JCI Reference Guide WR

MINISTRY OF NATIONAL GUARD HEALTH AFFAIRS
King Abdulaziz Medical City - Jeddah
JCI Survey 2015

Reference Guide
JCI Survey Reference Guide (2015)
CEO’s Message
Dr. Bandar Al Knawy, MD, FRCPC
Chief Executive Officer, Ministry of National Guard Health Affairs

President, King Saud bin Abdulaziz University for Health Sciences
Dear Colleague,
Patients and Family Safety First is the shared commitment in the Ministry of National Guard Health Affairs
and it is within this principle that the organization continues to explore means of advancing its services.
The approach is strengthening the organization’s ability to achieve world class outcomes in education,
research and patient care through an atmosphere of team work, trust, passion and pursuit of excellence.
As part of the journey to provide the best care to our patients and their families, the MNGHA made the
decision to pursue the Joint Commission International (JCI) accreditation and successfully achieved the
initial accreditation in 2006 and re-accreditation in 2009 and 2012.
This achievement was a product of the collective work of each and every one of us and once again the
opportunity calls on us as members of this great organization to improve the safety and quality of care that
we provide by implementing and complying with the organizational and JCI standards.
The third re-accreditation of the organization is due by end of 2015, and in order to increase the awareness
of the JCI re-accreditation, your colleagues in the Department of Quality Management in collaboration with
other departments developed this pocket guide that outlines the most important JCI standards, safe practices
as well as pertinent policies and procedures. I have found it most useful and I am sure you would too.
I would like to thank you on behalf of all the patients and their families for your excellent hard work and to
congratulate you for your unwavering commitment and loyalty to this organization in its pursuit of
excellence.
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TABLE OF CONTENTS
CEO’s Message 1
Table of Contents 2
Ministry of National Guard Health Affairs: Mission, Vision, Values ………………………………….... 3
The JCI Survey Overview……………………………………………………………………………….... 4
Tracer Methodology ……………………………………………………………………………………... 4
DO’s and DON’Ts during the Hospital Survey………………………………………………………….. 5
Accreditation Preparation Requirements (APR)…………………………………………………………. 6
International Patient Safety Goals (IPSG) ……………………………………………………………….. 8
IPSG 1: Identify Patient Correctly……………………………………………………………...... 8
IPSG 2: Improve Effective Communication……………………………………………………... 9
IPSG 3: Improve the Safety of High-Alert Medications…………………………………………. 11
IPSG 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery…………………….. 14
IPSG 5: Reduce the Risk of Health Care Associated Infections …………………………………. 16
IPSG 6: Reduce the Risk of Patient Harm Resulting from Falls…………………………..……… 17
Access to Care and Continuity of Care (ACC)…………………………………………………………… 19
Patient and Family Rights (PFR)………………………………………………………………………….. 20
Assessment of Patients (AOP) …………………………………………………………………..………... 24
Care of Patients (COP) ………………………………………………………………………………….... 27
Anesthesia and Surgical Care (ASC) …………………………………………………………………….. 32
Medication Management and Use (MMU) ……………………………………………………...……… 33
Patient and Family Education (PFE) ……………………………………………………………….…….. 36
Quality Improvement and Patient Safety (QPS) …………………………………………………….…... 37
Prevention and Control of Infections (PCI) ……………………………………………………………... 40
Governance, Leadership and Direction (GLD) ………………………………………………….………. 45
Facility Management and Safety (FMS) ………………………………………………………….……… 46
Staff Qualifications and Education (SQE) ……………………………………………………………..… 50
Management of Information (MOI) …………………………………………………………………..… 51
Medical Professional Education (MPE) ……………………………………………………………..…… 52
Human Subject Research Program (HRP) ……………………………………………………………….. 53
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INTRODUCTION
This reference guide has been developed to provide education regarding accreditation standards, and
information about how King Abdulaziz Medical City-Jeddah utilizes these standards to continually improve
care, treatment, and services. We ask that you review and refer back to this booklet as we embark together
on our journey towards another successful Joint Commission International re-accreditation survey.
In previous surveys, our staff have stepped up to the plate and been able to demonstrate the exemplary care
they provide. It is our goal that the information contained within this booklet will prove useful for your day
to day practice, and also serves as a guide in the quest to provide excellent patient care.
MINISTRY OF NATIONAL GUARD HEALTH AFFAIRS
 MISSION
Ministry of National Guard Health Affairs (MNGHA) provides optimum healthcare to SANG personnel,
their dependants and other eligible patients. MNGHA also provides excellent academic opportunities
conducts research and participates in industry and community service programs in the health field.
 VISION
Ministry of National Guard Health Affairs will be recognized as an internationally acclaimed Center of
Excellence to enhance individual and public health status.
 Values
Ministry of National Guard Health Affairs adheres to core values taken from religious, social and
professional principles, abiding by:
1. Respect of religious and social values – Respect for religious and social values of the Saudi society,
and refrain from violating the rules.
2. Patient safety and satisfaction – Focusing on patient safety, through provision of outstanding
services that guarantee patient satisfaction.
3. Quality performance – Continuously seeking improvement and development of quality
performance.
4. Respect and dignity – Valuing Patients and families and employees with respect and dignity.
5. Transparency – Being open and direct in dealing with patients and staff.
6. Teamwork – Workplace cooperation for optimum utilization of team members and positive
performance and patient outcomes.
7. Productive work environment – Provision of work environments that encourage productivity,
efficiency and optimum utilization of resources.
8. Accountability – Building individual and team loyalty and responsibility toward work activities.
9. Behavior and work ethic – Performing work in accordance with behavior and work ethics which
include truthfulness, sincerity and mutual respect for each other.
10. Excellence and innovation – Innovation and excellence in dealing with all health organizational
activities.
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THE JCI SURVEY OVERVIEW

A Joint Commission International on-site accreditation survey provides an assessment of an organization’s
compliance with standards and their measurable elements of performance.
TRACER METHODOLOGY
The Joint Commission International uses the “Tracer Methodology” as a method of

assessment.
What are the primary objectives of tracer activities?
1. Follow the course of care, treatment, and services provided to the patient by and within the hospital
using current records when possible.
2. Assess the interrelationships between and among disciplines and departments, programs, services,
or units.
3. Evaluate the performance of relevant processes, with particular focus on the integration and
coordination of distinct but related processes.
4. Identify potential concerns in the relevant processes.
Who will participate during Tracer Activity?

During a tracer, the surveyor(s) will converse with
a wide variety of staff involved in the patient’s
care, treatment, and services. Staff could include
nurses, physicians, medical students, trainees,
therapists, managers, patient care technicians,
pharmacy staff, lab personnel, dieticians,
respiratory therapists, patient educators and
support staff.
What will occur during Tracer activity?
1. Observation of direct patient care, medication processes, infection prevention and control issues,
care planning processes, impact of the environment on safety and staff roles in minimizing
environmental risk.
2. Review of the record with the staff person responsible for the patient’s care, treatment, and services
provided.
3. Discussion of data use in individual departments/services. (NEW REQUIREMENT)
4. Review of emergency equipment, supplies, and processes.
5. Interview with the patient and/or family (if it is appropriate and permission is granted by the
patient and/or family).
6. When visiting the emergency department, the surveyor(s) will also address emergency management
and explore patient flow issues. (NEW REQUIREMENT)
7. The surveyor(s) may pull and review two to three additional records to verify issues that may have
been identified. (Concurrent chart review)
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DURING THE HOSPITAL SURVEY
DO’s DON’Ts
1. Welcome the surveyor to your area 1. Argue with the surveyor or defend your
2. Allocate appropriate space for the tracer team practice
to do the interviews
3. Be truthful, describe your regular practice 2. Mislead the surveyor
4. Be professional in your attitude and 3. Volunteer unnecessary information.
appearance 4. Provide non requested documents
5. Reply to surveyors’ questions directly and
5. Use phrases such as, “most of the time”, “we
concisely
usually”, “well, sometimes we do”
6. If unsure of the answer, the safest response is
that you would check the policy or ask your 6. Talk about past surveys or the future plan of
supervisor the department
7. Keep your answers focused and specific to 7. Offer gift as this may be intepreted as
their questions
bribery, offering water will be sufficient
8. Answer with confidence
8. Prompt the staff during the interview
9. If you don’t understand something, ask the
surveyor to clarify or explain
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ACCREDITATION PREPARATION REQUIREMENTS
NEW JCI STANDARD (APR.9)
To create a “safe” reporting environment, the hospital educates all staff that concerns about the safety or
quality of patient care provided in the hospital may be reported to JCI. The hospital also informs its staff that
it will take no disciplinary or punitive action because a staff member reports safety or quality-of-care
concerns to JCI.
1. Any hospital staff member (clinical or administrative) shall report

concerns about patient safety and quality of healthcare through
Safety Reporting System(SRS).
2. If there is no Corrective Action at the hospital level, staff can report

the concerns to Joint Commission International Accreditation (JCI)
without retaliatory action from the hospital.
What to report to JCI What NOT to report to JCI
Concerns about patient safety and

quality of care:  Billing issues
 Payment disputes
 Patient rights
 Care of patients  Staff conflicts
 Safety  Employee Relations issues
 Infection control  Individual clinical management
 Medication use of a single patient
 Security
There will be NO formal disciplinary actions (for example, demotions, reassignments, or change in working
conditions or hours) or informal punitive actions (for example, harassment, isolation, or abuse) will be
threatened or carried out in retaliation for reporting concerns through SRS or to JCI.
HOW TO REPORT TO JCI

