Prince Sultan Military Medical City Universal Healthcare Provider JCI Accreditation Preparation Awareness Manual

Transcription

1 Prince Sultan Military Medical City Universal Healthcare Provider JCI Accreditation Preparation Awareness Manual Facilitated by Continuous Quality and Patient Safety Department In coordination with JCI Accreditation Chapter Committees

2 Table of Contents I Introduction 3 II PSMMC Mission and Vision.. 3 III JCI Accreditation standards, Accreditation Preparation, Survey Process and Scoring What is JCI? Joint Commission International Standards What Is a Standard? Types of Expectations in Standards IV How to talk to a JCI Surveyor? V Joint Commission International Accreditation for Hosp. Standards, 5 th Ed., April VI Applying JCI Standards to PSMMC Services P a g e

3 I Introduction: This manual is intended to provide an overview of the basic knowledge required by any healthcare provider to practice within PSMMC in accordance with the Joint Commission International Accreditation (JCIA). All healthcare providers including; doctors, nurses, pharmacists and technicians are required to read, understand and abide by the content of this manual. Certain departments i.e. medical laboratory and radiology department have additional policies that staff working there must be fully aware of and abide with. This manual is based on PSMMC hospital policies and procedures and does not substitute approved policies and procedures. This is for the end-user s awareness purposes only. If any conflict is found between this manual and an updated PSMMC policy or procedure, the conflict will be overruled by the updated approved policy and procedure. II Prince Sultan Military Medical City Mission: PSMMC Management is committed in providing the best expectations; full commitment to the Principles of Continuous Quality Improvement; providing the optimum support to all employees through effective training; improving the management operations efficiency; and to ensure a continuous improvement work culture. Vision: Prince Sultan Military Medical City is inspired to be the premier hospital in providing the highest standards of healthcare services for its patients, to be the benchmarked hospital in the kingdom, and to achieve Excellency in all specialties in the Middle East. III JCI Accreditation standards, Accreditation Preparation, Survey Process and Scoring What is JCI? Joint Commission International (JCI) is the international arm of The Joint Commission (USA) that surveys and accredits Health Care Institutions. JCI Accreditation: Determined by the JCI surveyors whether the healthcare organization complies with standard requirements set (by JCI) with respect to local laws, rules and regulations. Joint Commission International Standards Focus on the patient Set optimum, achievable expectations Designed to be interpreted/surveyed within the local culture and legal framework Stimulate continuous improvement

4 What Is a Standard? A statement that defines the performance expectations, structures, or processes that must be in place in an organization to provide safe and high quality care, treatment, and services. Types of Expectations in Standards: Inputs (Structures): Resource Processes: Activities Outcomes: Results IV How to talk to a JCIA Surveyor? Useful tips in responding to surveyor questions: a) Take note that all JCI Surveyors are HIGHLY EXPERIENCED in patient and staff safety in clinical, organizational/administrative and facility management fields. b) The surveyors are FOCUSED ON PATIENT SAFETY through observation of our PSMMC Policies, Plans, Programs and Regulations. c) Surveyors look into how PSMMC Policies, Systems and Programs are being implemented and complied with and documented evidence. d) Surveyors do not look into individual errors. They basically facilitate PSMMC to determine strengths and areas of improvement. e) They are SEEKING EVIDENCE OF COMPLIANCE to elements of performance and standards based on the JCI Accreditation for Hospital standards Manual. f) They are here to evaluate us based on our policies abiding to JCI Standards. g) They are in search for documented evidence of quality processes and to assess for variation to process and to identify system issues. h) DO NOT ATTEMPT, JUDGE OR TRY TO OUTSMART THE SURVEYOR. The surveyor's questions cover all priority Issues and Focus Areas: Organizational Structure and Ethics Patient Safety Culture Efficient Patient Care Flow Assessment and Care of Patient Infection Control Practices Quality Improvement and Perf. Measurement Patient Education Medication Management Communication and Documentation Credentialing and privileging Staffing, Orientation and Training Patient s Rights Use of equipment Physical Environment Safety and Security DO s and DON T s when answering the Surveyors: Maintain level of Professionalism at all times. Be relaxed when answering the JCI Surveyors enquiries and maintain eye contact and demonstrate confidence and pride. Do not rush to answer. Take your time and think. Always make sure you understand the question before you answer. Ask for clarification if you are not sure. Remember, the survey process is based on PSMMC policies, programs, plans, systems, etc. If the enquiry is related to PSMMC staff practices, policies, processes, programs, and systems, answering must start with; 4 P a g e

5 According to our Policy.., the process is/are.. or According to my Job Description,... By answering in this manner, we will be able to express our standardized processes in a unified manner to our surveyors. NEVER begin to answer with the following words; USUALLY, MOST OF THE TIME OR SOMETIMES If you don t know the answer, tell them you do not and refer them to someone who knows such as your supervisor/department Head. I may have an answer to your enquiry but to make sure, may I refer you to my Supervisor/Department Head. Keep your answers focused and specific to the question they ask. Don t give more information than what is being asked for. If the question requires only a YES/NO answer only, do not volunteer for further explanation. If they ask for explanation/examples, then that would be the time you should respond with what you know according to our PSMMC Approved Policies, Procedures, Plans and Programs. Policies, Evidence of Compliance or specific documents must be well-organized and prepared and must be READILY AVAILABLE to the JCI Surveyors when needed. YOU must be fully aware how to locate PSMMC Policies/Plans in your department or in the Intranet. Remember that anytime you say WE the surveyor will expect that you are referring to ALL OF PSMMC. Don t discuss your personal issues with them. This is not the time to ask answers to your personal issues or discuss problems.

