration of Sedation
Response to verbal commands is a guide for the level of sedation for early
detection of adverse drug responses which need to be treated in a timely
manner.
Through observation and auscultation to early detect drug-induced
respiratory depression, which is a primary cause of morbidity-associated
with sedation and analgesia.
The use of pulse oximetry with an appropriate alarm for the early
detection of hypoxia and early oxygen desaturation.
Heart rate, pulse rate, respiratory rate and blood pressure to be
monitored continuously at regular intervals for the early detection of
tachycardia or hypotension to reduce adverse outcomes during the
administration of sedation.
E-cart to be available in the procedure room daily.
Policy CL# 6032…….Basic Anesthesia Monitoring
Policy CL # 6029…Moderate Sedation and Analgesia by a Non-Anesthesiologist
7. Who should monitor the patient post-anesthesia?
A qualified nurse with specific competencies should monitor the patient post-anesthesia and document his/her
status.
8. Who discharges the patient from recovery?
The patient is discharged from Recovery by a privileged anesthesiologist or other individual authorized by the
individuals responsible for managing anesthesia services based on the patient’s record, which contains the
evidence that the post-anesthesia criteria is met.
Policy CL# 6035……..Post Anesthesia Care Unit Discharge Criteria and the Role of the Anesthesiologist
9. Who should write the surgical report and when does it need to be completed?
34
The responsible physician should write the surgical report (Operative Note) prior to the patient’s transfer to
the post-anesthesia / recovery area.
10. What should the surgical report contain?
At a minimum, the surgical report should include:









Post-operative diagnosis.
Name of the operative surgeon and his assistant.
Name of the procedure performed and a description of each finding.
Surgical specimen sent for examination.
Perioperative complications
Amount of blood loss and the amount of transfused blood.
Registry number of all implantable devices.
Post-operative patient’s care plan and
Date, time, signature and stamp of the responsible physician.
Policy CL # 6046……Surgeon’s Operative Notes/ Documentation
Policy CL# 6103………. Surgical Care of Implantable Medical Devices
MEDICATION MANAGEMENT AND USE - MMU
Medication management is an important component in the symptomatic, preventive, curative, and palliative
treatment and management of diseases and conditions.
35
The medication is defined as any prescription medications; sample medications; herbal remedies; vitamins;
nutriceuticals; over-the-counter drugs; vaccines; or diagnostic and contrast agents used
on or administered to persons to diagnose, to treat, or to prevent disease or other abnormal conditions;
radioactive medications; respiratory therapy treatments; potential nutrition; blood derivatives; and
intravenous solutions (plain, with electrolytes and/or drugs). Medications are either diagnostic or therapeutic.
1. How is the medication management process managed across the corporation?
Medication Management and the process for its use is organized to meet a patient’s needs and complies
with applicable laws and regulations.
Policy CL # 7205………..Medication Management Program
2. How are orders verified and medication(s) identified before being administered to patients?
All personnel permitted to administer medication must check for the following Seven "Rights" of Medication
Administration:
1)
2)
3)
4)
5)
6)
7)
The right medication.
The right patient.
The right dose.
The right route.
The right time.
The right to refuse.
The right to educate.
Policy CL # 6050……………Medication Administration
3. How do you handle a patient’s home medications when they bring these into hospital?
 The patient home medications should be validated by the pharmacy.
 Healthcare staff must have sufficient competence and knowledge about the effects, dosing, and care of
potential resources, the indications, actions, and side effects of the drug to be administered.
4. What will you do with patient home medications?
 If the medication is not authorized for use by the patient, the medication(s) should be sent home
with a family member.
 If the patient's family fails to collect the medication, it should be placed in a sealed bag with a list of
the contents and the patient’s name, signature, room number, date and sent to the pharmacy or
kept in Automated Dispensing as per process.
36
Policy CL # 6055 …………………..Storage and Use of Patient’s Own Medication
5. What is the process when a patient needs medication(s) not available at the hospital?
The pharmacy will inform the physician and the hospital administration, either to purchase or obtain the
medication from another facility, pharmaceutical company, or outside agency.
6. What are Adverse Drug Reactions?
Adverse drug reactions are defined as any unwanted or unexpected response to a drug that happens
within the recommended drug manufacturer dosage range.
Policy CL 6057…….Suspected Adverse Drug Reactions, Reporting and Monitoring
7. What do you do if you suspected Adverse Drug Effects?
 All adverse reactions will be reported to the physician in order to give appropriate treatment.
 Adverse drug reactions should be documented in the patients' medical record and an Adverse Drug
Reaction Report form should be completed by the Physician.
 The completed Adverse Drug Reaction Form should be sent to the Pharmacy or assigned staff for
evaluation, documentation and for analysis.
 Compiled and analyzed results should be presented to health care professional staff to continue to
improve services.
Policy CL # 6057……..Suspected Adverse Drug Reactions, Reporting and Monitoring
8. Who can report Adverse Drug Effects?
Anyone can initiate the reporting process when any effect occurs – physician, nurse, pharmacist, any health
care provider or patient.
9. What do you know about the Medication Recall System?
The medication recall system is an action taken to remove a drug or a defective batch of drugs from the market
or a patient’s use.
Policy CL# 6065---------Medication Recall System
10. What do you know about Medication Errors and Near Misses?
37
 Medication errors are any preventable event that may cause or lead to inappropriate medication
use or patient harm while the medication is in control of a health care professional.
 Near misses are an event or situation that could have resulted in an accident injury or illness, but
do not happen and are prevented either by chance or through timely intervention.
11. How are Medication Errors and Near Misses managed and reported?
 The immediate supervisor should be informed immediately of a medication error or near miss.
 Medication errors and near misses should be reported immediately and investigated by the concerned
department.
 The person, who discovers the medication error and near miss, should complete an incident report.
 The completed incident report should be forwarded to the immediate supervisor who should further
initiate an investigation into the incident and take action.
 A medication error resulting in an adverse event should be documented in the Physician’s Progress
Notes and the Nurse’s Progress Notes.
Policy CL # 7045………..Managing and Reporting Medication Errors and Near Misses
Patient and Family Education “PFE”
1. How are patient education needs met?
Patient /family education needs are diagnosed and start upon entry into any of HMC facility.
38
Policy CL # 6090……….Patient and Family Education
2. How are the assessment findings communicated to the healthcare providers?
Documentation on interdisciplinary education forms, communication through interdisciplinary rounds and
healthcare conferences; and consultation.
3. When do you provide patient and family education?
Patients/family education should be provided during:





Each visit to hospital.
As per their individual needs.
Any change in the patient’s Plan of Care.
Before obtaining informed consent.
Before performing any procedure.
4. What are the important elements to be assessed before providing Patient / Family Education?
All healthcare providers should consider the following elements:






Beliefs and values.
Education levels.
Language.
Emotional barriers.
Physical and cognitive limitations.
Readiness to learn the information.
5. What are the main topics to be taught to the patient / family?
The following (although not limited to) topics:






Safe and effective use of all medications.
Pain management.
Potential interactions between prescribed medications and food.
Safe and effective use of medical equipment.
Diet and nutrition.
Rehabilitation techniques.
Policy CL # 6090...........Patient and Family Education
6. How to identify whether the patient and/or theirfamily understood the education provided?
39
 Interaction between the healthcare providers and the patient and their family confirms that the
information was clear and understood.
 Encourage the patient and their families to ask questions and speak up as active participants.
 Verbal information is reinforced with written materials appropriate to the patient’s needs and learning
preference.
 Patients are asked about their preferred way of learning.
 Patients are asked to provide a return demonstration/repeat information back to the instructor.
 Appropriate family members and significant others are involved in patient education.
7. What resources are available for Patient/Family education?
Patient handouts, specialty consultations and staff who are assigned to communicate with the patients and
their family
8. How do you ensure that patient/family education resources are kept current?
Specific clinic materials for patient/family education are reviewed and updated for currency and relevancy
on an annual basis. Interim updates are conducted as needed.
9. When a patient is not ready to be taught, what is the next step?
Try to attempt the education again, when the patient’s clinical condition improves or family members are
available.
Policy CL # 6090..........Patient and Family Education
10. When and where will you will document Patient and Family Education?
All healthcare providers should document the Patient / Family Education provided on a Patient / Family
Education Form.
11. When are patients educated about the safe and effective use of medications?
All issued prescriptions should have a detailed drug summary at the time of dispensing from the
pharmacy for both inpatients and outpatients.
12. Who is responsible for providing the patient with the education needed?
The prescribing physician, assigned nurse, and pharmacist have ultimate responsibility for educating
patients on their medication regimes for inpatient, outpatient and other patients’ care settings. A
medication list will be provided to all patients.
13. How do you ensure that patients are educated about potential drug-food interactions and are provided
with counseling on nutrition and modified diets?
40
 Drug-food interactions are part of the essential education provided to patients by pharmacists,
physicians, nurses and dietitians.
 Nutrition screening on the patient database determines the need for a nutritional assessment.
 Medication educational handouts contain the possible drug food interactions. In addition to
initial education, learning needs are assessed throughout the regime on a regular basis.
Policy CL # 6067 ………..“Food and Drug Interaction”
14. Who is responsible for educating the patient about rehabilitation and rehabilitation techniques?
A multidisciplinary healthcare team provides the patient with rehabilitation education. The team may
include staff from the physical medicine, physical therapy, occupational therapy and speech therapy units.
Policy CL #7038………. Interdisciplinary Plan of Care
15. How are patients instructed on the use of medical equipment /supplies?
All patients should be instructed and provided with adequate education on the safe use of medical
equipment /supplies by the assigned nurse and physician.
Policy CL # 6090 (part 5.7.5)..........Patient and Family Education
QUALITY IMPROVEMENT AND PATIENT SAFETY “QPS”
1. Who is responsible for quality in Hamad Medical Corporation?
Quality is everyone’s responsibility
2. What is the methodology that HMC has adopted for Quality Improvement (QI) activities?
41
The specific methodologies adopted for Quality Improvement are the Model for Improvement and/or FOCUS/
PDSA
FOCUS/PDSA
F.O.C.U.S:
FIND a process to improve.
ORGANIZE a team that knows a process.
CLARIFY current knowledge of the process.
UNDERSTAND causes of process variation.
SELECT the process improvement strategies.
P.D.S.A:
Plan the change.
Do or implement the changes.
Study the results (data collection and analysis) and lessons learned.
Act to hold the gain and continue to improve the process.
Plan
Act
PDSA
42
Do
Study
Policy OP # 4078 Quality Improvement and Patient Safety Program
3. Who prioritizes the quality improvement and patient safety activities in your hospital?
 Hospital leadership identifies the priorities for measurement and improvement.
 The hospital QPS Committee provides an oversight of all QPS activities through ongoing monitoring
of selected performance measures.
4. What is the basis for performance measures selection?






Relevance to mission - whether the indicator addresses the population served
Strategic planning priorities
Proactive risk assessment and safety needs
Needs identified in operational processes
Patient care and organizational function
Clinical importance - whether it addresses a clinically important process that is:






high volume
problem prone
high risk
International Patient Safety Goals
new policy/procedure/process
new form
5. How were you educated on the quality improvement activities?
 Staff will be taught about the QPS Program during their initial orientation and on an annual basis
thereafter.
 This education will include a description of the QPS Program and how they fit into the program,
based on their particular job responsibilities.
 Staff educational sessions are provided to ensure that the QPS program, QI principles and
improvement methodologies are communicated to all staff.
43
6. How were you informed about the QI activities and information about quality issues throughout the
hospital?
 The QI activities are communicated to all the hospital staff through departmental meetings.
 We also have regular monthly unit meetings to discuss all unit /departmental issues.
 In addition, organizational-wide memos are posted on the intranet.
 The Unit QI boards are another method to share QI / QPS Committee activities.
7. What are the measures selected for your unit/department for monitoring?
Be familiar with the unit/departmental performance measures and be able to explain the results based on
the collected data and actions taken for improvement.
8. When is data validation required?
Data validation is required in the following circumstances:
 When a new measure is implemented
 When data is made available to public on the organization’s website or in other ways
 A change has been made to an existing measure, such as the data collection tools have changed or the
data abstraction process or abstractor has changed
 The data resulting from a existing measure has changed in a unexplainable way
 The data source has changed, such as when part of the patient record has been turned in to an
electronic format and thus the data source is now both electronic and paper
 The subject of the data collection has changed, such as changes in the average age of patients, co
morbidities, research protocol alterations, new practice guidelines have been implemented, or new
technologies and treatment methodologies introduced
9. What type of quality improvement projects is your unit/department/clinic involved in?
Why did you choose that QI activity?
 Staff should be familiar with QI projects and data collected at their unit/ department/ clinic. It is
important to be able to discuss QI projects and the reasons for the selection of the specific
project/measure.
 For example, because we had a problem with ....... a performance improvement team was created to
collect and analyze data, the result of the collected data indicated there was a problem in..., and
therefore the following actions were taken to address the problem...... After implementing those
actions we audited/measured again to determine if an improvement was achieved.”
10. Do you evaluate the cost and efficiency of your improvement project?
Every year, one improvement project is selected to evaluate the improvements on cost and efficiency.
This year, our impact analysis project is……………………..
44
“Be prepared to talk about the hospital’s ‘Impact Analysis’ project for the year”.
11. How are the results of department/service quality improvements communicated to leadership?
 Monitoring results are reported to the QPS Committee as per the agreed reporting schedule.
 Collected data are analysed, aggregated,reported and displayed on the dashboard.
12. In which way you are involved in quality improvement activities?
We participate in quality improvement activities and have input in their performance in a variety of ways:
 Data collection.
 Monitoring activities.
 Reporting of incidents.
 Identifying processes for improvement.
 Supporting fellow staff members in improvement activities.
 Participation in staff meetings.
 Participation in teams.
 Participating in formulating action plans for improvement.
13. How do you report incidents?
Incidents are reported through the Electronic Incident Reporting System (EIRS).
Policy OP # 4070…………. Reporting of Occurance, Varaiances and Accidents
14. What is a sentinel event?
 A sentinel event is an unanticipated occurrence involving death or a major permanent loss of function.
 Such events are called sentinel because they signal the need for immediate investigation and response.
Sentinel events include:
 Unanticipated death of a patient unrelated to the natural course of the patient’s illness or underlying
conditions.

Death of a full term infant.
45

Suicide.

Major permanent loss of function unrelated to the natural course of the individual’s illness or
underlying condition.

The occurrence of a surgical procedure characterized by a wrong procedure, wrong patient, or wrong
site or side of surgery.

Transmission of a chronic or fatal disease as a result of infusing blood or blood products or transplanting
contaminated organ or tissues.

Infant abduction, abduction of any patient receiving care, treatment and services.

Discharge of an infant to the wrong family.

Rape, workplace violence or homicide of a patient, staff member, trainee, visitor or vendor.

Hemolytic transfusion reaction involving the administration of blood or blood products having
major blood group incompatibilities (ABO, Rh, other blood groups).

Unintended retention of a foreign object in a patient after surgery or other invasive procedure.

Severe neonatal hyper-bilirubinemia (bilirubin >30 milligrams/deciliter).

Prolonged fluoroscopy with cumulative dose >1.500 rads to a single field or any delivery of radiotherapy
to the wrong body region or >25% above the planned radiotherapy dose.
Policy # OP 4055.............. Management of an Untoward Clinical Event
15. How are sentinel events reported and managed?
All sentinel events, serious untoward events and near miss events should be reported through the
Electronic Incident Reporting System (EIRS).