1. Summarize your Patient Safety concerns (1-2 pages)
2. Include the Name, street address, city, and country of the health care organization
3. Name and contact information of the individual submitting the complaint (optional)
 Complaints that contain contact information will allow JCI to follow up with the submitter if
further clarification is needed or to request additional necessary information.
4. The name and contact information of the individual or individuals submitting the complaint will
be kept confidential and will not be disclosed to any other party
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NEW JCI STANDARD (APR.11)
The hospital also needs to inform the public about how to report concerns about patient safety and quality
of care to JCI, in particular when the hospital process has not been effective in resolving the concern.
Patient Relations Department
Patient Relations staff answer questions, provides information, assist with special needs and facilitate
problem solving and complaint management and ensure that all issues and complaints are handled with
sensitivity and confidentiality. They identify opportunities to improve the patient experience, assist
caregivers in meeting patients' needs, expectations and concern, and gather data for patient satisfaction.
Whether you have a question, concern, complaint or compliment, our Patient Relations team ensures that
you have a voice.
APP 1431–17 Patient Complaints, Suggestions and Compliments
APP 1433–21 Rights and Responsibilities if Patients/Families
APP 1432–09 Patient Visiting Hours and Regulations
The program must recognize the right of the patient to receive a high standard of care and treatment.
The patient/family has the RIGHT to make a complaint or suggestion when the expectations are not met
or the patient/family experiences/notices any lapse in the service rendered.
The Program must establish and maintain an open and transparent system to respond to complaints and
suggestions of patients, their families and visitors.
The complaints and suggestions must receive sympathetic attention and must be investigated and
resolved as expeditiously as possible, in accordance with the MNGHA complaint handling process.
Email: PatientReWR@NGHA.MED.SA
Patient Information Desks :
22019 / 22731 / 22933
Staff, patients and the public can contact JCI offices directly to report patient safety issues that are not
resolved by the organization.
To contact JCI office visit their website

http://www.jointcommissioninternational.org/reporting-quality-and-safety-issues/
or email jciquality@jcrinc.com
Mail
Quality and Safety Monitoring
Joint Commission International Accreditation
1515 West 22nd Street, Suite 1300W
Oak Brook, IL 60523 USA
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IPSG INTERNATIONAL PATIENT SAFETY GOALS
It is critical that EVERYONE be familiar with the International Patient Safety Goals (IPSGs)
and other Joint Commission patient safety-related standards and incorporates them into
your daily practice.
The purpose of the IPSG is to promote specific improvements in patient safety. The goals
highlight problematic areas in health care and describe evidence- and expert-based
consensus solutions to problems related to patient safety.
IPSG
Identify Patients Correctly
The hospital develops and implements a process to improve accuracy of
1 patient identifications.
APP 1430–16 Patient Identification
DPP 7800-01-016 Patient Identification
THE INTENT OF THIS GOAL IS TWO FOLD:

 FIRST, to reliably identify the individual as the person for whom the service or treatment is intended.
 SECOND, to match the service or treatment to that individual.
1. Patients must be identified using “two unique identifiers” i.e. FULL NAME and MEDICAL RECORD
NUMBER (MRN) throughout the organization.
2. MUST NEVER use patient’s room or location to identify patient.
3. Patients are identified before providing treatments and procedures (Such as administering
medications, blood, or blood products; serving a restricted diet tray; or providing radiation therapy,
taking blood and other specimens for clinical testing)
4. Patients are identified before any diagnostic procedures (performing a cardiac catheterization or
diagnostic radiology procedure)
You should always check the “two identifiers” from:

 Patient’s Medical Record
 Patient’s Identity band
 Electronic Medical Record
ALWAYS ask the patient/guardian/parent to verbalize patient’s name if possible.
8
Improve Effective Communication

The hospital develops and implements a process to improve the effectiveness of verbal
IPSG and/or telephone communication among caregivers.
2 APP 1429–03 Prescribing and Dispensing Medication Guidelines
DPP 7800-01-071 Improve Effective Communication
DPP 7800-01-171 Clinical Communication
Verbal Orders
Verbal orders are reserved for codes and emergency situations ONLY, and must be ordered
in the system within 4 hours.
Telephone Orders
Telephone orders are reserved for situations in which the Physician cannot access the
hospital’s electronic health system, and a delay will compromise patient care. Telephone orders
must be entered into the system within 24 hours.
When receiving a telephone order from a Physician:

1. Nurse A writes the order in the physician order sheet.
2. Nurse B will read back the order written by Nurse A to the physician.
3. The prescriber will verify the order is correct to Nurse B.
4. Both Nurse A and Nurse B must document the date and time the order was received, badge
number of the prescriber, and their own names, job title and badge numbers and both must
sign the order sheet.
The hospital develops and implements a process for reporting critical results of
IPSG diagnostic tests.
2.1 APP 1426–06 Reporting Critical Laboratory Values

APP 1426–09 Reporting Critical Radiological Findings
DPP 7800-01-071 Improve Effective Communication
Read back procedure for the receipt of laboratory or radiology results:
1. The technologist/reporter will provide the report to the Receiver (Requesting Physician/Ward
Nurse).
2. The receiver will document (hand -WRITE) the critical results.
3. The receiver (or another person - could be another nurse) will READ BACK the information
provided, including the patient’s medical record number and name to the reporter.
4. The technologists/reporter will verify the information is correct.
5. Both the reporter and the receiver must document the READ BACK verification procedure was
carried out; date and time the report was received, badge number of the person providing/receiving
the report.
ALWAYS REMEMBER
Physicians MUST ALWAYS respond to critical result notification.
Document the results in the patient chart, and the corresponding action needed
ACTION NE based on the patient’s clinical condition.
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The hospital develops and implements a process for handover communication.

IPSG
APP 1430–33 Integration and Coordination of Patient Care
2.2 DPP 6020-01-09-01 SBAR Communication within Nursing Division
DPP 7800-01-171 Clinical Communication
Effective communication, which is timely, accurate, complete, unambiguous, and understood by the
recipient, reduces errors and results in improved patient safety. Breakdowns in communication can occur
during any handover of patient care and can result in adverse events.
The SBAR technique provides a framework for communication between members of the health care team
about a patient's condition.
(S) Situation: a statement of the problem (What is happening at the present time?)
(B) Background: sets the context by providing background information (What are the circumstances
leading to this situation?)
(A) Assessment: Based on your assessment. (What do I think the problem is?)
(R) Recommendation: What is the recommendation or what is the problem that needs addressed. Provides
an opportunity to make a request for action. (What should we do to correct the
problem?)
Handovers of patient care within a hospital occur:

 Between health care providers and during shift changes;
 Between different levels of care in the same hospital (General ward to Critical care);
 From inpatient units to diagnostic units (endoscopy, physiotherapy, Cath Lab, etc.);
 When temporarily transferring nursing assignments of a patient for an extended period (greater
than 30 minutes) such as meal breaks;
 When referring any abnormal values or change in patient’s condition to the Physician or another
Colleague.
ALWAYS REMEMBER
The standardized approach to patient care handover, namely SBAR, must be used by all
MNGHA healthcare workers (Physicians, Pharmacists, Residents and all other Healthcare
Professionals) in all situations without fail.
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Improve the Safety of High-Alert Medications

IPSG The hospital develops and implements a process to improve the safety of high-alert
3 medications.
APP 1429–02 Look–Alike, Sound–Alike and High Alert Medications
High Alert Medications are medications that pose an increased risk of causing significant harm to
patients if used in error.
1. Standardized auxiliary labels will be used for high alert medications.
2. An independent double check procedure will be performed for some High Alert
Medications (APP 1429-02 Appendixes C and D) and Paediatric/Neonatal Medication
administration.
3. Independent double check procedure must be completed without distractions or

interruptions.
4. Always use the 5 Rights before medication administration: Right Patient, Right
Medication, Right Time, Right Dose and the Right Route.
5. Segregate them to reduce the risk of error.
6. Store the High Alert medications in RED BOXES with standardized medication labels.
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Look-Alike and Sound-Alike Medications are medications whose names/packages sound/look similar
to other drug names/packages.
Healthcare providers will adhere to the following:
1. Use TALL man Lettering labels for (Look-Alike, Sound-Alike) LASA medications that are available
via the Intranet, One Stop Resource.
2. Look-Alike, Sound-Alike medications without approved TALL Man Lettering will be labelled as
“Name Alert”.
3. Use medication segregation methods for LASA medications, e.g., separate according to routes of
administration, drug formulary status, LASA names or packaging, high alert designation, etc.
Rather than following an alphabetical sequence of storage.
4. Be aware of automated alerts/advisories for LASA medications that are in the HIS-CPR System.
5. Logistics & Contracts Management will consider the List of Look-Alike, Sound-Alike Medications
in the process of medication procurement. PURCHASE FOR SAFETY.
For more information on MEDICATION SAFETY please visit “ONE STOP RESOURCE” site on the hospital
Homepage
12
Improve the Safety of High-Alert Medications

IPSG The hospital develops and implements a process to manage the safe use of concentrated
3.1 electrolytes.
APP 1433–18 Concentrated Electrolytes
Concentrated Electrolytes are High Alert Medications that must first be diluted prior to parenteral
administration, to ensure patient safety.
Concentrated electrolytes will be:
1. Stored and kept in a locked cabinet, with

a similar sign in/out procedure used for
Narcotics and Controlled Substances.
2. Separated from other medications and

stored in red boxes with lids
3. Labeled with “High Alert

Medication/Concentrated Electrolyte”
Outside of the Pharmaceutical Care Services, concentrated (undiluted) electrolytes will be limited for
handling ONLY by the staff during the medical emergencies in which Magnesium Sulphate is presented
on the crash carts.
NOT ALL High Alert Medications require an INDEPENDENT DOUBLE CHECK. Please review the revised
Policy (APP 1429-02 Appendixes C and D)
13
Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

IPSG The hospital develops and implements a process for ensuring correct-site, correct-
procedure, and correct-patient surgery.
4 APP 1426-08 Surgical / Procedural Site Verification
DPP 7800–01–17 Verification Of Correct Patient, Correct Procedure, Correct Site for
Surgical and Invasive Procedures
Wrong-site, wrong-procedure, wrong-patient surgery errors are the result of ineffective or inadequate
communication between members of the surgical team, lack of patient involvement in site marking, and
lack of procedures for verifying the operative site.
The essential processes found in the Universal Protocol are: marking the surgical site; a preoperative
verification process; and a time-out that is held immediately before the start of a procedure.
REMEMBER - These requirements also apply for any invasive procedures that are performed outside of the
OR.
Surgical and invasive procedure site marking

should:
 be done by the person performing the
procedure with a permanent skin
marker.
 take place with the patient AWAKE and
AWARE, if possible.
 be done in all cases involving laterality
(right, left), multiple structures (fingers,
toes, lesions) or multiple levels (spine).
 be done using an instantly recognizable
mark (ARROW as per policy) that is
consistent throughout the hospital.
Preoperative verification
There are various elements of the preoperative
verification process that can be completed before the
patient arrives at the preoperative area:
 Ensure that documents, imaging and test results,

vital signs and paperwork are properly labeled and
readily available.
.
 Informed consents are completed and signed by the
Physician, Patient/Guardian or Parent and the
witness.
 Proper handover is done in the preoperative area

and all discrepancies should be corrected before
sending the patient into the Operating Theatre.
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Time Out
This is the final verification that is
performed immediately prior to the start of
any surgical and invasive procedure
whereby the entire care team actively and
verbally confirms:
 Patient's identity (two identifiers)
 Procedure to be performed
 Correct procedure side/site
 Necessary imaging, equipment, implants
or special requirements are present
PAUSE WITH A PURPOSE