6 V Joint Commission International for Hospital Standards 5 th Edition, April 2014 SECTION I: Accreditation Participation Requirements Accreditation Participation Requirements (APR) SECTION II: Patient-Centered Standards International Patient Safety Goals (IPSGs) Access to Care and Continuity of Care (ACC) Patient and Family Rights (PFR) Assessment of Patients (AOP) Care of Patients (COP) Anesthesia and Surgical Care (ASC) Medication Management and Use (MMU) Patient and Family Education (PFE) SECTION III: Health Care Organization and Management Standards Quality Improvement and Patient Safety (QPS) Prevention and Control of Infections (PCI) Governance, Leadership, and Direction (GLD) Facility Management and Safety (FMS) Staff Qualifications and Education (SQE) Management of Information (MOI) Section IV: Academic Medical Center Hospital Standards Medical Professional Education (MPE) Human Subjects Research Programs (HRP) Standards Content: Each JCI standard contains three components: The standard represents the principle The intent describes the rationale of the standard The measurable elements are the detailed requirements from the standard and intent that are scored Hospital Standards and Requirements: 316 Standards* and 1,218 Measurable Elements* Required compliance with all International Patient Safety Goals At least five clinical measurements have to be selected from JCI s Library of Measures. Scoring of Lists in Statements: Note that there are two ways the lists in the Statements are scored. Lists that are designated by letters (e.g. a h) or numbers (e.g. 1 11) are mandatory. Lists that are marked by bullet points ( * ) are advisory in nature. 6 P a g e

7 The mandatory elements are reflected in the Measurable Elements and full compliance with them is required. The bulleted elements are not scored as such, but ignoring them completely will lead surveyors to drill down and ask what else was considered in compliance with the standard. SCORING THE SURVEY RESULTS: Each Measurable Element (ME) is scored Met (9-10) Partially Met (5-8) Not Met (0-4) ACCREDITATION DECISION RULES: Each Standard must have a score of at least 5 Each Chapter must have a score of at least 8 All standards together must average at least 9 NO MEASURABLE ELEMENT in the IPSG is scored NOT MET. DENIED ACCREDITATION RULES: One or more standard is scored less than a 5. The aggregate score of one or more chapter of standards is less than a 8. The aggregate score for all standards is less than 9.

8 VI Applying JCIA Standards to PSMMC Services Patient-Centered Standards International Patient Safety Goals (IPSG) IPSG.1 IDENTIFY PATIENTS CORRECTLY: To reliably identify the individual as the person for whom the service or treatment is intended; To match the service or treatment to that individual. What is the process of correctly identifying the patient in PSMMC? Patient s should be identified using two patient identifiers, which includes the; Patients Three Full Names Medical Record Number Caution Never use the patient s room number or location as a means of identification When correct patient identification must be used? Before providing treatments, performing procedures or any diagnostic procedures. Treatment, service or medical/surgical intervention will not take place if the patient cannot be identified except in life threatening situations. All healthcare providers must ensure that all forms they fill and any specimen collected must be labeled with patient full (3) names and medical record number. Related Policy for correct identification of patient: Patient Identification Policy ( ) IPSG.2 IMPROVE EFFECTIVE COMMUNICATION: Effective communication reduces errors and results in improved patient safety. A formal reporting system that clearly identifies how critical results of diagnostic tests are communicated to health care practitioners and how the information is documented to reduce patient risks What is process for Telephone/Verbal Orders and when receiving Critical Values Result? For verbal/telephone orders or telephone receiving critical values/test results, verify the complete order or test results by: Writing it down Reading it back Confirming the result or order and documented in the patients record 8 P a g e

9 For Telephone Orders, responsible physicians requires to sign within 24 hours For Verbal Orders, physicians require signing after situation is over or before physician leave the area. Verbal communication of orders should be limited to urgent situations where immediate written or electronic communication is not feasible. Verbal / Telephone orders WILL NOT be accepted for the following events; Physical Restraints Starting Patient Controlled Analgesia (PCA) Starting Narcotic or Scheduled Medications Initiating TPN Therapy Category of Care (DNR/Code Status) Withdrawal of Life Support Chemotherapy Ordering Related Policies for Telephone/Verbal Orders and when receiving Critical Values Result Reporting: Reporting and Documentation of Verbal and Telephone Orders Policy ( ) Laboratory Critical Test and Critical Result Reporting Policy ( ) Radiology Critical Test and Critical Result Reporting Policy ( ) What is the process for patient handovers? A communication approach (ISBAR format) to hand-off patient information will be used under the following circumstances in order to improve the effectiveness of communication : Transfer of patient-specific information Staff-to-Staff (i.e., nurse-to-nurse) interaction about a patient-specific information Handover of patients should follow the I-SBAR tool. Content example when using ISBAR during patient transfer (for full details, kindly refer to the Hand-off / Hand-over Communication I-SBAR Communication Tool Policy ( )) Introduction : patient name, age, gender, MRN, service, date of admission, height/weight, transferring unit, Situation : chief complaint, reason for admission, diagnosis, medical, surgical, estimated blood loss, Background : medical and surgical history, prosthesis, previous tests/procedures/treatments/ medications Assessment : systems assessment, response to treatments, vital signs, ongoing treatments, IV s, pain mgt. Recommendation: daily goals, sedation interruption, care pathway, ramsay sedation scale, new medication/treatment Related Policy for patient hand-off/hand-over; Hand-off / Hand-over Communication I-SBAR Communication Tool Policy ( ) IPSG.3 IMPROVE THE SAFETY OF HIGH-ALERT MEDICATIONS: To manage and reduce or to eliminate occurrences that is caused by or likely to be caused by an inadvertent administration of high-alert medications. What is your process to ensure safe identification, storage, preparation and dispensing of High Alert Medications (HAM)? IDENTIFICATION: PSMMC has developed an approved list of high alert medication. STORAGE:

10 All high alert medication shall be stored in secured cabinets and clearly labeled. Concentrated electrolytes are stored ONLY an in area that requires it with appropriate labeling. Storage bins for HAM based on its strengths shall be segregated. Look-alike and Sound-Alike (LASA) medications are recommended to have Tall Man letters over the medication storage. PREPARATION and DISPENSING: Responsible pharmacists (of at least two) will have a verification process that will ensure that the HAM prescription and dispensing is in accordance to pharmacy policies. What is the process of ensuring safe Administration of High-Alert Medication? When administering high alert medication, Two (2) nurses must be present to complete medication verification and ensure to follow the six patient rights in medication administration. Related Policies for Ensuring the Safety of High Alert Medications Prescription, Storage, Labeling, Preparation and Administration; High Alert Medications Policy ( ) Medication Administration Policy ( ) Look Alike Sound Alike (LASA) Medications Policy ( ) 6 RIGHTS OF MEDICATION ADMINISTRATION Right Patient Right Medication/Drug Right Dose Right Route Right Time Right Documentation IPSG.4 ENSURE CORRECT-SITE, CORRECT-PROCEDURE, CORRECT-PATIENT SURGERY: To ensure that the patient undergoing surgery or procedure that requires verification process is verified appropriately pre-surgery / procedure. Time-out will be utilized just before starting the procedure. Who performs the surgical site marking in your unit? The physician in-charge of the patient has the over-all responsibility and must be marked by an arrow ( ) on the appropriate site. Any delegated health practitioner (medical member of the surgical or procedural team) delegated to mark the site must be sufficiently competent and knowledgeable about the patient s case. What is the nursing responsibility in ensuring the correct patient prior to procedures or surgery? Staff completes pre-verification process checklist (Surgical Safety Checklist) prior to sending the patient to the designated procedure area (OR, Cath-Lab, etc.) Staff completes patient endorsement/handover to relevant area ensuring verification procedure utilizing the checklist. 10 P a g e Time-Out components 1. Correct patient identification, 2. Correct side and site, 3. Proper agreement of the procedure to be done, 4. Confirmation that the verification process has been completed.

11 When does the Time-out conducted? Immediately prior to the procedure or first skin incision. All activities should be STOPPED and all members of the surgical/procedural team should fully participate in the TIME-OUT. Related Policies for Ensuring Correct-Site, Correct-Procedure, Correct-Patient Surgery Correct Patient, Correct Procedure and Correct Surgery Policy ( ) Operating Room Surgical Safety Checklist (MSD Form Stock # ) Safety Checklist (Time-out) for Non Operating Room (MSD Form Stock # ) Informed Consent Policy ( ) IPSG.5 REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTIONS To reduce or eliminate Healthcare Associated Infections (HAI s) through scientific evidence-based implementation of Hand Hygiene guideline (CDC and WHO). What is the process in your department/unit to reduce HAI s? Use of an alcohol based hand rub from patient-to-patient contact, handshake encounters in the clinical area. Washing of hands with water and soap shall be required in the following situations: Hands are visibly dirty or visibly soiled with blood or other body fluid. When contact with patients having or is strongly suspected for spore forming organisms e.g. clostridium difficile After using the toilet When do you perform Hand Hygiene Practices? All health care providers must adhere to PSMMC hand hygiene practices during the following moments: Before touching a patient After touching a patient Before clean/aseptic procedure After body fluid exposure After touching patient surroundings Related Policy for Reduce the Risk of Health Care Associated Infections Hand Hygiene Policy ( ) WHO Hand Hygiene Posters IPSG.6 REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS: The hospital establishes a fall-risk reduction program based on appropriate policies and/or procedures. The program monitors both the intended and unintended consequences of measures taken to reduce falls What is the role of healthcare providers in implementing fall-risk reduction program? Nurses must ensure that all patients are assessed for risk of falls using the official PSMMC fall risk assessment tool. When a patient is found to be at risk of falls, the healthcare

12 providers must ensure that fall preventions interventions (as mentioned in the fall risk assessment tool) are fully implemented. When is fall risk assessment/reassessment conducted/done? ASSESSMENT: Upon patient admission in the unit/department. REASSESSMENT: Transfer of patient from one unit to another within the facility Any changes in patients status/condition Following a fall What your responsibility as a staff upon witnessing a patient fall in your unit? Any health care worker that witness a patient fall or near fall must attend to the patient and ensure to provide a safe environment for the patient. Ensure that the incident is reported using the PSMMC incident reporting system. Related Policy for Reducing the Risk of Patient Harm Resulting from Fall: Fall Prevention and Management Policy ( ) Fall Assessment Tool (Adult) Morse Fall Scale (MSD Form Stock # ) Fall Prevention Intervention Checklist Adult (MSD Form Stock # ) Fall Assessment Tool (Pediatrics) Humpty Dumpty (MSD Form Stock # ) Approved Fall Prevention Intervention Checklist Pediatrics (MSD Form Stock # ) Access to Care and Continuity of Care (ACC) ACC.1 SCREENING FOR ADMISSION TO THE HOSPITAL To match patient s needs with the hospital s mission and resources. Obtaining information from patient s and identify his/her needs and condition through screening, usually at the point of first contact. What is the screening process implemented in PSMMC ED? All patients presenting to the A&E must be triaged by the triage physician using the Canadian Triage System and the results of the triage is documented in the patients medical record. Patients should receive the care as designated by the triage category. ACC.2 ADMISSION TO THE HOSPITAL The process addresses the registration for outpatient services or admission for inpatient services; Admission directly from the emergency service to an inpatient unit; and the process for holding patients for observation. How are patients accepted for inpatient admission or outpatient care at PSMMC? Patients are accepted based on the criteria (emergency and Elective Admissions) indicated in the Admission Policy. Admission criteria for specialized units: All patient being admitted to critical care units and the burn unit must meet the admission and discharge criteria for the designated unit 12 P a g e