Notify hospital/entity executive of all sentinel events immediately on discovery of the incident but
no later than 24 hours after the discovery of the incident.

A written report of the preliminary investigation must be forwarded by the concerned department
to the Chief Executive Officer or appointed deputy, the Risk Management Section of the Quality
and Patient Safety Department, and the Adverse Medical Outcome Committee (AMOC) within 3
working days of the incident occurring.
 Conduct a root cause analysis and submit the complete report including the action plan within 45 days.
46
Policy # OP 4055 ......... Management of Untoward Clinical Event
Policy # OP 4118 .......... Conducting a Root Cause Analysis
16. If medical equipment is involved in a sentinel event, how will you deal with that?
 If medical equipment or a medical device is involved in the event, the device name, manufacturer,
model and HBE number should be noted on the electronic OVA report.
 The equipment involved in the incident should be removed from service, clearly tagged as “OUT OF
SERVICE - DO NOT USE,” isolated in a room not normally associated with the use of that equipment,
and left in exactly the same state as it was at the time of the incident.
 No changes of any type should be made to the fittings or settings, and under no circumstances
should staff attempt to repair the faulty equipment.
 The equipment should not be used until it is checked and released for service by the Biomedical
Engineering Department.
17. What is a near miss?
A near miss is any process variation that did not affect an outcome, but for which a recurrence carries a
significant chance of a serious adverse outcome.
An example of a near miss would be surgical or other procedures almost performed on the wrong patient
due to lapses in the verification of patient identification but caught at the last minute by chance.
18. What are the tools for proactive risk analysis that the hospital uses?
Failure Mode and Effect Analysis (FMEA) is a systematic way of examining a design prospectively for
possible ways in which failure can occur.
Hazard Vulnerability Analysis (HVA) is used for the identification of potential emergencies and the
direct/indirect effects these emergencies may have on the hospital operations and services.
“Be prepared to talk about the hospital FMEA project for the
year”.
19. How are clinical and non-clinical risks managed at the hospital?
47
All units/departments conduct risk assessments at least annually or more frequently if required to
identify clinical and non-clinical risks. Hospitals maintain a risk register and the risks are dealt and
escalated based on the risk scoring.
Policy # OP 4072 .............HMC Risk Management Strategy
PREVENTION AND CONTROL OF INFECTIONS “PCI”
1. What is the most important measure to prevent infection?
48
The most important measure to prevent infection is hand hygiene.
2. When do you perform hand hygiene?
 Before touching the patient.
 Before the cleaning/antiseptic procedure.
 After body fluid exposure risk.
 After touching the patient.
 After touching patient surroundings.
 If hands will be moving from a contaminated-body site to a clean-body site during patient care
 After glove removal
Policy CL # 7241………Hand Hygiene
3. How do you prevent health care associated infection?
What are Standard Precautions?
Apply standard precautions for all patients regardless of their diagnosis and treatment.
Standard Precautions include:
1) Hand hygiene.
2) Use of personal protective equipment (e.g. gloves, gowns, facemasks), depending on the anticipated
exposure.
3) Respiratory hygiene and cough etiquette
4) Safe injection practices
5) Safe handling of potentially contaminated equipment or surfaces in the patient environment.
Policy CL # 7233…….Category of Isolation Precautions
4. How do you control the transmission of infection? Or what are the different transmission based
precautions and give an example?
Apply three categories of transmission-based precautions including:
1) Contact precautions.
49
2) Droplet precautions.
3) Airborne precautions.
5. Who is responsible for Infection Control?
Infection Control is everyone's business.
6. Why is the Infection Control Program important?
To prevent and control health care associated infections amongst all patients, health care workers and visitors
whilst they are in the health care setting.
7. What is PPE? What does it include?
PPE stands for “Personal Protective Equipment” and includes gloves, gowns, masks, face shields, protective
eyewear/goggles, head covers and boots.
Policy CL # 7246………..Infection Control Practices
Policy CL # 7233……..Category of Isolation Precautions
8. How are visitors informed about the precautions to be taken before entering an isolation room?
Transmission based isolation precaution posters are placed on the patient's door or by their bedside.
The visitors have to contact the nurse before entering the room.
9. What is MDRO? Can you give an example?
 Multidrug resistant organisms are organisms that are resistant to two or more groups of antibiotics.
 Example: MRSA (methicillin resistant staphylococcus aureus), ESBL (extended spectrum beta lactamases),
VRE (vancomycin resistant enterococcus).
Policy CL # 7268……. Multidrug Resistant Organisms and Epidemiologically Important Organisms (MDRO)
10. How do you identify if the patient has Multidrug Resistant Organisms (MDROs)?
 The microbiology laboratory informs the requesting physician and the Infection Control Practitioner (ICP).
 ICP will notify the concerned unit.
11. How do you isolate a patient with MDRO?
 Apply contact precautions in addition to standard precautions.
50
 Patient is placed in a single room or with a patient with same organisms.
12. How do you manage a patient with clostridium difficile?
 Apply isolation precautions.
 Hand washing with soap and water.
 Do not use alcohol hand rub.
 Clean and disinfect patient care items and environment with 0.1% sodium hypochlorite solution (supervise
housekeeping staff).
 Teach the patient, family and visitors to wash their hands with soap and water during visits and when
leaving the patient's room.
 Patient should be referred to an infectious disease physician for treatment and management of antibiotics.
13.
How do you manage a patient with pulmonary tuberculosis (PTB)?
 All suspected and/or confirmed cases shall be isolated in an airborne isolation precaution (negative
pressure room with 6-12 air exchanges per hour).
 Keep the door closed always.
 Wear N95 mask when entering the patient's room and remove it outside the patient room.
 Place surgical mask on patient during transport.
Policy CL # 7233…….Category of Isolation Precautions
14. How do you monitor the negative pressure room?
 When the patient is on Airborne Infection Isolation, daily monitoring of the pressure is done and
documented.
 If unoccupied, it is checked on a monthly basis by the Engineering Department.
Policy CL # 7233…..Category of Isolation Precautions
15. How do you know if the negative pressure room is functioning properly?
The monitoring device alarms when negative pressure falls below the -2.5 Pascal.
51
16. What should you do if the negative pressure room alarm rings with a red indicator?
 Mute alarm.
 Close both doors of the isolation room.
 Monitor the red indicator light for 20 minutes (the alarm should return to green indicator light).
 If the red indicator light is still illuminated or alarm continues to ring after 20 seconds, contact the Control
Room immediately for further action by the Engineering Department.
17. How do you dispose of infectious wastes (e.g. blood, blood components and body fluids)?
Dispose in yellow biohazard labeled containers requiring special treatment prior to going to landfill.
Policy CL #7249…Management of Infectious Waste
18. How do you maintain clean and dirty items to prevent the spread of infection?
 Do not store clean and dirty items together.
 Dirty utility room doors must remain closed.
 Once a clean item enters the dirty utility room, it is considered dirty and will need to be disposed or
reprocessed prior to re-use.
19. How do you maintain sterility of items?

Clean and sterile supply closets must remain locked and with limited access and controlled traffic patterns.

Once a clean/sterile item is removed from the clean/sterile supply closet, it must be used, disposed of, or
reprocessed.

Sterile items are not to be stored in drawers or other areas not designated for the storage of sterile
supplies.

Prior to use, sterile packages need to be inspected for tears, holes or other damages that would indicate a
compromise in package integrity.