(AORN)-Association of peri-
Operative Registered Nurses
1. Time Out should be performed in a "fail-safe" mode, i.e., the procedure is not started until all
questions or concerns are resolved.
2. The responsibility for the "Time Out" process lies with the Physician performing the surgery/
procedure on that patient.
ALWAYS REMEMBER
Surgical- and invasive procedure-site marking is done by the person performing
the procedure and involves the patient in the marking process.
The full team conducts and documents a time-out procedure in the area in which
the surgery/invasive procedure will be performed, just before starting a
surgical/invasive procedure.
“SAFE SURGERY SAVES LIVES”
15
Reduce the Risk of Health Care–Associated Infections

IPSG The hospital adopts and implements evidence-based hand-hygiene guidelines to reduce
the risk of healthcare–associated infections.
5
ICM–II–04 Hand Hygiene
Clean Hands Save Lives

MNGHA adapted the WHO Guidelines of Hand Hygiene in Health Care 2009 to reduce the risk of health
care-associated infections.
5 Moments for Hand Hygiene:
40-60 seconds
20-30 seconds
 Wash hands with soap and water when hands are visibly soiled.
Limitation of alcohol based hand rub (ABHR):

 ABHR is inactive when hands are visibly dirty and when dealing with spore forming bacteria, i.e.,
clostridium difficile patients.
Using alcohol-based sanitizers

 Use alcohol-based hand rub when hands are NOT visibly soiled.
* Note: Always be AWARE of your unit’s hand hygiene compliance rate.
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Reduce the Risk of Patient Harm Resulting from Falls

The hospital develops and implements a process to reduce the risk of patient harm
IPSG resulting from falls.
6 APP 1430–05 Fall Prevention & Management Program
DPP 7800-01-084 v4 KAMC-Jeddah Falls Program
Many injuries in hospitals to both inpatients and outpatients are a result of falls. Risks associated with
patients might include patient history of falls, medications use, alcohol consumption, gait or balance
disturbances, visual impairments, altered mental status, and the like.
Joint Commission Requirements:
1. The hospital implements a process for assessing all inpatients and those outpatients whose
condition (patients with gait or balance disturbances, visual impairments, altered mental
status, and the like), diagnosis, situation (such as patients arriving by ambulance, patient
transfers from wheelchairs, or the use of patient-lifting devices, or location (such as the
physical therapy department) identifies them as at high risk for falls.
2. The hospital implements a process for the initial and ongoing assessment, reassessment, and
intervention of inpatients and outpatients identified as at risk for falls based on documented
criteria.
3. Measures are implemented to reduce fall risk for those identified patients, situations, and
locations assessed to be at risk.
NURSING STAFF RESPONSIBILITIES ON FALL PREVENTION
1. The nurse shall assess all inpatients for any high

fall risk factors within four (4) hours of
admission and /or their condition or level of
care changes.
2. Identify High Risk patients with a “Falling Star” logo

on the Nursing White Board, patient’s wrist band,
head of the bed, and medical file.
3. Perform an Environmental Fall Risk Safety Check of

each patient's room and bathroom once per shift.
4. Educate the patient/family/sitter as required.
5. Implement an age sensitive Nursing Plan of Care

aimed at managing the risk of the patient falling.
6. Process a Direct Referral from Nursing to Clinical

Pharmacy or Physiotherapy as per Policy DPP 7800-
01-084 v4.
17
PHYSICIAN’S ROLE IN FALLS PREVENTION
1. Upon initial admission assessment,

Physicians should screen Patient’s
Functional status which include “FALL
RISK”.
2. Functional Screening should be

documented in the Physicians History
and Physical.
3. Fall Risk assessment should be

complementary with the Nursing Fall
Risk assessment.
PHARMACIST’S ROLE IN FALLS PREVENTION

Pharmacist review within twenty-four (24) hours,
if the patient has all three (3) criteria as follows:
1. Patient is more than sixty (60) years old.

2. Patient takes two (2) or more High Risk Fall
Medications
3. Patient has a history of falls within the past
six (6) months, except for complete
paralysis or completely immobilized
patients.
PHYSIOTHERAPIST’S ROLE IN FALLS PREVENTION
Physiotherapist / Occupational Therapist (PT /

OT) screen within thirty-six (36) hours, if the
patient:
1. Is more than sixty (60) years old
2. Has a history of falls within the past

six (6) months
3. Has mobility impairment
ALWAYS REMEMBER
Any member of the patient care team (Nurses, Physicians and other Healthcare Professionals) shall use their
assessment and clinical judgment to determine if a patient is at risk for falls, and shall communicate with
the primary nurse to implement appropriate falls prevention.
18
ACC ACCESS TO CARE AND CONTINUITY OF CARE
These standards address which patient needs can be met by the health care organization, the efficient flow
of services to patients, and the appropriate transfer or discharge of patients to their home or to another
care setting.
NEW JCI STANDARD

IMPROVE PATIENT FLOW
APP 780–06 Managing a Bed Shortage and Activation of Code Bed Crisis
DPP 7800-01-150 Bed Management
During Bed crisis, JCI requires the hospital to develop a process to manage the flow of patients throughout
the hospital by providing:
a. Adequate inpatient beds

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

APP 1428–19 Management of Missing or Absconded Patients
When a patient decides to leave the hospital after an examination has been completed and a treatment
plan recommended, whether it is an inpatient or an outpatient, this is identified as “leaving against
medical advice.”
The Joint Commission Requirements
1. There is a process for the management of inpatients and

outpatients who leave the hospital against medical advice
without notifying hospital staff.
2. There is a process for the management of outpatients

receiving complex treatment who do not return for
treatment.
3. If the family physician is known and has not been

involved in the process, the physician is notified.
4. The process is consistent with applicable laws and

regulations, including requirements for reporting cases of
infectious disease and cases in which patients may be a
threat to themselves or others.
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PFR PATIENT AND FAMILY RIGHTS
These standards address issues such as promoting consideration of patients’ values, recognizing the
hospital’s responsibilities under law, and informing patients of their responsibilities in the care process.
Standards regarding patient rights with respect to informed consent, resolution of complaints, and
confidentiality are also included.
APP 1433–21 Rights & Responsibilities of Patients/Families
The “Patient’s Rights & Responsibilities” brochure is provided to the patient at the time of
Admission or Outpatient Visit.
Privacy
The patient has the right to refuse to talk to or meet anyone
who is not officially and directly involved in the healthcare provided to
him/her including visitors.
Medical assessments and examinations are to be conducted in designated areas out of the sight and
hearing of others.
Confidentiality
Only direct health care providers have access to patients’ files and details of
their condition.
Refusal of Treatment
When a patient refuses care or chooses to discontinue treatment, he/she will be advised of the
consequences of his/her refusal and the expected outcome of this decision.
Complaints Resolution
The Patient Relations Department and its representatives familiarize patients and their families with valid
rules and regulations and how to submit proposals, opinions, and complaints and provide them with the
required feedback.
Informed Consent
The patient (or his/her family) is entitled to have a complete explanation of
the medical procedure required for his/her treatment, including risks and
benefits of the proposed procedure, its complications, and alternative
treatments.
Pain Management
Patients have the right to have his/her pain assessed and addressed as part of his/her
treatment plan.
Safety
The Patient has the right to expect appropriate and reasonable provision of personal safety insofar as
MNGHA treating/healthcare facilities, the environment, and personnel practices are concerned.
20
Respect, Dignity and Consideration

Patients have the right to considerate and respectful care at all times and under all circumstances with
due recognition of his/her personal dignity.
Privacy and Confidentiality

These are some best practices to maintain patient privacy & confidentiality:
DO’s DON’Ts
1. Log-out after using the computers in patient 1. Do not share computer passwords.
care areas. 2. Do not discuss patient-specific information in
2. Knock before entering a room. public areas like elevators, food courts and
3. Close doors and curtains during treatment hallways.
and examination. 3. Do not display patient-specific information on
4. Cover patients notice boards
appropriately during accessible to the
treatment and public.
transport. 4. Do not leave medical
5. Modulate voice records in public
volume in areas areas or unattended
where privacy could by staff.
be compromised. 5. Do not give treatment, or perform physical
examination or procedures if the patient belongs
to the opposite gender, without the presence of a
person/chaperone/care-provider of the same
(patient’s) gender present.
21
Informed Consent
APP 1419–08 Patient Informed Consent
It is the process whereby the attending physician or designee, from the team performing the
surgery/procedure, provides the following information to the patient, legal guardian, custodian about
specialized (non-routine) procedure(s).
JCI REQUIREMENTS
Staff members clearly explain any proposed treatment(s) or procedures to the patient and the family.
The information provided includes

1. the patient’s condition;
2. the proposed treatment(s);
3. the name of the person providing the treatment;
4. potential benefits and drawbacks;
5. possible alternatives;
6. the likelihood of success;
7. possible problems related to recovery; and
8. possible results of non-treatment.
Consent for:
1. Surgery/Procedure
2. Anesthesia and Sedation
3. Blood and Blood Products
4. Instrumental delivery Valid for
5. Manual removal of placenta 90 days
6. Termination of pregnancy Unless there are changes to
7. DNA banking and genetic studies the patient’s condition
8. Photography
9. Elective Cesarean Section
10. Sterilization
VALIDITY PERIOD FOR OTHER CONSENTS
Outpatient: All subsequent

outpatient visits
Consent for General Treatment Inpatient: Only for the duration of
that hospitalization
Consent for Imaging of Pregnant Patients’ Abdomen or Pelvis 30 Days
One Session only (Preservation is
Consent for Cryopreservation of Sperm valid for two years)
One Session only (Preservation is
Consent for Cryopreservation of Embryos valid for two years)
Consent for IVF Treatment One cycle ONLY
Consent Form for Critical Care Patients Per admission
Consent for Chemotherapy Per protocol
22
General Consent
JCI requirements for the General Consent
General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for the
first time as an outpatient, is clear in its scope and limits.
1. General consent for treatment, if obtained when a patient

is admitted as an inpatient or is registered for the first time
as an outpatient, is clear in its scope and limits.
2. Patients and families are informed as to the scope of a

general consent, when used by the hospital.
3. The hospital has defined how a general consent, when

used, is documented in the patient record.
4. Patients and families are informed about which tests and

treatments require informed consent. (Also see PFR.5.1)
5. The general consent notes if it is likely that students and

trainees will participate in care processes.
THINGS TO REMEMBER ABOUT THE INFORMED CONSENT