13 All staff working in such units must be aware of such criteria What information should the patient receive upon admission? All patients being admitted to PSMMC must receive information about the proposed care, which includes the expected outcomes of the care provided. It is the responsibility of the main responsible physician to ensure that such information is provided to the patient in a language that the patient can understand. What is the process if there would be delays in inpatient admission (due to nonavailability of bed in the units/department floors or delay of tests results)? Strategies will be initiated by the Most Responsible Physician in the emergency Department where patient will be notified for the reason of such delay (and also for waiting periods for diagnostic and/or treatment) and on how to manage patient admission effectively. Reducing avoidable admissions effectively Shortening emergency department length of stay appropriately ED census assessment will be conducted each shift, noon and midnight daily. In the event that all strategies have been exhausted and volume of ED patients exceeds ED bed capacity and inpatients bed are fully occupied, patients will be referred to another healthcare facility. Who shall be the individual most responsible for patient s care when patient is admitted? Main Responsible Physician (MRP) would be responsible for admitted patients in their care and service (Continuity of Care) that; will be the admitting consultant. coordinates the patient s care and is identified in the patient's record and available through all phases of inpatient care. when transferring the care of an inpatient from on physician to another, the transfer process must adhere to hospitalwide Transfer Policy ( ) and be documented in the patient transfer form. ACC.3 CONTINUITY OF CARE Primary source of patient record/information should be made available during patient care. Leaders of the departments and services work together to design and to implement the processes of care coordination and continuity. Individuals may coordinate all patient care (for example, between departments) or may be responsible for coordinating the care of individual patients (for example, case manager). How is patient continuity of care ensured in PSMMC? PSMMC have designed to implement a process to ensure continuity of care and coordination of patient needed treatments and services carried out by physicians, nurses and other healthcare practitioners. Services coordinated are as follows; Inpatient admission and emergency services Laboratory and radiologic diagnostic services and/or treatment services;

14 Surgical and nonsurgical treatment services; Outpatient care services How is the Care of Patient and Continuity of Care is coordinated in PSMMC? Multidisciplinary care is coordinated in PSMMC led by the Main Responsible Physician effectively and efficiently based on the patient needs. Care of patient Tests (Laboratory, Radiology, etc...) Timely referrals and/or discharge Patient health status awareness and instructions ACC DISCHARGE, REFERRAL, AND FOLLOW-UP ensure that the patient have the right to refuse medical treatment or leave the hospital against medical advice. in addition, medical risks involved for such actions must be thoroughly explained and efforts should be made by the physician explaining the treatment plan to keep the patient in the hospital. What is the process for transferring patients within (Internal) PSMMC? The referring physician/team is responsible for assessing the fitness of the patient for transfer. The referring team/physician should determine the appropriate responsible staff during transfer and what supplies and equipment are required during transport MRP will call the accepting team and hand over the patient MRP will fill the in-patient transfer form that must be signed by the transferring physician and the accepting physician. The MRP shall write a transfer order in the physician order sheet. The transferring ward nurse shall make all the necessary arraignments for the transfer of the patient as described in HWP Transfer of Infected Patients: It is the responsibility of the ward staff to inform the accepting ward and ambulance/transport staff of the patient s infection status and the medical staff to inform the receiving physician or team. The information shall include actual and potential risks of infection and any clinical practice required to control or prevent infection. The accepting ward/hospital shall be advised of precaution or treatment needed in the management of known infection risks to individuals. For certain infections, the infection control team will communicate with their colleague at the receiving hospital to ensure continuity of infection control precautions. Transfer of critical patients GICU, PICU, NICU: Refer to department specific high risk transfer acceptance criteria and protocols. When do physicians initiate Discharge Planning? Upon patient is admitted in the inpatient units. 14 P a g e

15 What is the process for discharging a patient in the unit/department floor? The main responsible physician is the only authorized person to discharge the patient after he/she determines that the patient is fit for discharge. Upon discharging any in-patient, the main responsible physician must complete the discharge summary (using PSMMC discharge summary form) which contains the following; Reason for admission, diagnoses, and co-morbidities Significant physical and other findings Diagnostic and therapeutic procedures performed Medications administered during hospitalization with the potential for residual effects after the medication has been discontinued and all medications to be taken at home. The patient s condition/status at the time of discharge (examples include condition improved, condition unchanged, and the like) Follow-up instructions The patient must be provided with a copy of the discharge summary that includes follow up instructions. A copy of the discharge summary must be kept in the patients file. Upon his/her request the patient will be given a copy of the discharge summary How do you manage and follow-up patients who Leave Against Medical Advices? REGULAR WORKING HOURS: The nurse must notify the consultant in-charge, nursing supervisor, head nurse and charge nurse. OUTSIDE REGULAR WORKING HOURS: The nurse must notify the resident on-call and nursing supervisor The responsible physician explains the consequences to the patient/family if the patient insists to leave the hospital against medical advice. The patient or legal guardian of the patient must sign the discharge against medical advice form provided. Patient will be given discharge summary including medications with instruction. Related Policies for Access to Care and Continuity of Care standards: Transfer Policy ( ) Leave Against Medical Advice(LAMA) ( ) Discharge Policy ( ) Patient Referral ( ) Outpatients Clinical Summary ( ) ACC TRANSFER OF PATIENTS Transferring a patient to an outside organization is based on the patient s status and need for continuing health care services. This may be in response to a patient s need for specialized consultation and treatment, urgent services, or lessintensive services, such as sub-acute care or longer-term rehabilitation. To ensure continuity of care, patient information is transferred with the patient. A copy of the discharge summary or other written clinical summary is provided to the receiving organization with the patient. What is the process for transferring patients to other hospitals (External)? The transferring MRP shall fill a transfer form and coordinate with patient affairs