If damage is visible or the integrity of the package is questionable, the item will be considered
contaminated and disposed of or reprocessed.
20. If you are exposed to blood or body fluids, what will you do?
First Aid:
52
 Wash with soap and water.
 Flush area thoroughly when exposed to eyes/mucous membrane.
 Report exposure to the supervisor and an infection control practitioner immediately.
 Proceed to the staff clinic during duty hours or ED during outside of duty hours.
 Complete OVA and Blood and Body Fluid Exposure Forms when reporting to the Staff Clinic or the
Emergency Department.
Policy CL #7251….Management of Sharp Injuries and Exposures to Blood and Body Fluid
21. How do you manage blood spillage?
For a small spillage:
 Place a CAUTION sign if required.
 Wear appropriate PPEs.
 Wipe the area with absorbent paper towel and dispose in a yellow bag.
 Spray 0.05% sodium hypochlorite solution and wait for 2 minutes.
 Mop the area as required.
For a large spillage:
 Secure the area.
 Call the Safety Officer.
22. How do you dispose of sharps such as needles and scalpels?
 Do not bend or recap needles.
 Place in a sharps container as soon as possible after use.
 When the container is 2/3 full, close permanently and replace.
23. How do you clean patient care areas (e.g. floor)?
53
Double bucket system for mopping the floor using hospital approved disinfectants. Example hypochlorite
solution.
24. What should you do if you are exposed to a communicable disease (e.g. TB, chickenpox)?
 Report to Infection Control.
 Initiate OVA.
 Report to the Staff Clinic for assessment and management.
Policy CL# 7263……Work Restrictions and Job Related Illnesses and Exposures
25. What will you do if you have an employee with active skin lesions?
 Employees with a communicable disease or infected skin lesions are prohibited from having direct
contact with patients or their food, if direct contact will transmit the disease.
 The affected employee will need to report to the Staff Clinic for evaluation and management.
Policy CL# 7263……Work Restrictions and Job Related Illnesses and Exposures
26. How do you get information about the health care associated infections in your unit?
An infection control practitioner will notify the concerned unit/department monthly and quarterly as required.
27. What are healthcare associated infections?
Associated infections are infections acquired from a hospital, normally after 48-72 hours of admission which are
not present or incubating at the time of admission.
28.
How do you report communicable diseases admitted to your unit?
Report to the Supreme Council of Health Communicable Disease Center’s Infection Control Department by
completing a Notification of Communicable Disease form.
General Questions
1. Do you know the assigned infection control practitioner in your unit/department?
2. What are the infection control indicators in your unit/department?
3. Have you attended in-service education, related to infection control?
4. How are bio-hazardous wastes handled?
54
5. Where is PPE (Personal Protective Equipment) kept?
6. How do you monitor negative pressure rooms?
7. How do you clean the equipment (i.e., wheelchairs, laryngoscopes, blades, etc.)?
8. How do you give and receive feedback from infection control?
9. How do you know if items are clean or dirty in the dirty utility rooms?
10. What actions have you taken to control outbreaks of healthcare associated infections?
11. What actions have you taken to reduce risks or prevent healthcare associated infections?
Things that require continuous monitoring:
 Storage of dirty and clean supplies.
 Cleanliness of ice machines and water fountains.
 Hand washing facilities in medication areas.
 Changing gloves and washing hands between patients.
 No recapped needles.
 Sharps container not overfilled and changed in a timely manner as per policy.
 Cleanliness of refrigerators; no food in the medication refrigerator.
 Function of the thermometers in refrigerators.
 Outdated medications.
 Cleaning storage and equipment.
 No food or drinks where there is a potential for blood or body fluid exposures.
Reminder:

Eat and drink only in designated areas.
 All employees need to be aware of how to access the infection control policies on the Intranet. If you
do not know where they are, ask your immediate supervisor.
GOVERNANCE, LEADERSHIP AND DIRECTION - ’GLD’
55
 HMC ission ,vmision,and values.
 Applicable laws and regulations.
 Scope of services.
 Staffing plan.
 Hospital and departmental structure.
 Budget and resources allocation.
 Strategic planning and related documents.
 Information management plan
 Quality improvement program.
 Supply chain management and evidance –based purchasing interview.
 Ethical framework and culture of safety interview.
 Organ and tissues transplant services.
 Medical professional education.
 Human subjects research process.
Samples of the questions related to focus standards.
GLD:




Do you have a strategic plan?
Who is responsible for developing the strategic plan?
What are the strategic priorities for your hospital?
Do you have a quality improvement program?
56
 Do you have clinical pathways?
 Did you conduct patient satisfaction surveys?
 Explain the process you, as leaders; use to approve the policies and plans used to operate your
organization.
 What did you do to achieve the IPSG?
 What kind of communication do you have with other facilities related to IPSG at all levels?
 What are your strategies and programs for health care professional education and research?
 How do the governing leaders support your facility?
 How do you know that your documents are current?
 Do you provide the "e.g." housekeeping staff education for fire safety, hazardous and waste
management and infection control?
 Did the contract companies conduct any patient satisfaction surveys / communicate the results with
you?
 How do you manage the language barriers among patients and staff?
 How do you manage ethical issues?
 How do you manage hospital staffing to meet patient needs?
 Do you have any vacant positions that need to be filled?
 What is your plan for the acting positions?
QPS:
 What are the measures that are being used for improvement?
 What are the improvements that have been made as a result of data collection and analysis?
 How are performance improvement methods used throughout the organization?
The basics of data gathering and preparation, including:
1. Selection of measures.
2. Data collection and aggregation.
3. Data analysis and interpretation.
 Dissemination/transmission of findings.
 Taking action.
 Monitoring performance/improvement.
Examples of such data based on an assessed risk point might include but are not limited to:





Number of pharmacy interventions
Turn-around times from order to administration
Adverse drug events.
Use of high risk medications
All suggested measures in QPS.3.5 and 3.6 (use of antibiotics)
SQE:
57











Do you have a staffing plan?
What is your process for recruitment?
Do you have a program for staff orientation and continuous education?
Does each staff have a defined job description?
What is the evaluation process at your organization?
Do you have a process to ensure that your staff have received resuscitation training?
What’s the hospital process to evaluate the credentials of medical staff, nursing staff and other
health professional staff?
What is the verification process for staff certificates?
Are all your staff required to have licensure?
Do all medical staff have certain privileges to perform any procedure?
Do you have a process to clarify the privileges?
PFR:












Do you have a process that supports patient/family rights during care?
What measures do you take to protect patients’ belongings from theft or loss?
How do you protect vulnerable children, disabled and other at risk members of the population?
To what extent do your patients participate in the care process?
Do you inform the patients/families about their right to refuse or discontinue treatment?
Do you have a process to receive and act on complaints?
Do you obtain general or informed consent before any procedure?
Who is responsible for carrying out the consent form procedure?
Do you perform any research at your facility?
Do you inform patients/families that they'll be included in any of this research?
What are the processes for organ donation?
Do you have a process to withhold resuscitative services or stop treatment?
MMU
Specific aspects of medication management that may be addressed during the discussion and focused-tracer
include:










Medication selection, procurement and storage including IPSG #3.
Ordering, order entry, and transcription and IPSG #2.
Preparation and dispensing.
Administration and IPSG #1.
Monitoring and IPSGs #5 and # 6.
Reporting of errors/system breakdowns/near misses
Data collection, analysis, evaluation of systems and actions taken including any performance
improvement initiatives related to medication management.
Medication education (patients/family and staff).
Information management related to medication management.
Patient involvement as part of a medication management team.
58
PCI









Do you have an infection control program?
How are patients with infections identified by the organization?
How are patients with infections considered within the context of the infection control program?
What type of analysis is being conducted on infection control data, including comparisons with other
facilities?
How often is the infection control data reported and for whom?
What are the infection control and prevention activities?
Do you have any physical facility changes, either completed or in progress, that have an impact on
infection control?
What actions are taken as a result of surveillance and the outcomes of those actions?
What infection control practices are related to emergency situations?
MOI:
1. How are confidentiality, access, integrity, and security of data and information maintained?
2. What is the process for releasing confidential information requiring patient consent?
3. What kind of information management training is available?
4. What activities has HMC undertaken to improve medical records?
FMS