FROM THE HOSPITAL POLICY
1. The legal age to give consent is eighteen (18) Hijrah years for both males and females
2. Consent must be obtained by the attending physician or designee (R3 or above) who is going to perform
the treatment, procedure/intervention from the patient, legal guardian.
3. The attending physician or designee will write in full on the respective consent form (no abbreviations
will be accepted), the name of the procedure, the site, side, and level (if applicable) of the procedure to
be performed.
4. The consent form shall be completed in English for non-Arabic speaking patients and in both English
and Arabic for Arabic speaking patients.
5. Consent must be obtained from a patient or legal representative on behalf of the patient (should the
patient be unable to give consent) for all treatments, procedures.
Consent must be obtained by the attending physician

or designee (Resident 3 or above) as per policy.
23
AOP ASSESSMENT OF PATIENTS
This chapter addresses patient assessment at all points of care within the hospital. Assessment includes
collecting information and data on the patient’s physical and psychosocial history, analyzing the data and
information to identify the patient’s health care needs, and developing a plan of care to meet those
identified needs. This chapter also includes standards that address laboratory services and diagnostic
imaging and radiology services.
APP 1430–27 Patient Admission (H&P) Assessment
The Initial Admission Assessment will include at a minimum, an evaluation of patient's:
 Presenting illness.
 Medical, Surgical and Family History;
 Psychosocial and Economic Assessment.
 Nutritional and Functional Screening.
 All medications being taken at admission.
 Allergies.
 A complete Review of Systems.
 Pain Screening.
 A Complete Physical Exam.
 Initial Assessment Impression.
 Initial Care Plan
 Educational and Discharge planning needs
A Detailed History and Physical examination MUST be completed and documented in the
clinical record (Physician Admission Assessment) within 24HRS of admission.
DAILY REASSESSMENT OF PATIENTS
1. Reassessments are conducted by the MRP (or consultant

designee) daily including weekends and holidays, or more
often as required by the patient's condition until
discharge.
2. Each reassessment will result in an update to the care plan

and will be documented in the Physician Progress Notes.
3. Discussion with the patient (his/her family) will be

documented in the progress notes or appropriate form.
24
APP 1430–32 Patient Assessment & Reassessment by Allied Health Professionals
1. The initial physician assessment process may identify a need for additional specialized
services such as, but not limited to, Respiratory, Speech Therapy, Nutrition,
Psychology, Audiology, Physiotherapy and Occupational Therapy.
2. All specialized assessments and reassessments must be completed and documented in

the patient clinical record (electronically or hardcopy) within the timeframe
stipulated in each discipline's DPP.
DPP 7800-01-175 Interdisciplinary Assessment and Reassessment of patient: Inpatient
1. Initial Nursing Assessment: a systematic collection of

data collated during admission to aid in the
determination of the patients health status and the early
identification of any actual or potential health problems
and discharge needs.
2. Nursing Reassessment: an ongoing systematic collection

of data, to identify patient's clinical status and response
to therapy and interventions.
3. Core Nursing Assessment: minimal, age sensitive,

Nursing Admission Assessment and Reassessment
elements to be performed on all Inpatients.
All unit-based nursing orientation programs will include a

review of the policies and procedures related to Nursing
Assessment or Reassessment Standards.
CORE INPATIENT NURSING ADMISSION ASSESSMENT STANDARDS
Nurses to observe the Time Frame indicated in the appendices of the Policy for the completion of
assessment and re-assessment of patients.
25
Pain Screening and Assessment

APP1430–07 Pain Management
DPP 7800-01-002 KAMC Pain Assessment and Management
The pain management standards address the assessment and management of pain. The standards require
organizations to:
1. Recognize the right of patients to appropriate assessment and management of pain.

2. Screen patients for pain during their initial assessment and, when clinically required, during
ongoing, periodic re-assessments.
3. Educate patients suffering from pain and their families about pain management.
Pain Assessment Tools for Different Age Groups
Patient Tools
Neonate- 3 months Cries

Infant above 3
FLACC(0-10)
months
Developmentally
FLACC(0-10)
delayed
3 yrs. and above Wong-baker
Numeric
7 yrs. and above Wong-baker
Scale (0-10)
Numeric
Verbal Adult Wong-baker
Scale (0-10)
Non-verbal Adult FLACC(0-10)
4-6/10
1-3/10 7-10/10
Moderate
Mild Pain Severe Pain
Pain
1. Check last time analgesic given.   
2. Give analgesic immediately if due within 30 minutes.   
3. Implement non-pharmacological interventions.   
4. Notify MRP if analgesic is not due for another 1 hour  
5. If no order present, obtain order immediately for pain
medication or if pain present despite interventions. 
DPP 7800-01-002 KAMC Pain Assessment and Management
PAIN RELIEF EVALUATION & OUTCOME

 15 min Post IV administration of analgesia.
 20 min Post SC administration of analgesia.
 30 min Post IM administration of analgesia.
 60 min Post oral analgesia.
 Immediately after Non pharmacological interventions.
26
COP CARE OF PATIENTS
This chapter discusses activities basic to patient care, including processes for planning and coordinating
care, monitoring results, modifying care, and conducting follow ups. The chapter also includes high-risk
care services, nutrition care, pain management, and end-of-life care.
JCI Standard requires organization to develop and document an individualized plan of care for each patient.
The plan of care for a patient must be related to his or her identified needs.
Examples of assessed needs and measurable goals include the following:
Diagnosis: Diabetes Mellitus
Assessed Needs Individual Measurable Goals

Blood sugar control Blood glucose reading <180mg/dL; fasting blood
glucose reading < 140mg/dL
Leg Ulcer Skin color red; not brown or black
No bad-smelling discharge
Infection Normal temperature after 48 hours of antibiotics
Hospitals Providing Organ and/or Tissue Transplant Services

New JCI Standard
Leadership’s commitment to creating a culture conducive to organ and tissue donation can have
significant impact on the overall success of the hospital’s organ and tissue procurement efforts.
These standards address the hospital’s organization-wide responsibilities for organ and tissue
donation and procurement.
APP 1433–11 Deceased “Brain-Dead” Organs & the Organ Procurement Process
 The Program recognizes the major contribution of organ

transplantation for the good of human health and relief of human
suffering.
 The human organ procurement and transplantation process must

conform to the SCOT (Saudi Center for Organ transplantation)
policies and regulations.
 Respect and full support must be offered to patients and families

regarding their choices to donate human organs and other tissues.
 The provisions of this APP apply to all medical, clinical and

administrative staff involved in organ procurement and
transplantation at MNGHA or any affiliated facility.
27
End-of-Life Care
APP 1430–06 Palliative Care and End-of-Life Care
Patients who are dying have unique needs for respectful, compassionate care. To accomplish this, all staff
are made aware of the unique needs of patients at the end of life.
This Policy aims to:
 Address ethical and medical standards and

religious issues related to end-of-life care.
 Define the responsibilities of MNGHA

employees involved in caring for patients
diagnosed with a terminal illness, when
functionally debilitated, dying, and/or after
their death, regardless of their nationality or
age.
Joint Commission Standard recommends that End-of-life care provided by the hospital includes:
a. Providing appropriate treatment for any symptoms according to the wishes of the patient and
family;
b. Sensitively addressing such issues as autopsy and organ donation;
c. Respecting the patient’s values, religion, and cultural preferences;
d. Involving the patient and family in all aspects of care, and
e. Responding to the psychological, emotional, spiritual, and cultural concerns of the patient and
family.
No patient should die alone. When death occurs, the patient must be treated with dignity.
(APP 1430–06 Palliative Care and End–of–Life Care)
28
APP 1430–21 Physical Restraint

DPP 7800-01-00-42 Restraint of Patient
Physical Restraint is an approved mechanical device or devices which restrict the movement of the whole or
a portion of the patient’s body for the purpose of preventing harm to self or others.
POINTS TO REMEMBER:
1. Initiation of Physical Restraint is by the Physician’s order only. Orders for the restraints shall not
exceed twenty-four (24) hours in duration.
2. Recurrent use of Restraint: A registered Nurse or Physician shall document in the patient's record the
justification for recurrent use of restraints in addition to the patient's physical and behavioral status.
3. Assessment of patient’s physical and psychological well-being shall be made throughout the restraint
period with a maximum of two (2) hours interval.
a. Application of restraint devices – ensuring that patients have as much freedom as possible.
b. Circulation and degree of movement in the extremities are evaluated.
c. Each restrained limb is released from restraints and examined from bruising or skin tears
and exercised (range of motion) every two (2) hours.
4. Meals are provided at regular time and fluids are offered every two (2) hours to ensure nutrition and
hydration.
5. Elimination needs are met at least every two (2) hours or as requested. Hygiene is offered on a daily
basis.
Restraint must not be applied before physician assessment and order, patient are assessed every 2 hours,
and restraint order evaluated every 24 hour
CODE BLUE
APP 1430–41 Cardiopulmonary Resuscitation & Activation of Code Blue
JCI Requirements
1. Resuscitation services are available and provided to all

patients 24 hours a day, every day, throughout all areas of
the hospital.
2. Medical technology for resuscitation and medications for

basic and advanced life support are standardized and
available for use based on the needs of the population served
3. In all areas of the hospital, basic life support is implemented

immediately upon recognition of cardiac or respiratory
arrest, and advanced life support is implemented in fewer
. than 5 minutes.
29
NEW JCI STANDARD