16 Patient affaires shall send fax of medical transfer report requesting beds to other hospitals in collaboration with the treating and transferring physician. Patient affairs shall send a medical report to accepting hospital in coordination with the transferring physician. Patient affaires shall ensure that bed booked is confirmed by the receiving hospital. Transport process shall be according to Hospitalwide Policy. What is the process of Out-on-Pass if a patient wants to go home for couple of days? Written approval from the attending doctor should be obtained (completed Out-On- Pass Form) and must be restricted to a maximum of twenty-four (24) hours only and IV cannula (if present) shall be removed before patient leaves the hospital premises. Patient must take sufficient medications with them during the Out-On-Pass period. Admission office will be notified by the responsible nurses for the purpose of updating the bed state of the hospital. What is the process if a patient does not come back following an Out-On-Pass deadline? Patients on Out-On-Pass will be discharged from the hospital system if the patient did not yet return to the ward at 10:00PM. Admission office will then be notified eventually by the responsible nurse of the vacant bed availability and ready for new patient occupancy. What is the process to know the concurrent condition of patients who have multiple visits in PSMMC? Clinical Summary must be initiated and available for all patients with medical problems and have multiple scheduled hospital visits. The clinical summary form must be updated every six (6) months or if there is a change in the patient s condition and documented in patient s medical record. It is the responsibility of the last physician seeing the patient in the clinic to ensure that the clinical summary form is updated. Do you have a process for providing Patient s transportation needs? Patient transportation must be requested by the treating physician except during emergency cases. Transportation needs assessment will be performed by the treating physician for any patient that will be transferred internally or externally. Patient transportation needs is based on two (2) categories, UNPLANNED and PLANNED UNPLANNED (24 Hours Service) Emergency Emergency Critical Care Transfers Urgent (High Dependency) Disaster Response PLANNED: Routine 16 P a g e

17 What is the process of requesting Patient Transportation? EMERGENCY: Patient transportation request will then be communicated to the Ambulance Dispatcher (Senior Crew) EMERGENCY CRITICAL CARE TRANSFERS: Ambulance request form must be completed and must call Ambulance dispatcher (Senior Crew). ROUTINE: Ambulance request form must be completed and submitted twenty-four (24) Hours prior to appointment to the Ambulance Department. How does the hospital maintain and manage patient ambulances? Hospital Ambulances are checked (with documentation) by the ambulance department personnel every shift for mechanical and operational functionality. All ambulances are ensured to be well-maintained and must have appropriate equipment and supplies needed for patient care during transport. How does the healthcare provider adhere to Infection Control and Prevention regulations during patient transport? Ambulance department personnel / Emergency Medical Technicians and other healthcare providers adheres to infection control measures as per Standard Precautions Policy ( ) Is there a process/policy that tells us that the patient should be monitored during patient transfer? Yes, there is a policy that defines that the patient should be monitored based on his/her need which should be determined by the referring physician what to monitor. Critically Ill Patient should be continuously monitored during the transfer. In case of emergency, the patient should be brought to Emergency Department. Related Policies for Access to Care and Continuity of Care standards: Reduce Barriers To Healthcare ( ) Transfer Policy ( ) Administrative Admission Policy ( ) Managing Delay of care in ED due to Excess Volume of Patients ( ) Leave Against Medical Advice(LAMA) ( ) Discharge Policy ( ) Patient Referral ( ) Triage Policy ( ) Outpatients Clinical Summary ( ) Medical Treatment Abroad Policy ( ) Patient Out-On-Pass Policy ( ) Patient and Family Rights (PFR) PFR.1 4 RIGHTS OF PATIENTS The hospital supports the implementation of patients and family rights during care. Staff is made aware of the patient and family rights. Patient has the right to be informed about all aspects of care and are about the privilege to participate in care during the course of treatment A patient complaint process is established by the hospital. When do patient and family rights and responsibilities information provided to the patient?

18 Information about patient rights and responsibilities is provided to the patients and family as early as possible during the course of treatment. Information is provided in writing to each patient. The statement of patient rights and responsibilities is posted in all clinical areas or otherwise available from nurses stations at all times in a form of pamphlets. The hospital has a process to inform patients of their rights and responsibilities when written communication is not effective or appropriate (patient/family illiterate); INPATIENT: Health educator, patient affairs, and ward bilingual nurses should explain upon patient admission OUTPATIENT: Appointment is set for patient/family to attend a session for their rights and responsibilities. As a staff, how do you perform Patient privacy and confidentiality in your unit? All information about a patient is considered confidential, including information that: Is received, maintained or transmitted in ANY format Relates to the patient s past, present or future medical condition, treatment or care. Identifies the patient or could be used to identify the patient Confidential health information should be limited to the minimum necessary and only be accessible or shared with those who need to know in order to care for the patient or do their job. Confidential Health Information about a patient should never be posted on a social networking site such as Facebook, MySpace, Twitter, Whatsapp, etc. for personal use even if the patient may be the only person who may be able to identify him or herself based on the description. PSMMC staff shall avoid discussing patient information in public areas in the hospital such as elevators, restrooms, and lobbies or outside the hospital, such as conferences (except if it contains no patient identifying information). Patient information should be kept confidential to any healthcare professional/administrative staff member who is not providing care to the patient (not part of the patient healthcare team). Having access to the information shall not mean having the right to view the information. The Medical Record held by any department/committee must be kept under adequate security to ensure that confidentiality is maintained at all times. The transport of the Medical Records must be in a manner that ensures that confidentiality and security is maintained at all times. Ensure consideration of patient s privacy concerning his/her care, as per patient expectations and needs. Patients are to be treated with respect and dignity at all times and under all circumstances. 18 P a g e

19 What hospital process is established that supports Informing patients about all aspects of care? Patients are informed of their medical conditions and any confirmed diagnosis. Patients are informed of the planned care and treatment(s). The hospital supports and promotes Patient and Family participation in care processes. The hospital facilitates a patient s request to seek a second opinion without fear of compromise to his or her care within or outside the hospital. How do you Reduce Language barriers to patients and/or patient s family? Patients receiving healthcare services in the organization, and their families should be informed, in a manner and language they can understand, of their rights and responsibilities using verbal instructions, displayed posters and patient information booklets. How do the staff protect the Patient s Possessions? Patients possessions are safeguarded when the hospital assumes responsibility or when the patient is unable to assume responsibility. How do the staff protect vulnerable patients in PSMMC? Staff should pay special attention to maintain and respect patient and family rights for vulnerable patients (which include at least children, disable individuals, elderly, comatose patients and individuals with mental or emotional disabilities), in addition to protecting their safety (such as evacuating them in case of fire and adapting facilities of their special needs), and protecting them from negligent care, abuse and withholding of services. If a patient refuses for any treatment, what should be done thereafter? The hospital informs patients and families about their rights to refuse or to discontinue treatment and the hospital s responsibilities related to such decisions. The hospital informs patients about the consequences of their decisions, their responsibilities related to such decisions and available care and treatment alternatives. How is the patient complaints handled in your unit/department? Patients are informed about the process for voicing complaints, conflicts, and differences of opinion. Complaint of the patient will be forwarded to the Complaint Unit and categorized/routed as Clinical and Non-Clinical Complaint Tickets. Complaints, conflicts, and differences of opinion are investigated by the responsible personnel of the hospital. FEEDBACK: An SMS will be received by the complainant that the complaint is received and logged by the responsible authority (Complaint Unit) Result/outcome of the investigation will be disclosed to the patient by the hospital administration.