What specific risks related to its environment of care have been identified by the organization?
How have the roles/responsibilities for each staff member been communicated by the organization?
What procedures and controls does the organization implement to minimize the impact of risk to
patients, visitors and staff?
What procedures does the organization implement to respond to an FMS incident/ failure?
How/ when/ and to whom are FMS problems, incidents, and/or failures reported within the
organization?
How is FMS performance monitored by the organization?
What monitoring activities have taken place within the last 12 months?
What facility management and safety issues are currently being analyzed?
What actions have been taken as a result of FMS monitoring activities?
FACILITY MANAGEMENT AND SAFETY “FMS”
59
The target of the hospital administration and all the staff working at HMC is to provide and maintain safe,
functional, and supportive facilities for patients, families, staff and visitors.
To reach this goal, the physical facility, medical and other equipment and also staff must be effectively
managed. They must strive to:
 Reduce and control hazards and risks.
 Prevent accidents and injuries.
 Maintain a safe facility.
Effective management should include multidisciplinary planning, education,
and continuous monitoring and inspection.
1. Who is responsible for overseeing safety measures at your facility?
The Facility Safety Committee “FSC” members are responsible for monitoring and recommending
corrective actions for any findings that may affect the safety of all patients, families, visitors and staff.
2. What does the facility safety committee do?
The FSC committee members are representatives of different department and oversee staff compliance and
implementation of all FMS related policies/programs throughout the hospital. There are seven main areas
involved in FMS activities. These areas are explained in detail in the following programs:







Safety Management Program.
Security Management Program.
Hazardous Materials and Waste Management Program.
Emergency Preparedness and Evacuation Program.
Fire Safety Management Program.
Medical Equipment Management Program.
Utility Management Program.
SAFETY MANAGEMENT PROGRAM:
60
1. What’s your process to ensure that you have a safe facility?
We have a multidisciplinary team “FSC” who conduct an environmental round on a monthly basis to assess
the facility in general and to closely monitor all the safety aspects, each member does this for his/her
specialty and develops a general report and sets an action plan for the findings. A copy of this report will be
submitted to the hospital CEO and the inspected department.
Policy SA # 1070……..Multi-Disciplinary Environmental Round (MDER)
2. How to reduce the evident risks?
Qualified safety officers conduct regular risk assessments for the whole facility. These include
environmental safety, fire safety as well as security risks. They also provide specific staff education and
training. One of the hospital goals is to prevent accident and injuries.
Policy SA # 1017 ………….Design Hazard Identification and Risk Assessment
3.How to reduce and control hazards and risks during construction or renovation?
Before initating any construction or renovation projects the safety officer will perform a risk assessment.
The site of construction should be kept clear at all times.
No project should commence prior to obtaining an approval signature with safety recommendations from
the fire safety officer and the infection control department. A copy of the project notification should be
posted at the site and should also be signed by the contractors concerned and the hospital senior engineer.
Policy SA # 1000……Construction Site Safety
4. Do you have a written plan to reduce the evidence of risks?
Occupational health and safety have developed a safety management program to establish roles for all staff
and visitors, independent entities and contractors to ensure a safe and secure facility.
Policy SA # 1015……Safety Management Program
SECURITY MANAGEMENT PROGRAM:
61
1. How do you get assistance if you need to deal with a disruptive person?
Security officers are available 24 /7. Security staff responds to any calls related to security issues. The contact
numbers for security desks are as follows:
Hospital
Hamad General Hospital.
Women's Hospital.
Rumaillah Hospital.
National Centre for Cancer Care and Research.
Al Khor Hospital.
Al Wakra Hospital.
The Cuban Hospital.
HMC Ambulance Services.
“HGH”
“WH”
“RH”
“NCCCR”
“AKH”
“AWH”
“TCH”
“HMC AS”
Security Desk No.
4439 – 2441 / 2442
4439 - 3294
4439 - 7023 / 7025
4439 - 7925 / 7832
4474 - 5404
4011 - 4599
4015 - 7999
4439 - 1239
2. How can security be ensured for all patients, staff, visitors, vendors and others in the hospital?
 All staff, visitors, contractors and vendors shall have an identification card with their pictures, job title
and the validity period permitted by Human Resources and the Security Department.
 No one is allowed to enter a patient care area or have direct contact with a patient without proper
identification and permission from the head of the unit and the security officer.
Policy HR # 3010……Employee ID Cards
3. Do you allow patients or visitors to smoke in your hospital?
Smoking isn’t allowed inside any HMC facilities at any time. Any violations of this HMC policy will result in
the situation being reported to the Security Department. Disciplinary action will be taken in compliance
with State of Qatar Laws and Regulations.
Policy SA # 1052………No Smoking
4. What would you do if you find any suspicious packages or bomb threats?
The Security dDepartment should be notified immediately and the area secured until the arrival of the
security officers.
Policy SA # 1006........Bomb Threats
62
5. What would you do if you find a baby missing?
All staff should receive training on abduction prevention and response in the event of abduction (Code Pink).
Additional training on the risks, physical security safeguards and infant abduction drills are scheduled and
conducted for all patient care units, especially NICU/postnatal and pediatric units.
Policy SA #1005……Infant and Child Security, Prevention and Response in the Event of Abduction
6. Do you have a written plan to reduce the evidence of security risks?
The Security Department has developed a security management program to establish the role of all staff,
visitor, independent entities and contractors to ensure a safe and secure facility.
Program SA # 1058……Security Management Program
HAZARDOUS MATERIALS PROGRAM:
The hospital develops and maintains a program for the inventory, handling, storage, and use of hazardous
materials and the control and disposal of hazardous materials and waste management.
Program SA# 1054 …Hazardous Material and Waste Management Program
7. What are the elements of hazardous communication?