CRITICAL CARE RESPONSE TEAM CALLING CRITERIA
DPP 7800-01-54 Adult Critical Care Response Team
for unexpected deterioration in patient’s condition.
Critical Care Response Team is a formally designated multidisciplinary critical care team that assesses and
manages a patient demonstrating the early signs of deterioration in clinical status, prior to the development
of progressive and irreversible deterioration.
ACTIVATION SYSTEM FOR THE CCRT: THE AFFERENT ARM
1. Initiation of the CCRT is at the discretion of the bedside healthcare provider(s), including the
primary nurse, respiratory therapist, physician or other healthcare workers.
2. Activation of the CCRT does not require a prior order or an explanatory progress note.
3. CCRT will not be activated for patients who are labeled with “NO CODE” status.
Indicators of sudden or unexpected deterioration in adult patient’s condition may include but not limited
to:
1. Hypotension (systolic blood pressure less than or equal to 90 mmHg
2. Hypertension (systolic blood pressure more than or equal to 200 mmHg
3. Hypoxaemia with SaO2 of less than 90%
4. Respiratory distress (RR less than 8 or greater than 24)
5. Onset of chest pain
6. Increase in heart rate to greater than 130
7. Decrease in heart rate to less than 40
8. Fever of 38.5oC in neutropenic/immunocompromised patients (with no written orders to cover
such event)
9. Bleeding with hypotension
10. Seizures
11. Onset of confusional state
12. Deterioration in level of consciousness (GCS decreased by two (2) points)
ALWAYS REMEMBER THE CCRT CALLING CRITERIA
For those departments that have implemented Modified Early Warning Scoring System
The Modified Early Warning System (MEWS) is a tool for nurses to help monitor their patients and improve
how quickly a patient experiencing a sudden decline receives clinical care.
Front of the MEWS Score Card

MODIFIED EARLY WARNING SCORING (MEWS) SYSTEM
If AIRWAY is threatened: Total MEWS is = 9 (Immediately refer to back of the card)
Criteria MEWS Value
Score 8 5 3 2 1 0 1 2 3
AVPU Responsive Responsive to Alert

to Pain verbal
Respiration <8 Unrespon 9-20 21-30 31-35 >35

(RR/min) sive
30
SPO2 (%) <84 85-89 90-92 >93
Temperature (°C) <34 34.1-35 35.1-36 36.1-37.9 38-38.5 >38.6
Heart Rate (b/min) <40 40-50 51-99 100-110 110-130 >130
Circulation Markedly >2sec / weak or <2sec /

(Capillary delayed / bounding pulse full pulse
Refill/Pulse) weak pulse
Systolic BP <79 / 80-89 or 145- 90-144

(mmHg) >190 190
Urine Output (mL <80 / 80-119 / 120-800/ >800/

for last 4H) Anuria Oliguria Normal/ polyuria
Reg HD
Get Total MEWS (score), Refer to back of card for ADVISORY
Back of the MEWS Score Card
TMEWS System Advisory Nursing Actions/Remarks
0 Routine Care Routine Care and Monitoring as per unit workflow
1-4 Continue Inform Nurse-in-Charge or Physician as necessary

Monitoring Monitor pt. as per sorklist and more as appropriate
(e.g. vital signs q 1 hour)

Document in QCPR
5-8 Contact Inform Nurse-in-Charge

Physician and Call/Page Senior Physician (Follow Physician Notification / Call Out
Activate MEWS Protocol)
Monitor pt. as per worklist and more as appropriate
(e.g. vital signs q 15 min, Adult LOC, Blood Glucose)
Document in QCPR
Expectation: Physician review and assess patient within 30 min.
9 or > 9 Activate CCRT Inform Nurse-in-Charge

Protocol Call/Page Senior Physician (Follow CCRT Protocol)
Monitor pt. as per worklist and more as appropriate
(e.g. vital signs q 5 min, Adult LOC, Blood Glucose)
Stay with patient
Document in QCPR and CCRT form
Expectation: Physician review and assess patient within 30 min.
31
ASC ANESTHESIA AND SURGICAL CARE
This chapter addresses sedation and anesthesia use and surgical care. Topics include procedures for
preparing, monitoring, and planning for aftercare for patients who received sedation or anesthesia and/or
who had surgery.
APP 1433–31 Sedation by Non Anesthesiologists

DPP 7800-01-013 Sedation by Non-Anesthesiologist at KAMC-Jeddah
1. PRE –SEDATION ASSESSSMNET- Pre-Procedure Preparation: An appropriate pre-procedure

evaluation of the patient will be undertaken and documented on the sedation form.
2. INTRA-SEDATION ASSESSMENT: All patients will have the indicated minimum parameters
monitored and documented at least every five (5) minutes during the procedure.
3. POST-SEDATION ASSESSMENT- All monitored vital signs will be recorded at least every five
(5) minutes until the patient has achieved the criteria for discharge from the recovery area.
STAFF CREDENTIALING:
 Current BLS or preferably ACLS or PALS issued by MNGHA
 Physician sits for the Sedation/Analgesia Competency Course On-line consists of multiple
choice questions. Passing score is 80%.
 Competency recertification is mandated if the physician performed less than 10
moderate/deep sedation procedures per year.
NEW JCI STANDARD (ASC 7.4)

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

b. modifications to the surgical checklist to ensure that implants are
present in the operating theatre an special considerations in marking
the surgical site;
c. the qualifications and training of any outside technical staff required
during the implant procedure;
d. an understanding of and reporting process for device-related adverse
events;
e. unique infection control considerations;
f. any special discharge instructions to the patient; and
g. the traceability of devices in the event of a recall
32
MEDICATION MANAGEMENT AND USE

MMU
This chapter addresses systems and processes for selecting, procuring, storing, ordering/prescribing,
transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring
medication therapies.
APP 1427–16 Error Prone Abbreviations, Symbols and Dose Designations
Abbreviations Why this is not to be used What is acceptable practice

Can be mistaken for mg (milligram), which
µg can result in a thousand-fold dosing Use ‘microgram’
overdose
Can be mistaken for units (with the cc
cc Use ‘mL’ or ‘ml’
looking like a ‘u’ or ‘0’)
Can be interchanged to mean discontinue or
D/C Use ‘discharge’ or ‘discontinue’
discharge
IU Can be mistaken for intravenous or 10 (ten) Use ‘international units’
QD, o.d, OD, q1d Can be mistaken for ‘right eye’ Use ‘daily’
q.o.d, QOD Can be mistaken for q.i.d. Use ‘every other day’
SC can be mistaken for SL, and the ‘q’ in
SC, SQ, Sub q Use ‘subcut’ or ‘subcutaneously’
‘sub q’ can be mistaken as ‘every’
Can be mistaken for the number 0 or the
U or u Use ‘unit’
number 4
HS Mistaken as bedtime
Use ‘half-strength’ or ‘bedtime’
hs Mistaken as half-strength
Dose Designations Why this is not to be used What is acceptable practice
Trailing zero after Do not use trailing zeros for
decimal point doses expressed in whole
Can be mistaken as 10 mg if the decimal
numbers.
point is not seen
Example: 1.0 mg
Example: 1 mg
Dose Designations Why this is not to be used What is acceptable practice
No leading zero Use zero before a decimal point
before a decimal when the dose is less than a
point Can be mistaken as 5mg if the decimal point whole unit
is not seen
Example: .5mg Example: 0.5mg
Symbols Why this is not to be used What is acceptable practice

Can be misinterpreted to mean the opposite
> and < Use ‘greater than’ or ‘less than’
of what is intended
Stemmed Drugs
Why this is not to be used What is acceptable practice
Names
Shorten Names of
Can be mistaken for other drug names, such
Drugs Write out the ‘complete name of
as in the example –’Nitro’ drip can mean
drug’
nitroglycerin or sodium Nitroprusside
Example ‘Nitro drip’
33
MEDICATION ADMINISTRATION
DPP 7800-01-040 Medication Administration Times & Guidelines
The safe administration of medications includes verifying the:

1. Medication with the prescription or order;
2. Identity of the patient;
3. Time and frequency of administration with the
prescription or order;
4. Dosage/amount with the prescription or order; and
5. Route of administration with the prescription or order.
JCI REQUIREMENTS ON MONITORING
The purposes of monitoring are to evaluate the medication’s effect on the patient’s symptoms or illness, as
well as blood count, renal function, liver function, and other monitoring with select medications, and to
evaluate the patient for adverse effects. Based on monitoring, the dosage or type of medication can be
adjusted when needed.
1. Medication effects on patients are monitored.

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

Safety Reporting System (SRS)
Hierarchy of Medication Safety Incidents
Medication
Safety
Incident
Potential Adverse Drug Event

Adverse Drug Event (ADE)
(PADE)
Near Miss Hazardous Condition Adverse Drug Reaction Medication Error

(ADR)
34
EMERGENCY MEDICATIONS
APP 1430–41 Cardiopulmonary Resuscitation and Activation of Code Blue

APP 1433-16 Allergy & Hypersensitivity Recording & Documentation
Emergency medications are available, monitored, and safe when stored out of the pharmacy.
When patient emergencies occur, quick access to appropriate emergency medications is critical. Each
hospital plans the location of emergency medications and the medications to be supplied in these locations.
CRASH CART
ANAPHYLACTIC KIT MEDICATIONS ANTIDOTES
 Emergency medications are available in the units where they will be needed or are readily
accessible within the hospital to meet emergency needs.
 The hospital establishes and implements a process for how emergency medications are stored,
maintained, and protected from loss or theft.
 Emergency medications are monitored and replaced in a timely manner after use or when
expired or damaged.
MEDICATION PREPARATION
ICM-II-05 Aseptic Technique
The hospital identifies the standards of practice for a safe and clean preparation and dispensing
environment. Medications stored and dispensed from areas outside the pharmacy (for example, patient care
units) comply with the same safety and cleanliness measures.
1. Medications are prepared and dispensed in clean and

safe areas with appropriate medical technology,
equipment, and supplies.
2. Staff preparing sterile products is trained in the

principles of medication preparation and aseptic
technique.
35
PFE PATIENT AND FAMILY EDUCATION
This chapter contains standards that address the effectiveness of education that is provided to patients and
families and the modalities employed to successfully educate these individuals. This chapter also examines
patients’ readiness to learn by considering their language needs and learning preferences.
APP 1426–18 Patient & Family Education
Providing education to the patients and their families about their health or medical problems enables them
to make informed decisions about their healthcare needs. It is important for our patients and families to
assume a proactive role in the maintenance and/or improvement of their own health.
A patient/family’s educational needs assessment includes an assessment of their preferences or

barriers to learning, such as sensory impairment, language barriers, as well as, cultural and
religious beliefs.
 The Patient Educators complete the initial educational needs assessment within 48 hours of
admission.
All health care providers are responsible to provide patient education to meet their health needs or to
achieve their health goal. All activities or any actions relating to patient/family education will be
documented in QCPR and can be reviewed in the electronic Interdisciplinary Patient / Family Education
Record (e-IPER).
e-IPER Screenshots:
Patient education is the most vital step toward making the patient independent
in his own care.
36
QPS Quality Improvement and Patient Safety
The standards in this chapter identify the structure, leadership, and activities to support the data collection,
analysis and improvement for the identified priorities hospital wide and department- and service-specific.
This includes the collection and analysis of data on, and response to, hospital wide sentinel events, adverse
events, and near-miss events.
Science of Improvement: Testing Changes