20 Related Policies for implementing Patient and Family Rights Standards: Patient and Family Rights Responsibilities Policy ( ) Patient s Bill of Rights and Responsibility handouts / posters Reduce Barrier to Healthcare Policy (AOP ) Protection of Patient at risk of abuse policy (COP ) Patient Privacy and Confidentiality of Care Policy ( ) Handling Patients and Family Complaints and Conflicts Policy ( ) Patient s Valuables Policy Loss and Found Policy PFR.5.1 INFORMED CONSENT Patient must be informed of those factors related to the planned care required for an informed decision. Informed consent can be obtained when the patient is admitted for inpatient care in the hospital and before certain procedures or treatments for which the risk is high.. What is PSMMC Policy on informed consent? Only members of the medical staff are permitted to obtain informed consent and provide adequate information for the patient or patient's legal representatives to make an informed decision on the purpose of consenting, proposed tests/treatment, including medications or procedure. Consent must be obtained for all treatments, procedures/ interventions, research participation required through the following specific informed consent forms: Consent for Procedure or Surgery Consent to Anesthesia (General or Local) Consent for Blood Products Transfusion Consent to Participation in Research Study Consent for Patient Information Release Consent for Photography A legal age of 18 Hijra years or older for Muslims and 18 Gregorian years for Non- Muslims can sign for him or herself except in special situations where the approval of another party when required. A patient who is judged to be incompetent (incapacitated) must have the consent form signed by his/her substitute decision maker. Related Policies for implementing Patient and Family Rights Standards: Patient and Family Rights Responsibilities Policy ( ) Patient s Bill of Rights and Responsibility handouts / posters Informed Consent Policy ( ) Handling Patients and Family Complaints and Conflicts Policy ( ) PFR ORGAN DONATION The hospital is responsible for defining the process of obtaining and recording consent for cell, tissue, and organ donation in relation to international ethical standards and the manner in which organ procurement is organized in their country (KSA). The hospital has a responsibility to ensure that adequate controls are in place to.prevent patients from feeling pressured to donate. What is PSMMC s process on Organ/Tissue Donation? PSMMC supports organ and tissue donation and transplantation programs. PSMMC provides information to patients and families on the donation process. 20 P a g e

21 Complete process is described in the Organ Donation and Transplantation Policy ( ) Related Policies for implementing Patient and Family Rights Standards: Organ Donation and Transplant Policy ( ) Patient and Family Rights Responsibilities Policy ( ) Patient s Bill of Rights and Responsibility handouts / posters Reduce Barrier to Healthcare Policy (AOP ) Patient Privacy and Confidentiality of Care Policy ( ) Informed Consent Policy ( ) Assessment of patients (AOP) AOP.1 4 ASSESSMENT OF PATIENT Comprehensive clinical including pain, psychological, nutritional, social and special needs assessment process should be established by the organization that addresses the healthcare needs of patients performed by qualified individuals (physicians, nurses and other responsible disciplines) within the organization. An interval patient reassessment process is established by the organization following the patient condition and treatment per se. A discipline collaborative approach is in place to integrate patient assessment findings to prioritize most essential patient care needs. A. PATIENT ASSESSMENT AND REASSESSMENT PROCESS IN PSMMC: What are the Types of Patient Assessment in PSMMC? As per Healthcare provider Medical assessment Nursing assessment Other discipline assessment As per patient location In patients assessment Out patients assessment Emergency assessment What is the Goal of Assessment in PSMMC? All PSMMC inpatients shall have their health care needs identified through an assessment and reassessment process to plan their care, determine their response to the provided care and plan for continued care after discharge. What is your policy on who should be performing the Assessment? Physicians, nurses and other healthcare providers licensed by the Saudi Commission for Healthcare Specialties. Data and information obtained by all healthcare practitioners involved in the care of a patient shall be reviewed, analyzed and integrated by the Mainly Responsible Physician. What is the timeframe for initial medical/nursing assessment? within 24 hours of admission What is the content of initial medical/nursing assessment? Health history, physical examination, psychological assessment, pain assessment and initial care plan. In addition to MEDICAL Initial Assessment, it will result to; An initial diagnosis

22 What is the validity of the initial medical assessment? Initial Medical Assessment is valid for thirty (30) days provided that the patient s assessment condition is the same upon patient admission. Do we have generic initial medical/nursing assessment form? Yes we have the generic forms; Initial Physician Assessment Form (No /02) Initial Adult Inpatient Assessment Form ( ) Reassessment form No Do we have special population in PSMMC? Yes we have including: Children /Adolescents/Frail elderly/terminally ill/dying patient/patients with intense or chronic pain/women in labor/women experiencing terminations in pregnancy/patients with psychiatric disorders/ Patients suspected of drug and/or alcohol dependency /Victims of abuse and neglect / Patients with infectious or communicable diseases / Patients receiving chemotherapy or radiation therapy /Patients whose immune systems are compromised How about the special population, they will use the generic one? Some will use special assessment form and others will use the generic one What is time frame for assessment of patients referred for Consultation? Depends on the nature of the consultation: Immediately for emergency consultation Two (2) hours for urgent consultation Twenty four (24) hours for routine consultation What is the reassessment frequency? For Medical Reassessment: At least Every twenty-four (24) hours including weekends or more frequently. For Nursing Reassessment: Every shift or every twelve (12) hours unless patient condition needs more frequent reassessment. For Emergency department and outpatient setting, do nurses have to conduct the same initial assessment? No, for Emergency or clinic setting, the scope of assessment is different. Initial Nursing Assessment Emergency Department ( /2) Outpatient Initial Nursing Assessment Form ( /01) For more information, please read In-Patient Medical Assessment and Reassessment Policy (No ) and Initial Nursing Assessment and Reassessment Policy (No ) 22 P a g e