Inventory list of chemicals.
Material safety data sheet “MSDS”
Labeling and marking.
Staff training and education.
Written hazardous materials and waste management Program.
8. How does hospital staff receive training on hazardous materials and waste management?
Through general and yearly re- orientation programs and e-Learning.
9. What is a Material Safety Data Sheet “MSDS”?
MSDS is a fact sheet disseminated by the product manufacturer that gives pertinent information about all
chemical hazards that could be present in the department.
It provides information on product/ chemical properties, hazards, safety measures (i.e., personal protective
equipment and first aid).
63
Policy SA # 1049…….Supply of Material Safety Data Sheet - MSDS
10. Where are the MSDS for chemicals located in your work area?
In a blue colored folder labeled "MSDS"
11. Could you name one (1) product in your work area for which you would need to have an MSDS?
For example, acetone, isopropyl alcohol, and methanol…etc…..
12. Where do you keep or store flammable or hazardous chemicals used in your unit?
All flammable or hazardous chemicals used in the unit are kept in a dedicated secured and locked yellow
cabinet for hazardous materials.
Note:
Any pharmaceutical items for patient use, tagged as hazardous must be kept in a separate
yellow cabinet for hazardous materials
13. What must a product label include?
All chemicals must be labeled with the chemical's name, hazard warning, and the manufacturer's name,
address and telephone number. The original label may not be removed, defaced, or changed.
14. Do you have chemical spill kits in your department?
Check this with the department/unit head.
15. What do you do if you have a spillage in your work area?
Follow the S.P.I.L. Procedure:
Secure the area and wear PPE.
Protect patients/visitors by keeping them away from the spill.
Inform the Control Room and fill in an OVA form
Leave the clean up to a trained OHS representative.
16. What would you do if you are exposed to corrosive chemicals?
Wash the affected area with copious amount of water for at least 15 minutes.
17. How does your hospital dispose of the generated waste?
Follow the hospital guidelines using color coding.
Black
Domestic waste
Yellow
Infectious waste.
Red
Cytotoxic, pathological waste.
18. When are the sharp containers considered to be full?
64
When they are 3/4 or 75% full
19. Who is responsible for replacing full sharp containers?
The unit is responsible for the replacement of any sharp containers and housekeeping staff are responsible
for the disposal.
20. What kind of material should be placed in a sharps container?
Any sharp object that may break the skin if handled by an employee during disposal that is contaminated
with blood or body fluid. It should be small enough to be safely disposed of in the sharp box. Typical items
are needles, syringes with needles attached, scalpels, razors, small glass ampoules, and lancelets.
21. What are the types of Personal Protective Equipment (PPE) you would wear while working with
hazardous chemical or infected patients?
Examples of PPE include but are not limited to the following:
 Gloves
 Gown
 Mask
 Face shield
 Protective eyewear
 Apron
DISATER PREPAREDNESS PROGRAM:
The hospital develops and maintains a Major Incident Plan and an implementation process to respond to
likely community emergencies, epidemics, and natural or any unexpected disasters.
Program SA # 1053……………Major Incident Program
1. What would be your role during a Major Incident?
 The hospital emergency preparedness team had developed a written Major Incident Plan to set specific
roles and responsibilities for all hospital staff with an action card in response to any kind of emergencies
(Internal / External).
 The plan is approved by the hospital Facility Safety Committee “FSC” as well as the hospital administration.
65
 All staff shall receive training and education about the Major Incident Plan based on their job
responsibilities and their expected role during emergencies.
 Job action cards are posted on the Emergency Preparedness board and every staff member is made aware
of their delegated role.
 The approved plan is accessible to all staff and is posted on the HMC intranet.
 An emergency drill was conducted with the participation of hospital staff.
FIRE SAFETY PROGRAM:
The hospital plans and implements a process to ensure that all the occupants are safe from fire and smoke
and are ready for any other emergencies.
Program SA # 1055……Fire Safety Management Program
1. What would you do in the case of a fire situation?
In case of fire, we have to initiate R. A. C. E
Raise the fire alarm – call code red – phone the control room HGH 4439- 2333 / AKH 4474 – 5455 / AWH
4011- 4333/ TCH 4015 – 7999, phone other units.
Assist with the evacuation of patients and equipment.
Close doors and windows.
Extinguish the fire only if safe and you are confident that you can do so.
.
IF EVACAUTION IS IMMINENT, FOLLOW THE HOSPITAL EVACUATION PLAN
2. How do you operate the fire extinguishers?
Follow the P. A .S. S technique
Pull the safety pin.
Aim at the base of the fire.
Squeeze the handle.
66
Sweep the fire from side to side
3. Who is responsible for shutting off the zone oxygen valves in case of a fire or other emergency?
The ward/clinic supervisor in coordination with the hospital engineer and the fire safety officer will shut–off
oxygen to a specific zone. In a real life or death situation, any ward/clinic staff member could shut-off medical
gas to a zone/room as long as it would not jeopardize the safety of another patient utilizing medical gas. The
valves should be shut off only with the permission of the charge nurse.
4. What are the types of fire extinguishers you have at the unit?
Dry Chemical
All types of fire (A,B,C)
Compressed water
Type (A) fire.
Carbon Dioxide
Type (B, C) fire.
5. All staff shall:












Attend the orientation and re-orientation sessions related to fire safety.
Participate in the fire drills and know the last time they attended one.
Comply with the Fire Safety Management Program.
Report any incident that may cause a fire.
Be able to demonstrate the use of fire extinguishers.
Know the type of evacuations.
Keep fire doors closed at all times.
Keep objects away from the ceiling or sprinkle heads at the storage areas.
Comply with the No-Smoking policy.
Maintain safe storage and handling of potentially flammable materials, including medical gases.
Safe and unobstructed means of fire exit routes in case of fire.
Do a proper and safe evacuation with coordination of fire safety officers in case of fire situations.
Able to identify the following:




Nearest fire extinguishers.
The fire alarm boxes/hoses.
The assembly points.
Oxygen shut-off valves.
67
MEDICAL TECHNOLOGY PROGRAM:
The hospital develops and implements a program for inspecting, testing, and maintaining all the medical
equipment and documenting the results of monitoring.
Program SA #1056 ---------- Medical Technology Program.
1. Do you have an inventory list for all the medical equipment in your department?
Yes and the list is available from the department’s head office.
2. What’s your process in a case of broken equipment or operation failure?
 The broken equipment will be removed and tagged as not to be used. The person in charge of the
unit/department should be informed and it should be sent for repair with a request form to the bioengineering department. A replacement should be obtained if required.
 If the particular equipment involves patient care, we have to support patient care manually until a
replacement is obtained
3. How do you know that the equipment has been checked and maintained?
All equipment is checked by bio-medical engineering on a regular basis and prior to use and tagged to
indicate the next maintenance date.
4. What would you do if the equipment does not have a maintenance tag or sticker?
Any medical equipment will not be used without maintenance/checking tags. The Bio-medical Engineering
department will be notified; the equipment must be checked and /or replaced with a substitute piece of
equipment.
8. What is the process to improve or replace medical equipment?
The hospital collects monitoring data for the medical equipment management program, and the results of
this data are used to plan for future needs to upgrade or replace the medical equipment in coordination
with the Bio-medical Engineering Department.
9. Do you have a process for receiving and returning medical equipment?
Yes, there is a process for identifying, receiving and returning or destroying equipment recalled by the
manufacturer or supplier.
68
Program SA #1056 ----------Medical Technology Program
UTILITY MANAGEMENT PROGRAM:
The hospital engineering department had developed and implements Utility Management Program to assure
the availability of potable water and electricity power supplies 24/7 through regular or alternate sources to
meet the essential patient care needs.
Program SA# 1057………Utility Management Program
1. What action would you take should any of the following utility systems fails?
Inform the engineering control room and use an alternative for each system as follows:
Electricity outage:
Use the backup emergency generator supply (red or labeled electrical outlets).
Water supply failure:
Use water from reserve tanks sparingly; use bottled water; use chemical hand cleaner/waterless hand
soaps.
Medical gases:
Use portable tanks.
Vacuum system failure:
Use portable suction equipment or switch to gravity flow (after consultation with the physician).
2. What type of medical equipment needed to be connected to the engineering control room?
All the equipment that may affect patient safety such as but not limited to:





Mechanical ventilators,
Defibrillators,
Medication refrigerators.
All medical equipment in the operating room.
Anesthesia machine.
3. How often is the emergency generator tested?
There are regular generator tests scheduled by the Engineering Department and the units / departments will
be notified ahead of time through an official memo and via the HMC intranet.
69
Program SA #1057………Utility Management Program
STAFF QUALIFICATIONS AND EDUCATION “SQE”
1. What is the purpose of the job description?
The information in the job description is used for many different purposes including: job
classification/evaluation, training and development and performance management.
2. How often does do you need to review staff job descriptions?
Job descriptions should be reviewed and updated when duties and responsibilities, or reporting
relationships, are changed, it is recommended that managers review job descriptions annually in line
with the performance evaluation process.
3. How do managers communicate a job description to an employee and ensure that the employee
understands the duties of the job?
 Managers should review the job description for an employee and ask for a signature.
 Staff should address concerns about the job description first to the manager and then,
if still not clarified, to the Human Resources Reward and Performance section for assistance.
4. Do all employees sign their job description?
Their director of a department should give employees a copy of their job description and it is HMC practice
to ask employees to sign their job description.
5. When should the job description be signed?
 It is HMC practice to review the duties and requirements of the job during the time of interview.
 The director of the department should review the job description during the early part of the
orientation process with the employee.
 Signed job descriptions are sent to Human Resources for filing in the personnel file, and a copy should
be kept in the departmental file.
70
Policy # HR 3019………. Job Description
6. What is the system for new employment orientation?
All newly recruited staffs should attend the Corporate Orientation program through an online booking
system, which is available on the HMC Intranet.
7. What happens if a member of staff fails to attend the scheduled orientation date?
It is the responsibility of the director of the department to reschedule the staff member onto the next
available orientation session through the online booking system.
Policy # HR3024………Corporate Orientation
8. What is the probationary period for staff?
The first three months of employment.
10. How is the competency of new members of staff ensured?
 The initial skills assessment should be completed before the end of the first three months of
employment.
 The initial skills assessment form for all non-clinical staff is available on the HR website on the intranet
or from HR Recruitment.
 Nursing may use a nursing-specific initial skills assessment form, which is available at each unit.
 The unit in-charge and employees should review the assessment and the employee should sign the
initial skills assessment form.
11. What is the process if the staff has a deficiency in competency?
If a deficiency in competency is found and an employee does not meet the requirement of the initial skills
assessment, the unit in-charge should set an improvement plan for the employee.
Policy # HR 3018……..Initial Skill Assessment
11. What is the process to ensure staff competency?
Staff will be evaluated annually on job effectiveness, identifying areas of strengths and limitations through
feedback from the unit head.
12. What is the process if an employee refuses to sign their performance evaluation?
The head of the department should:
71
 Discuss the evaluation with the employee.
 Document the reason for refusal.
 Send a copy of the document, along with the completed performance evaluation to Human
Resources for investigation.
Policy # HR 3027……..Performance Management
13. What is the process for providing employees with training and development?
 For all staff, training starts with orientation.
 Nursing staff are provided with opportunities for staff development to address competency
requirements. These opportunities include: department/unit orientation, in-services, and continuing
education.
 For non-nursing staff, it is the department manager’s responsibility to identify the training needs for staff
during their annual evaluation, and as required.
 The head of the department should maintain a record of staff training/education.
 The head of the department should submit documentation of training to Human Resources for inclusion
in the staff member’s personnel file.
Policy # HR 3048……..Training and Development
14. What is the process for credential verification?
Human Resources verify education and licensure credentials, if required, from the primary source.
15. What is the process for providing resuscitation training to staff?
 The policy identifies the staff groups required to take resuscitation training and directs the
requirements based on the clinical need.
 Hamad International Training Center is an internationally recognized center, and has training programs
for all the required resuscitation levels.
Policy # HR 4016……..Resuscitation Training Program
72
MANAGEMENT OF INFORMATION - “MOI”
1. Legibility of patient clinical record is evidenced.
2. Every clinical record entry identifies the date/time and name of the person who made the entry in the
records.
3. Doctors use the SOAP / SBAR format in writing case notes.
4. Order forms and checklists are adequately filled in (e.g. Radiology, Laboratory).
5. Integrated nursing records are adequately filled in.
6. Standardized symbols/abbreviations are used.
7. No part of the clerking sheet should be left blank. “N.A.” should be written in those not deemed to be
clinically relevant.
1. How are confidentiality, access, integrity, and security of data and information maintained?
 Locked and controlled by level of access.
 Verification codes and security system keys.
 Staff should not share codes and only have access to those computer programs needed to do their job.
 Access to Medical Records should be requested and approved by authorized personnel.
 A security program is in place to manage the conflicting access and security needs of the organization.
 Log off from the computer after each use.
 Monitored by the Health Information System (HIS).
Policy OP # 4042………Privacy Confidentiality and Access to Health Information
73
2. What is the process for releasing confidential information requiring patient consent?

Patient or his/her representative completely in full the consent for release information form.

Submits the completed form along with the patient’s identity card and health card to the cash
counter and pays the fees required. The cashier then issues an official receipt.

Submits the form and official receipt to the Medical Records Transcription area where a staff
member acknowledges the receipt, writes an appointment date and provides a copy to the patient.

The Transcription section informs the patient to bring the receipt copy and representative’s ID when
they pick up any request on the scheduled date.
Policy OP # 4042………Privacy Confidentiality and Access to Health Information
3. What kind of information management training is available to you?
The answer will vary depending on the staff position.
Options are:




Microsoft Programs – Word, Excel, Power Point, Access, and Outlook.
Keyboarding skills.
Work order processing.
Internet/intranet.
4. What are the documents that a patient record contains?
The patient record contains but is not limited to:









Admission assessments chart including pain assessment.
Consents forms.
Plan of care/problem list.
Medications charts.
Procedures forms.
Education needs assessment and teaching forms.
Laboratory reports.
Discharge plan.
Discharge summary sheets.
Policy MR # 8001…. Medical Record Creation, Contents, Writing In and Processing of the Medical
Record
74
5. What is a Medical Record?
A compilation of written and electronic health information, such as assessment, findings, treatment details,
progress notes, discharge summary and pertinent facts about a patient's life and health history, including
past and present illness(es) and treatment(s), documented by health professionals contributing to a
patient's care.
The medical record must be compiled in a timely manner and contain sufficient data to identify the patient,
support the diagnosis, justify the treatment, and accurately document the results.
Policy MR # 8001….. Medical Record Creation, Contents, Writing In and Processing of the Medical Record
6. What are the duplicate files?
Duplicate files are copies of the conducted treatment and a summary of the patient’s medical history.
These are generally maintained in specialty clinics e.g. dialysis units. The duplicate files must be confidential
and secured all the time.
7. Are medical records available 24 hours a day?
Yes! The medical record department operates 24/7.
8. How do you access medical records information?
Access to medical records by healthcare providers within and outside the HMC, other respective
departments for their patients’ continuity of care, research studies, review, case conference and other
should be requested and approved by their respective Department Chairman, Director or Unit Consultant.
9. How are medical records protected from loss, tampering and unauthorized use?
 Each HMC board member, employee, volunteer, or anyone with temporary medical staff privileges has a
personal responsibility to protect both the privacy and the confidentiality of HMC information.
 The security of health information records in each patient-care unit (e.g., Inpatients, Outpatient Clinics,
Emergency Departments, and Ancillary Services) is the responsibility of the person who signed them out
and they should safeguard them from unauthorized use, damage or loss. Medical records shall not be
kept in lockers, desks, or offices.
 The Medical Record Department is secured and controlled. Only authorized HMC personnel with
electronic access to the Medical Record Department can access the area.
75
 Any employee who has access to records, both electronic and paper, is responsible for the integrity and
confidentiality of the record.
 When clinical information is being sent via facsimile, the sending person shall ensure the receiving party
is available to receive the fax.
 All patient health information records shall remain within the department and while transporting, should
be covered or sealed in an envelope or bag in mobile trolleys within the hospital premises.
Policy OP # 4042………..Privacy Confidentiality and Access to Health Information
10. Activities HMC have undertaken to improve medical records?
Continually conducts closed and open medical record reviews, forwarding findings to the Medical Records
Committee and concerned department leaders and monitoring for clinical pertinence and completeness
involving the Quality Management Department.
11. What would you do if you did not recognize a person reading a patient's medical record?



Determine the person’s position.
Check their ID badge.
If suspicious, call Security.
12. Do you accept symbols or abbreviations in medical records?
Only approved symbols and abbreviations can be accepted.
13. What documents must not be abbreviated?
The following must not be abbreviated:





Writing the diagnosis and procedures on the face sheet
All informed consent.
Operative record.
Transfer/ discharge/ death summary /medical records/ consultation form
Physician’s orders
Policy CL # 6083-----Approved List of Abbreviations, Acronyms and Symbols
14. What must we keep confidential?
Information management considers electronic information as well as written or verbally communicated
information confidential.
Things that we must all do to protect the confidentiality of information are:
76
 Do not talk about patients in public areas such as the dining facility or hallways.
 Patient reports/papers should be discarded in designated containers.
 Never give your computer password to another individual.
 Always log off or lock your computer station when you leave so that others will not view information on
your screen.
 Do not use a sign in sheet for clinical patients that has clinical information that is linked to the patient’s
name.
 Do not leave medical records unattended.
Notes:
An ongoing review for the content of medical records for all patient records is performed by the Medical
Record Review Committee on a regular basis, as part of performance improvement activities. For
completeness, timeliness, and legibility, the reports are submitted to the Quality Management Department
and the concerned hospital department for information and appropriate action.
77
MEDICAL PROFESSIONAL EDUCATION “MPE”
MPE.1
1. Who decides to provide a medical education program and is it consistent with the organization’s mission?
2. How does the governance and leadership obtain, review and accept the parameters of the participating
medical school?
3. What opportunities for improvement were demonstrated in the review of the monitoring data of the
ongoing operation of the medical education program?
4. What is your mechanism to review medical education programs within the hospital?
5. What are your performance metrics to monitor and evaluate the on-going operation of medical education
programs?
MPE.2
6. What evidence does the hospital have that the facilities and technology support the agreed student
learnings?
MPE.3
7. What process does the hospital have in place to monitor academic titles and renewal requirements to
keep such titles current?
MPE.4
8. How do you know what activities and procedures you are allowed to do independently and which ones
require supervision?
9. What type of supervision is required when you examine a patient and write orders for that patient?
78
10. How does that supervision change as you progress through the program?
11. How do you know who should be supervising you?
MPE.5
12. What is the operational structure for medical student education and has it been implemented as
required?
MPE.6
13. What types of orientation programs are required for medical students and trainees?
14. How are trainees included in the data collection for the hospital’s quality monitoring program?
15. How do you participate in the hospital’s quality improvement and patient safety program?
16. What do you know about the International Patient Safety Goals? How does IPSG.2.2, ‘handover
communication,’ apply to you?
17. How are medical students and trainees involved in the quality improvement and patient safety program?
MPE.7
18. Do you provide any services to the hospital outside of your training program? If yes, how is the type of
service you provide determined?
79
HUMAN SUBJECTS RESEARCH PROGRAMS - HRP
HRP.1
1. How have the leaders of the hospital and research programs established and promoted a code of ethical
professional behavior?
HRP.2
2. How have the leaders identified the scope of research and potential research topics?
HRP.3
3. How do you know that sponsors of research within the hospital comply with hospital policies and
procedures for the monitoring and evaluation of the quality and safety of the research?
HRP.3.1
4. Are all contracts with research organizations in compliance with your hospital’s policy for determining the
activities and responsibilities of the contract research organization?
5. Do all contracts contain the required quality and safety program provided by the contract research
organization or the sponsor?
6. How do you know the sponsor is monitoring the contract and is responsible for the quality and integrity of
the research data?
HRP.4
7. What types of research have the leaders defined as exempt from the research review process?
HRP.5
8. What requirements for managing conflicts of interest has the hospital specified?
80
HRP.6
9. Have any adverse events related to research been reported within the hospital during the previous 12
months? If so, were the events analyzed and acted upon as necessary?
10. How does the pharmacy manage study drugs?
11. Do hospital leaders learn of near misses and adverse events related to the care of study patients?
HRP.7
12.
What’s your process to enable patients to make informed and voluntary decisions about participating
in clinical research, clinical investigations or clinical trials?
13.
Do you inform the patient about the duration of the research and the procedures to be followed?
14.
Did you let the patient know who to contact with any questions about the research?
15.
What kind of information do you provide to patients who participate in research?
Patients asked to participate are informed about the expected benefits, potential risks, and alternative
treatments and procedures that might also help them.
16.
How will you maintain patient records confidentiality?
17.
What kind of compensation do you provide to patients when injuries occur as a result of the research
process?
18.
Do you select the patients to participate in research regardless of their agreement?
Patients asked to participate are assured that participation is voluntary and refusal to participate or
withdrawal at any time will not compromise their care or access to hospital services.
19.
Do you have a process to review the research function?
20.
Does the hospital establish and implement how consent for participation should be obtained and
documented and under what circumstances consent will be obtained again during the research.
HRP.7.1
21.
How are patients and families informed about how to gain access to research trials?
81
Helpful Hints and Recommendations for the Survey:
 Be aware of the following:
















HMC and facility mission, vision and values.
Patient/family rights and responsibilities.
International Patient Safety Goals –‘IPSG’.
Strategic plan.
The required clinical policies.
Occurrence variance accident reporting.
Quality Improvement and Patient Safety Program.
The new requirements of the 5th Edition JCI Hospital Standards.
Your role and responsibilities within your department.
Think about how your work helps to meet your facility’s overall goals
Local laws and regulations.
Staff qualifications and education.
Management of information.
Fire, disaster, and other safety and security procedures.
Infection control guidelines.
Facility code ethics.
 All The Facility Safety Management Programs:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Safety Management Program.
Security Management Program.
Hazardous Material and Waste Management Program.
Major Incident Program.
Fire Safety Management Program.
Medical Technology Management Program.
Utility Management Program.
Quality Improvement and Patient Safety Program.
Prevention and Infection Control Program.
Medication Management Program.
 The Essential Hospital Committees:
1. Hospital Executive Committee “EC”
2. Quality and Patient Safety Committee ”QPS”
3. Facility Management and Safety Committee “FSC”
82
4.
5.
6.
7.
8.
Medical Executive Committee “MEC”
Prevention and Control Infection Committee “PCI”
Medical Record Committee ”MR”
Pharmacy and Therapeutic Committee “P&T”
Ethical Committee.
 Be sure:
1. That you attended and updated all the mandatory training sessions.
2. Ask questions if you are not sure how the standards affect your work.
 Participate in Mock Surveys:
Try to participate in mock surveys. These mock surveys or self-assessments can help to:
1. Improve policies and procedures
2. Ease anxiety by giving you a chance to practice and exposur to the real survey.

Practice explaining what you do:
1.
2.

Think about how you perform your work.
Note the procedure you follow and the forms that you use, etc.
Think carefully before answering the questions.
Only answer what the surveyor is asking for “DON’T VOULNTEER INFORMATION.” Take time to consider
what the surveyor wants to know. Ask for questions to be repeated or rephrased if you do not understand.
HELP each other.
In groups, the person with the answer should chime in. SPEAK OUT with the correct response if they see that
you are hesitating.

Be Honest:
If you do not know the answer, Don’t guess. Tell the surveyor how you would get an answer (in most cases
by asking a supervisor or referring to manuals).
 Refer to Policies:



Review key documents to get to know your facility.
Whenever possible, mention the facility policies and procedures that support your answers.
Be Specific and Give Examples:
For instance, if you are talking about a quality improvement story, mention it was a success in your
service/work area. Show the surveyors the forms, reports, etc., related to the improvement processes.
83

Be Ready to Demonstrate Procedures:
You should be able to describe the specific procedures related to your job. For example, if a surveyor asked
what you would do in case of a fire.
 Emphasize Teamwork:
Let the surveyors know how you work with each other, inside and outside of your service/work area, to get
the job done.
 Relax and Remember to:
1. Answer with confidence.
2. Be friendly and smile.
3. Be aware of your body language (expressions, gestures, attitude, etc.)
 How to act:
1. Be enthusiastic and excited about how good we are.
2. Be able to describe improvement in the patient care process that resulted from quality improvement.
Emphasize that we are always looking for ways to improve.
3. Listen carefully to the question being asked.
4. Be able to retrieve documents to support your answers, when requested.
5. If you do not know the answer, do not get upset or try to bluff the surveyor. Simply tell the surveyor
that you do not know.
6. NEVER use phrases, like, “sometimes,” “we try,” “but,” “occasionally,” ”may be” or “now and then.”
Any combination will send up a Red Flag implying that you are not consistent. This gives the surveyor a
reason to “DIG”. Use phrases like “ALWAYS” and “NEVER”
7. NEVER Volunteer information and give the surveyor an invitation to an open door. Only give what
you’re asked for, and something you know you have data to support.
8. Be cooperative, not defensive. “Defensive posture could trigger a defensive response”.
9. When answering questions, it is sometimes helpful to give real life example that illustrates how you
have used your practices/processes.
10. If the answer to a question is a Yes or No, then answer Yes or No and wait before elaborating. Do not
dig a grave for yourself.
11. It is suggested that you be comfortable with a little silence during the interview.
84
85