KAMC-WR uses the Model of Improvement as well as other methodologies for conducting performance
improvement projects.
The Model for Improvement is a simple, yet powerful approach to achieving rapid and significant
improvements in care delivery and outcomes. It has been used very successfully by hundreds of
health care organizations in many countries to improve many different health care processes and
outcomes.
What are we trying to accomplish? The improvement team

develops a specific, time-limited and measurable aim
statement (setting aims)
How will we know if a change is an improvement? The team
identifies process and outcome measures to collect over time
in order to track improvement and evaluate progress
(establishing measures)
What changes can we make that will result in
improvement? The team identifies ideas for changes to try
(selecting changes to test)
The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a

change — by planning it, trying it, observing the results, and
acting on what is learned. This is the scientific method, used for
action-oriented learning.
37
Electronic Safety Reporting System (SRS)

Guidelines for Management of Electronic Safety Reports (SR)
SRS is the first electronic web-based incidents reporting and management system at MNGHA. The system
was launched in May 2009 at the Central Region, and has been rolled out to all MNGHA facilities in May,
2013.
The Electronic Safety Reporting System (SRS) is a non-punitive system and is not a method of blaming any
particular individual/service. The emphasis is on the prevention of recurrence and on communication with
all affected departments and units in a context of a “JUST CULTURE”.
Staff involved in a serious event shall be offered appropriate support, which may involve psychological first
aid, or other support.
STAFF RESPONSIBLITIES FOR SAFETY REPORTING SYSTEM
RESPONSIBILTY OF HOSPITAL STAFF: RESPONSIBILTY OF A SUPERVISOR

Any employee involved in or eyewitnesses an 1. To review & investigate the Safety
incident is responsible for initiating a Safety Reports (SR) submitted within five (5)
Report as soon as possible within twenty-four working days for the report`s
(24) hours using the Hospital-wide electronic originating unit; another five (5)
Safety Reporting System (SRS) if any of the
working days for the other
following occur:
units/services involved in the incident.
1. An error or mistake that injures, or could 2. Ensure that the entered General
have injured a patient, employee or visitor. Incident Type, Person affected
2. Failure or shortage of direct patient care information, Specific occurrence
equipment, utility or material that had Location, Specific Incident Type and
adverse impact, or could have adverse Degree of Injury, are correct and
impact upon patient care outcome. appropriate to the nature and location
3. An incident that caused an angry reaction of the incident.
by a patient or family member.
4. An incident that inhibits process or system 3. To Analyze and Close the Safety Report.
and has an adverse effect upon patient
care. 4. Provide feedback for the reporting
employee and share the lessons learned
The report should focus on the objective and with other staff concerned to avoid
factual description of the incident; subjective recurrences of similar issues.
opinions on individuals or services should not
be included in reports.
38
SENTINEL EVENT
APP 1423–05 Sentinel Events and Root Cause Analysis
DPP 7800-01-106 Sentinel Event & Root Cause Analysis
A sentinel event is an unanticipated occurrence involving death or serious physical or psychological

injury. Serious physical injury specifically includes loss of limb or function. Such events are called sentinel
because they signal the need for immediate investigation and response.
Sentinel Events includes any occurrences that meet the following criteria:
a) an unanticipated death, including, but not limited to,
 death that is unrelated to the natural course of the patient’s illness or
 underlying condition (for example, death from a postoperative infection or a hospital-
acquired pulmonary embolism);
 death of a full-term infant; and
 suicide;
b) major permanent loss of function unrelated to the patient’s natural course of illness or underlying
condition;
c) wrong-site, wrong-procedure, wrong-patient surgery;
d) transmission of a chronic or fatal disease or illness as a result of infusing blood or blood products
or transplanting contaminated organs or tissues;
e) infant abduction or an infant sent home with the wrong parents; and
f) rape, workplace violence such as assault (leading to death or permanent loss of function); or
homicide (willful killing) of a patient, staff member, practitioner, medical student, trainee, visitor,
or vendor while on hospital property.
Root Cause Analysis

(RCA) is a process for identifying the basic or causal factor(s) that underlies variation in performance,
including the occurrence or possible occurrence of a sentinel event. RCA primarily focuses on Systems
and Processes, not individual performance.
Team Formation
Once a sentinel event has been identified the Executive Director of Medical Services immediately
appoints a multidisciplinary team to direct the investigation. The team members are staff trained in the
techniques and goals of RCA. The team utilizes the root cause analysis template and completes an
action plan. The Root cause analysis and action plan is completed within 45 days of the event or
becoming aware of the event.
Conducting Root Formulate Action

Multidisciplinary Team Cause Analysis Plan within 45 Days
39
PCI PREVENTION AND CONTROL OF INFECTIONS
These standards address the methods a hospital uses to design and implement a program to identify and
reduce the risk of patients and staff acquiring and transmitting infections. Areas covered in this chapter
include the process for reporting infections and the types of ongoing surveillance activities that are in
place.
Standard Precautions to prevent infection transmission
Foundation for preventing transmission of infectious agents during interactions between healthcare
personnel and patients are the work practices in having basic level of infection control to reduce the
risk of transmission. These infection control practices should be applied to all body fluids, non-intact
skin, and mucous membranes; and, should be used for all patients regardless of their diagnosis or
presumed infectious status.
5 Moments of Hand Hygiene

Strict Hand Hygiene (when and why?)
Use of PPEs (Personal Protective Equipment)

ICM–II–03 Standard Precautions
Put on in this order: Hand hygiene, gown, mask, (goggles or face shield), gloves.
Remove in this order: Gloves, gown, hand hygiene, mask or respirator.
Note: if goggles or face shield are worn, they should be removed after the gloves
because they are more cumbersome and would interfere with removal of other
PPEs. (Gloves, HH, goggles or face shield, gown, HH, surgical mask or
respirator).
 Use of aseptic techniques for all invasive procedures and any procedure
requiring asepsis
 Safe handling and disposal of sharps
 Proper handling of contaminated items
 Collection and handling of lab specimens (these are considered infectious
at all times)
 Respiratory Hygiene and Cough Etiquette (cover the nose/mouth when
coughing/sneezing; use tissues to contain respiratory secretions; dispose
the tissues in the nearest waste disposal; and, then perform hand hygiene)
40
What to do if you have an occupational exposure to blood and/ body fluid

ICM–VII–04 Management of Occupational Exposure to HBV, HCV and HIV
1. I will perform the First Aid :

(a) For percutaneous injuries
 I will wash needle sticks and cuts with soap and water.
 I will apply isopropyl alcohol 70%.
 I will place a bandage appropriately.
(b) For the Mucutaneous and non-intact skin exposures

 I will flush splashes to the nose, mouth, or non-intact skin with
water.
 I will irrigate the eyes with clean or sterile water or saline.
 I will flush site for 10 minutes.
2. Reporting the Injury

(a) I will report the incident to the supervisor and complete a Safety
Reporting System (SRS)
(b.) The report will include:

 The date and time of the incident.
 The location where the incident occurred.
 The department where the employee works.
 The source patient’s Medical Record Number (MRN), if known.
ALWAYS REMEMBER TO REPORT THE INCIDENCE TO:
 Employee Health Clinic during working hours
 Emergency Department (ER) after hours, weekends and holidays
41
What is the shelf life of patient care items and supplies by CSSD?
ICM–IX–01 Sterile Supplies and Equipment Management (Preparation, Storage and Shelf Life)
1. The shelf life for all items processed in CSSD is “event-related” and
are issued with a sterilization date.
2. Sterile packages processes by CSSD that are not used within 4 years
must be returned to CSSD for re-sterilization.
These items or supplies are considered sterile only if integrity of sterile

packs was inspected regularly especially prior to use, and found that the
packages possess no tears, compressions, abrasions, punctures, moisture,
dirt, bending or damage in any way.
ICM–I–05 Reporting Communicable Diseases to the Ministry of Health
The charge nurse will perform the following duties:
1. Confirm the diagnosis of the communicable disease with the MRP in

charge.
2. Verify the diagnosis of a communicable disease on clinical grounds and

confirm with Laboratory results when appropriate.
3. Immediately notify the Infection Control Practitioner (ICP) who covers

that area.
4. Fill out the appropriate form, refer to policy ICM–I–06 Ministry of

Health Forms, and fax to the Infection Control Department (22140),
who will forward the forms to the MOH.
APP 1425–05 Infection Prevention and Control Procedures during Healthcare Facility Construction,
Renovation or Maintenance
1. The IP&C will be pre-informed and involved in all current and

future construction activities at MNGHA healthcare facilities.
2. An Environmental Infection Control Construction/Renovation

PERMIT must be completed and signed prior to the
commencement of any project/task.
3. This PERMIT must be posted on the door of the work site and
copy of the permit must be given by the responsible Engineering
party to the head of the department hosting the construction
work.
42
ICM–IX–02 Waste Management

Waste segregation must be followed at the point of generation (i.e., by the end user):
a. Used to dispose of general hospital waste.

b. Items that would not release (drip) blood or other
Black Bags potentially infectious materials in a liquid or
semi-liquid state if squeezed.
a. Used to dispose of infectious waste.