23 PSMMC Pain Screening, Assessment/ Reassessment Process B. PAIN SCREENING, ASSESSMENT/REASSESSMENT PROCESS Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage, and which may occur independent of tissue damage. Step Description PSMMC ED, admitted as inpatient or seen as an outpatient must PAIN SCREENING be screened for pain by the attending physician/nurse Inpatients shall be screened for pain by the nurse at least once daily When patient found in pain after screening, the nurse shall COMPREHENSIVE PAIN conduct a comprehensive pain assessment ASSESSMENT A comprehensive pain assessment shall be conducted and documented by the physician addressing at least five component Frequency of assessment/reassessment shall be based on PAIN REASEESSMENT presence of pain, Pain severity & appropriate interval after interventions. PAIN Refer to PAIN MANAGEMENT, Care of Patient Section C of this manual, page 31. For more information, please read policy No Related Policies for Assessment and Reassessment of Patient Process Inpatient Medical Assessment and Reassessment ( ) Out-patient Medical Assessment and Reassessment ( ) Initial Nursing Assessment and Reassessment ( ) Nutrition Assessment and Reassessment ( ) AOP.5.3 LABORATORY SAFETY PROGRAM The laboratory safety program should addresses safety practices and prevention measures (eye wash stations, spill kits and the like). The program should be coordinated with the hospital s facility management and infection control programs. Does PSMMC have a Laboratory Safety Program? PSMMC Central Military Laboratory and Blood Bank (CML&BB) has an active safety program which addresses potential safety risks in the laboratory and in the other areas where laboratory services are provided. All divisions/sections of CML and BB are equipped with safety devices to reduce the safety risks and staff are oriented and received education/training for new practices/procedures. AOP.5.4 LABORATORY RESULTS The hospital defines a time period for reporting laboratory test results within time-frame based on patient needs, services offered and clinical staff needs. Is there a policy/process that describes how long will the Laboratory request result be made available from the requesting department/unit? Yes, there is a process. CML and BB established turnaround times FOR ALL TESTS according to the testing priorities i.e. Expedite, Stat or Routine according to patient needs. (The staff should cite some example/s)

24 AOP. 5.5 LABORATORY EQUIPMENT MANAGEMENT PROGRAM All equipment and medical technology used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. How do you ensure that laboratory equipment is working according manufacturer s requirements or regulatory standards? The CML and BB ensure that the quality control and performance of the laboratory equipment are maintained and sustained. In addition, the laboratory has a system to oversee, implement and monitor the selection and acquisition, inventory, maintenance and calibration, planned preventive maintenance, decommissioning and final disposal of equipment. AOP. 5.7 COLLECTING, IDENTIFYING, HANDLING, SAFELY TRANSPORTING, AND DISPOSING OF SPECIMENS There is a process established and implemented for ordering tests, collecting and identifying specimens, transporting, storing, and preserving specimens and receiving, logging in, and tracking specimens. As a staff in the clinical area, how do you perform proper identification and labeling for a specimen taken from the patient? Patient should be identified as per Patient Identification Policy using the two patient identifiers prior to obtaining the specimen. Patients Three Full Names Medical Record Number Specimen collected should be labeled right after the specimen is taken at beside to prevent misidentification. AOP. 5.8 LABORATORY REFERENCE RANGES The laboratory establishes reference intervals or normal ranges for each test performed. Is there a process that describes all laboratory result reference range/list? Yes. The CML and BB have established reference ranges for all tests performed in PSMMC and are included in the report of the tests results. Related Policies for Laboratory Services Policy Number: Policy Number: Policy Number: Policy Number: Policy Number: Policy Number: Policy Number: P a g e Care of Patients (COP) COP CARE DELIVERY FOR ALL PATIENTS Patients with the same health problems and care needs have a right to receive the same quality of care throughout the hospital. To carry out the principle of one level of quality of care requires that the department/service leaders plan and coordinate patient care. Integration and coordination of multiple care settings, departments and settings that result in efficient care processes, more effective use of human and other resources, and the likelihood of better patient outcomes. That there is a timely plan of care for every patient and achieve optimal clinical outcomes.

25 A. PLAN OF CARE DETERMINED FOR PSMMC PATIENTS: For whom we have to initiate a Care Plan? For all PSMMC patients ( inpatients, outpatients and ER patients) What are the main characters of care plan? Individualized care planning, integrated and coordinated Based on the data obtained, and the needs identified Initial care plan Documented, by the different healthcare practitioners within 24 hours. The goals in the care plan shall be updated or revised should needs arise. Do you have generic Care Plan form? No. Initial physician care plan must be documented in the 2 nd page of the initial assessment form. The care plan for all discipline must be documented in clinical/progress notes. Do you have high risk patients in PSMMC having a special care plan? Yes we have including: Emergency Patients; Comatose Patients; Patients on Life Support; Care of Patients With A Communicable Disease; Care of Immunosuppressed Patients; Care of Patients Receiving Dialysis; Care of Patients in Restraints; Care of Patients Receiving Chemotherapy; and Care of Vulnerable Patient Populations, Including Frail Elderly, Dependent Children, and Patients at Risk for Abuse and/or Neglect. How about the high risk patients, will they follow the same care? Yes, they will follow the same rules of care plan. In addition, they have individual guidelines for every group of patients. Does the Main Responsible Physician need to review other healthcare team members care plan caring for the same patient? Yes, for inpatient. The MRP should review and approve other discipline s Care Plan to ensure integration and good coordination in treating the patients well-being. Approval from the MRP should be documented in the Combined Care Plan Form ( /01). What will be the next step after care plan? Physicians shall write orders according to their granted privileges Other healthcare practitioners shall write orders according to their approved competencies.