b. Containers with blood/body fluids that cannot be emptied.
c. All microbiological waste (specimens, cultures, and
stocks of etiologic agents).
d. Items moderately or heavily soaked (dripping) in
Yellow Bags blood or body fluids.
e. Chemotherapy waste.
f. Place infectious waste in the appropriate designated
container, lined with yellow disposal bags.
g. One garbage bin lined with a yellow disposal bag can be kept in the
dirty utility room of non-ICU units or areas.
Red Bags a. Use to transport body parts, organs, or fetuses for

burial.
a. Used to dispose all needles, scalpels, pipettes,

Sharps Containers
syringes, and glass items.
APP 1430–31 Management of Spills of Hazardous Materials

ICM–IX–02 Waste Management
Every employee working with hazardous chemicals/drugs, blood and body fluid
or other potentially infections materials must have the knowledge for proper
handling and best resources for assistance in spill management.
1. Healthcare workers are responsible for the initial cleaning of the blood and
body fluids' spill and small chemical spill (non-toxic).
2. Housekeeping service is responsible for completing the cleaning process.
3. Fire Protection Services is responsible for cleaning chemicals spill.
4. Environmental Services are responsible on the proper disposal of spill
management process residuals through a competent contractor.
Call for assistance if needed e.g., Fire Protection Services including initiating the
call for CODE ORANGE CALL 88
Refer to the Policy to learn more about the management of SPILLS
43
Management of Local/Global Outbreaks

(e.g. MERS-CoV, Ebola)
Refer to the home page on the intranet:
Infection control is EVERYBODY’S BUSINESS

Refer to the Infection Prevention and Control Manual for more details
For more information contact Infection Control Department: ext. 22138/23476
44
GLD Governance, Leadership and Direction
Standards in this chapter are grouped using the following leadership hierarchy (and illustrated below)
LEADERSHIP STRUCTURE AND RESPONSINILTIES
Level 1- Governance
1. The governance structure approves or provides for all of the
Level I: GLD.1 – GLD.1.2 hospital’s programs and policies and allocates resources to meet the
hospital’s mission.
Governance 2. Those responsible for governance approve the hospital’s program
for quality and patient safety and regularly receive and act on
reports of the quality and patient safety program.
Level 11- CHIEF EXECUTIVE OFFICER (CEO)

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

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

Level IV: GLD.8 – GLD.11.2 Department/service leaders
Department/Service Leaders  Recommend space, medical technology,
Clinical Diagnostic Ancillary equipment, staffing, and other resources needed
Pharmacy by the department.
Departments Services Services
Managers of Clinical and Nonclinical  Improve quality and patient safety by participating
in hospital wide improvement
Services
 Priorities and in monitoring and improving patient
care specific to the department/service.
GLD.12 – GLD.19 Hospital leadership establishes a framework for ethical

Culture of Safety management that promotes a culture of ethical practices
Ethics and decision making to ensure that patient care is provided
Health Care Professional Education within business, financial, ethical, and legal norms and
Clinical Research protects patients and their rights.
45
FMS Facility Management and Safety
These standards measure the hospital’s maintenance of a safe, functional, and effective environment for
patients, staff members, and other individuals. Areas addressed include emergency preparedness, security,
safety, life safety, medical equipment, utility systems, hazardous materials, and waste management.
JCI REQUIRED PROGRAMS for FMS STANDARDS

The hospital develops and maintains a written program(s) describing the processes to manage risks to
patients, families, visitors, and staff.
Program oversight includes the following:

1) Safety and Security
1. Planning all aspects of the program
2) Hazardous materials
2. Implementing the program
3) Emergencies
3. Educating staff
4) Fire safety
4. Testing and monitoring the program
5) Medical technology
5. Periodically reviewing and revising the
6) Utility systems
program
6. Providing annual reports to the governing
body on the effectiveness of the program.
These standards
The Safety measure the
Management hospital’s ensures
Department maintenance of a safe,provide
that MNGHA functional,
a safeand
andeffective
healthyenvironment
environmentforby
patients, staffcreative
developing members, and other individuals.
collaborations Areasdepartments,
among various addressed include emergency
committees preparedness,
and individuals, security,
ensuring that
safety, life safety,safety
the healthcare medical
riskequipment,
(pertainingutility systems,
to building, hazardousand
equipment materials,
people) and waste management
are eliminated, . or
minimized
mitigated.
The Safety Management DepartmentMaterial Safety

ensures Data
that NGHASheet (MSDS)
provide Database
a safe and healthy environment by
developing creative collaborations among various departments, committees and individuals, ensuring that
the healthcare safety risk (pertaining to building, equipment and people)
How aretoeliminated,
access MSDSminimized or
Database
mitigated.
1. Open MNGHA Home Page
JOINT COMMISSION REQUIREMENTS
2. Click Regulations
3. Scroll down and locate

MSDS Database
4. Use Search Engine to filter

information according to
your Department
Discuss all you safety concerns with Safety Management Department

Location: MCI Fire Station
Extensions: 23436 / 23423
1. Departmental Email: SafetyManagement-WR <safetyMD@NGHA.MED.SA>
46
2.
Emergency Eyewash
Refer to NGHA Facility Safety Manual
Best Management Practices – American National

Standard Institute (ANSI . Z358.1-1998) :
 Eyewash units must be able to flush both eyes

simultaneously.
 The nozzles must be protected from the airborne
contaminants (e.g. Covers need to be cleaned
weekly).
 No Electrical Appliances within 18 inches or
plastic shield in between.
 The travel distance to the eyewash should be no
more than 50 ft.
 The units must be verified annually by Utility &
Maintenance Department.
 Valves must have a stay open feature (allowing
both hands to be free to open eyelids).
THINGS TO REMEMBER:
 Know the storage requirement of Hazardous Material

such as Alcohol Hand Rub Gel (AHRG) not more than 19
liters.
 Know the 6” inch clearance of wall mounted Alcohol
Hand Rub Gel (AHRG) from electrical outlets.
 Know the clearance of 36” inch in front and side of main
electrical panels.
 Know the clearance from sprinkler heads i.e. 18” inch for
any storage.
 Know the clearance in non-sprinkler areas i.e. 24” inch
for any storage.
 Know the storage limitation of compressed gas cylinders
i.e. less than 300 cubic feet.
 Mandatory Department to contact with before allowing
any construction(i.e. Safety Management, Fire Protection
Services & IPC)
Discuss all your safety concerns with Safety Management Department

Location: MCI Fire Station
Extensions: 23436 / 23423
Departmental Email: SafetyManagement-WR <safetyMD@NGHA.MED.SA>
47
Fire Safety
APP 1428–21 Hospital Fire Safety Program
When you discover a fire

JUST REMEMBER
CODE RED PROCEDURES FIRE EXTINGUISHER PROCEDURE
R Rescue patient in area of immediate hazard

P Pull out the safety pin
A Activate the Alarm – alert others and call 88 A Aim nozzle at the base of the fire
C Contain fire and smoke, ClOSE all doors S Squeeze the operating lever and handle
E Extinguish the fire if you can without endangering S Sweep over the fire
yourself
Remember: Always use proper type of extinguisher to fight fire
- HALON & DRY POWDER : CLASS "A","B" & “C" Class A: Solid or ordinary combustible
materials
- CO2 : CLASS "B" & "C" Class B: Flammable liquids and gases
Class C: Involving energized electrical
- WATER : CLASS "A" ONLY equipment
1. Ensure that your department/ward practices good housekeeping.

2. Observe
Report any faulty effective Fire safety and Fire prevention measures:
equipment.
3. Store flammable/combustible items properly.
4. Ensure that staff are aware of the procedures for safe handling of such items.
5. Ensure that staff are aware of the evacuation route(s) and assembly point of the
department/ward.
6. Know where your fire extinguishers are and how to operate them.
7. Familiarize yourself with the safety manual and attend regularly Fire safety drills & Fire safety in-
service training.
8. Always treat a spilled substance as hazardous until identified as non-hazardous by proper
authority.
9. Be aware of the Hazardous material spill procedure (by Fire Department).
48
Safety and Security System for Newborn

APP 1429–08 Safety and Security System for Newborns
The purpose of this APP is to identify areas and conditions where newborns are exposed to the risk of
abduction, and implement security measures that prevent abduction of newborns. All staff in the clinical
areas must be aware and uphold the provisions for visitors by allowing no more than two visitors at any
given time. All babies shall be transported in the hospital & discharge by a Nurse.
1. The Program endeavors to provide preventive and security measures that shall be implemented
24 hours/7 days to protect newborns from abduction.
2. All staff in the clinical areas must be aware and uphold the provisions for visitors, that is,
allowing two visitors at one time.
3. Abduction Prevention Team shall be established in each facility to develop, implement and
evaluate all quality improvement strategies, including education on neonatal / infant abduction.
4. Education programs shall be provided for patients and employees.
5. All women in the Obstetrics and Neonatal areas will receive education on risk reduction
strategies, which include patients in the Obstetrics Clinic.
6. All babies shall be transported in the Hospital and discharged by a Nurse.
7. Military Police / Security personnel shall guarantee the function of the security system
implemented and assure the presence and quality of work of the required security system and
military personnel around the clock.
8. RFID (Radio Frequency Identification) system will be implemented in all the areas where medical
care is provided to in-patient newborns and babies born in the Emergency Care Centre at any
hospital/healthcare facilities of NGHA.
Emergency Codes
APP 1428–16 Emergency Coding System
Code Incident Ext.
Code Red Fire 88
Code Blue Adult Cardiopulmonary Arrest 77
Pediatric Code Blue Pediatric Cardiopulmonary Arrest 77
CCRT Activation Hemodynamic Instability or respiratory compromise 77
Code Yellow Infant / Child is missing or is known to have been kidnapped 77
Code Gray Security Threat 77

Hazardous materials / spill emergency or biological agent
Code Orange 88
threat
Single or multiple trauma victims (does not require disaster
Trauma Team Activation 77
activation)
Code Black Disaster 77
Extreme shortage of bed capacity in the Emergency
Bed Crisis 0
Department
49
SQE STAFF QUALIFICATIONS AND EDUCATION
This chapter includes sections on human resources planning; staff orientation, training, and education; staff
competence assessments; handling staff requests; and credentialing and privileging of licensed independent
practitioners, nurses, and other practitioners.
APP 1427–02 Employee Personnel File
1. This APP applies to the personnel files/records of all employees hired by the Program at the Ministry
of National Guard Health Affairs (MNGHA) and affiliated facilities including the King Saud Bin
Abdulaziz University for Health Sciences (KSAU-HS) and King Abdullah International Medical
Research Center (KAIMRC).
JCI REQUIREMENTS FOR SQE

1. Personnel files must:
 Contain the qualifications of the staff member.
 Contain the job description of the staff member when applicable.
 Contain the work history of the staff member.
 Contain the results of evaluations (Probation and Annual Evaluation)
 Contain a record of in-service education attended by the staff member.
 Contain a proof of cardiac life support training for those staff who provide patient
care.
 Contain a proof of education, licensure/registration, and other credentials issued by
recognized education entities and verified from the original source that issued the
credential.(PSV)
 Standardized and current and maintained according to hospital policy.
New Requirement from the JCI 5Th Edition (SQE 8.2)
A hospital’s staff health and SAFETY PROGRAM is important to maintain staff physical and mental health,
satisfaction, productivity, and safe conditions for work. Staff health and safety must be a part of the
hospital’s quality and patient safety program.
1. The hospital identifies areas for potential workplace violence

and implements measures to reduce the risk.
2. The hospital provides evaluation, counseling, and follow-up

treatment of staff who are injured as a result of workplace
violence.
50
MOI MANAGEMENT OF INFORMATION
Formerly named Management of Communication and Information (MCI), these standards have been
focused to address how well the hospital obtains, manages, and uses information to provide, coordinate, and
integrate services.
APP 1430–10 Clinical Record Content & Documentation Standards
Physicians Documentation- Write it Right
 Write Legibly
 Use Black Ball Point Pen
 Gregorian Date: (dd/mm/yy)
 Time: Use 24 hr clock e.g. (1300 for 1 pm)
 The heading of all Physician entries should include the
Date, Time, Physician’s Name and Title (Intern, Resident,
Consultant etc)
 Documentation is co-signed by the Supervisor if the
author is a trainee.
The tail of Physician entries should include Signature, Name,
Badge Number, and Beeper. Physicians should include their
stamp when applicable.
Cross It Right
1. Cross out wrong entries with a single horizontal

line.
2. Write “Error” next to it.
3. Put your initials beside it.
Do Not Use
 Error-prone abbreviations, symbols, and dose designations (Refer to APP 1427–16 Error–Prone
Abbreviations, Symbols, and Dose Designations)
 Unapproved Abbreviations (Refer to APP 1430–10 Clinical Record Content &
Documentation Standards for the list of approved abbreviations)
51
MPE Medical Professional Education
These standards address how the academic medical center hospital educates, supervises, grants privileges,
and otherwise incorporates its medical students and trainees into its care processes and other daily
operations.
SAUDI COUNCIL RESIDENCY TRAINING PROGRAM
Residency Training Programs at KSAU-HS are designed to provide residents with an opportunity for the
incremental acquisition of knowledge, skills and responsibilities which will enable them proficiently to
practice medicine in their given specialties. KSAU-HS Residency Programs enjoy a reputation among the
local community for having outstanding training programs, because it starts with outstanding individuals,
who are driven to success and eventually become Saudi Board and/or Arab Board Certified.
JCI REQUIREMENTS FOR MEDICAL EDUCATION

DPP 7800-01-162 Supervision of Residents and Fellows
1. Those responsible for governance and leadership of the hospital approve and monitor the
participation of the hospital in providing medical education.
2. The hospital’s clinical staff, patient population, technology, and facility are consistent with the goals
and objectives of the education program.
3. Clinical teaching staff are identified, and each staff member’s role and relationship to the academic
institution is defined.
4. The hospital understands and provides the required frequency and intensity of medical supervision
for each type and level of medical student and trainee.
5. Medical students and trainees comply with all hospital policies and procedures, and all care is
provided within the quality and patient safety parameters of the hospital.
6. Medical trainees who provide care or services within the hospital—outside of the parameters of their
academic program—are granted permission to provide those services through the hospital’s
established credentialing, privileging, job specification, or other relevant processes.
Orientation for Medical Students must include the following:
a) Hospital quality and patient safety program

b) Infection control program
c) Medication safety program
d) International Patient Safety Goals;
e) All other required hospital orientation, including at the
department and unit level and
f) any ongoing required education
52
HRP Human Subject Research Program
Mission:
To generate cutting-edge scientific research that helps improve the health of the population.
Vision:
To be a leading international institution in biomedical and clinical research.
JOINT COMMSSION STANDARDS
1. Hospital leadership is accountable for the protection of human research subjects.

2. Hospital leadership establishes the scope of research activities.
3. Hospital leadership establishes requirements for sponsors of research to ensure their
commitment to the conduct of ethical research.
4. Hospital leadership creates or contracts for a process to provide the initial and ongoing
review of all human subjects’ research.
5. The hospital identifies and manages conflicts of interest with research conducted at the
hospital.
6. The hospital integrates the human subjects research program into the quality and patient
safety program of the hospital.
7. The hospital establishes and implements an informed consent process that enables patients to
make informed and voluntary decisions about participating in clinical research, clinical
investigations, or clinical trials.
APP 1419–005: Preparation of Research Proposal, Processing and Approval
The organization supports research programs for the advancement of knowledge in health sciences
and endeavors to maintain high quality level of health / medical researches through KAIMRC. All
proposed studies must be in compliance with the rules and regulations of the Kingdom of Saudi
Arabia, the institutional regulations of KAIMRC / MNGHA, and GCP.
APP 1426–02: Institutional Review Board (IRB) Policy and Procedures
Institutional Review Board (IRB) refers to an independent body constituted of medical, scientific,
and non-scientific members, whose responsibility is to ensure the protection of the rights, safety
and well-being of human subjects involved in a trial by, among other things, reviewing, approving,
and providing the continuing review of research study protocol and amendments, and of the
methods and material used in obtaining and documenting informed consent of trial subjects.
APP 1432–20: Monitoring Research Studies
This APP describes the policy and applicable procedures for monitoring approved research studies to
ensure that they have been executed in compliance with the approved study proposal, ICH/GCP
guidelines, King Abdullah International Medical Research Center (KAIMRC) and other requirements
from the regulatory authorities.
53
JCI Requirements on Informed Consent
1. The hospital establishes and implements an informed consent process that enables patients to make
informed and voluntary decisions about participating in clinical research, clinical investigations, or
clinical trials.
2. A hospital that conducts clinical research, clinical investigations, or clinical trials involving patients
knows that its first responsibility is to patients’ health and well-being.
The information provided during the informed consent process includes
 an explanation of the research, duration of patient participation, and

procedures to be followed by patients;
 expected benefits;
 potential discomforts and risks;
 alternative treatments and procedures that might also be beneficial;
 extent to which confidentiality of records will be maintained;
 compensation or medical treatments available if injury occurs;
 a statement that participation is voluntary; and
 assurance that refusal to participate or withdrawal from participation
will not compromise care or access to the hospital’s services; and who to
contact with questions about the research.
What will happen in Academic Medical Center Hospitals where patient tracers will include patients on a
research protocol?
The discussion for Research may include the following:
1. How staff were trained on the protocol.

2. How patients on research protocols were identified.
3. What staff understand about the informed consent process. Review HRP
4. What happens when a patient asks to leave the study. Standards
5. The process when a protocol has changed. and Policies
6. If a protocol changes, how patients are re-enrolled and sign another
consent.
7. The process when an adverse event occurs.
54

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MINISTRY OF NATIONAL GUARD HEALTH AFFAIRS

King Abdulaziz Medical City - Jeddah

JCI Survey 2015

Dr. Bandar Al Knawy, MD, FRCPC

Chief Executive Officer, Ministry of National Guard Health Affairs

MINISTRY OF NATIONAL GUARD HEALTH AFFAIRS

THE JCI SURVEY OVERVIEW

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

What are the primary objectives of tracer activities?

4. Identify potential concerns in the relevant processes.

Who will participate during Tracer Activity?

What will occur during Tracer activity?

3. Discussion of data use in individual departments/services. (NEW REQUIREMENT)

4. Review of emergency equipment, supplies, and processes.

DURING THE HOSPITAL SURVEY

ACCREDITATION PREPARATION REQUIREMENTS

NEW JCI STANDARD (APR.9)

1. Any hospital staff member (clinical or administrative) shall report

2. If there is no Corrective Action at the hospital level, staff can report

What to report to JCI What NOT to report to JCI

Concerns about patient safety and

HOW TO REPORT TO JCI

NEW JCI STANDARD (APR.11)

Patient Relations Department

To contact JCI office visit their website

IPSG INTERNATIONAL PATIENT SAFETY GOALS

THE INTENT OF THIS GOAL IS TWO FOLD:

2. MUST NEVER use patient’s room or location to identify patient.

You should always check the “two identifiers” from:

ALWAYS ask the patient/guardian/parent to verbalize patient’s name if possible.

Improve Effective Communication

When receiving a telephone order from a Physician:

2.1 APP 1426–06 Reporting Critical Laboratory Values

Read back procedure for the receipt of laboratory or radiology results:

The hospital develops and implements a process for handover communication.

Handovers of patient care within a hospital occur:

Improve the Safety of High-Alert Medications

1. Standardized auxiliary labels will be used for high alert medications.

3. Independent double check procedure must be completed without distractions or

5. Segregate them to reduce the risk of error.

Healthcare providers will adhere to the following:

Improve the Safety of High-Alert Medications

APP 1433–18 Concentrated Electrolytes

Concentrated electrolytes will be:

1. Stored and kept in a locked cabinet, with

2. Separated from other medications and

3. Labeled with “High Alert

Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

Surgical and invasive procedure site marking

 Ensure that documents, imaging and test results,

 Proper handover is done in the preoperative area

PAUSE WITH A PURPOSE

“SAFE SURGERY SAVES LIVES”

Reduce the Risk of Health Care–Associated Infections

Clean Hands Save Lives

5 Moments for Hand Hygiene:

Limitation of alcohol based hand rub (ABHR):

Using alcohol-based sanitizers

* Note: Always be AWARE of your unit’s hand hygiene compliance rate.