26 What are the essential elements of patient care orders? Must be documented in doctor s order sheet. Diagnostic imaging and clinical laboratory test(which is not routinely ordered for patients) orders must provide a clinical indication/rationale, except those in emergency department and intensive care units For more information, please read Care Delivery for All Patients Policy No: COP.3 CARE OF HIGH-RISK PATIENTS AND PROVISION OF HIGH-RISK SERVICES Hospital leadership is responsible for (a) identifying the patients and services considered high risk in the hospital, (b) using a collaborative process to develop guidelines and procedures for care, and (c) training staff in implementing the guidelines and procedures. Policies, guidelines, and procedures for managing the care of these patients are important tools for staff to understand and respond in a thorough, competent, and uniform manner. B. CARING FOR PATIENTS FOLLOWING THE USE OF RESTRAINT PROCESS: PSMMC promotes a culture that minimizes the use of restraint in accordance with the patients rights of freedom of movement, liberty and humane treatment as outlined in the Patients and Family Rights and Responsibilities What are the Types of Restraints? Mechanical Environmental Chemical Physical What is the process of Use of Restraints as per policy? A physician must carry out a face to face evaluation of the patient and write a new restraint order if a patient requires the use of a restraint that extends time limits. Reason of restrain must be explained to the patient/family and documented in restraint record. A physician restraint order must be obtained before conducting patient restraint except in emergency situations and followed by a documented order thereafter. EMERGENCY RESTRAINT FOR PATIENT WITH VIOLENT/SELF-DESTRUCTIVE BEHAVIOUR: Physician must be notified and must perform face to face assessment and write the restraint order within one (1) hour after restraints commencement. Time Validity Eight (8) Hours Four (4) Hours Two (2) Hours Age Bracket 18 years of age and older 9 17 years of age 9 years of age and younger RN must perform face to face evaluation and review of the continuing need for the use of restraints. 26 P a g e

27 Time Validity Four (4) Hours Two (2) Hours One (1) Hour Age Bracket 18 years of age and older 9 17 years of age 9 years of age and younger RESTRAINT FOR NON VIOLENT BEHAVIOUR PATIENTS: Can be initiated by Use of Restraints trained RN. Must secure written order as soon as possible but no later than twelve (12) Hours. Orders must be renewed every twenty-four (24) Hours by the responsible physician after face to face restraint evaluation. RN must perform face to face evaluation. Time Validity As required Twenty-four (24) Hrs Four (4) Hrs Evaluation for change in patients condition warrants re-evaluation Two (2) point restraints and vest restraints Four (4) point restraints (upper and lower restraints) Verbal, PRN or standing orders should not be accepted for any form of restraint or A trial release from a restraint procedure. Only approved restraint devices/appliances are to be used. In case of unavailability of approved devices an incident report will be completed and submitted to CQI&PS Department. A temporary release from restraint that occurs for the purpose of caring for the patient i.e. toileting, feeding is not considered a discontinuation as long as the patient remains under direct staff supervision. For more information, please read Patient Restraint Policy No COP.3.2 RESUSCITATION SERVICES Resuscitative services is available to the patients twenty-four (24) hours a day, every day. Essential to providing these critical interventions is the quick availability of standardized medical technology, medications for resuscitation, and staff properly trained in resuscitation. Resuscitation services available within the hospital, including medical technology and properly trained staff, must be based on clinical evidence and the population served C. RESUSCITATIVE SERVICES AVAILABLE IN PSMMC Cardio pulmonary resuscitation (CPR) is the process of restoring circulation and respiration to preserve cerebral and other vital organ function, utilizing basic and advanced techniques that include ventilation, chest compressions, use of resuscitation drugs and electrical therapy. These efforts apply to all subsets of patients, i.e. adult, pediatric and neonatal at Prince Sultan Military Medical City (PSMMC) and its clinics. What are the Types of Resuscitations in PSMMC? Adult CPR Pediatric CPR Neonatal CPR

28 What are the requirements for PSMMC staffing to ensure that patient s interventions are provided during life-threatening emergencies? All staff is required to be BCLS certified. All senior team members (medical staff, nursing officers, charge nurses and the equivalent in all clinical non-nursing/paramedical professions must be appropriately trained in one of the advanced CPR courses (ACLS, PALS or NRP) depending on their professional allocation/function. All clinical staff in adult General Intensive Care Unit (GICU) and Surgical Intensive Care Unit (SICU) shall be certified in ACLS. All clinical staff in Pediatric Intensive Care Unit (PICU) shall be certified in PALS. All clinical staff in Neonatal Intensive Care Unit (NICU) shall be certified in NRP. How do you ensure that resources are available to implement resuscitative services? CPR Trolley is available and located in all clinical areas. the Nurse In-charge, shall ensure that the resuscitation trolley and defibrillator are checked on a daily basis (plugged and unplugged testing) CPR Drugs (medication) shall be kept in a sealed container in the designated place in the CPR Trolley. The auditing processes are periodic with regular spot checks of CPR Trolleys and must be conducted to ensure that resuscitation trolleys are maintained and stocked according to the outlined standards. The CPR Trolley must be stored in direct view of the nursing station at all times to ensure the safety and security of the drugs in the crash cart. How do you respond to life threatening emergencies (Cardiac Arrest) in your unit/department? Start. The person observing the cardiac arrest will start CPR immediately after calling for help Helper telephone the switchboard using the designated cardiac call telephone numbers specify the ward (or department) and building, as well as the category of the victim The switchboard operator must record the received message and repeat the message back to the calling person End When announcement is heard and/or bleeps are activated, nearby staff or members of the relevant resuscitation team immediately attend the site The switchboard operator will then alert the designated CPR Team by activating their bleeps over the Public Address System Where do you document performed resuscitation measures for coded patient? The approved Cardio-pulmonary Resuscitation Evaluation Form (Section I) must be utilized and completed as soon as possible after the resuscitation attempt. This form must contain all information regarding the outcome, any problems with code and comments. For more information, please read CardioPulmonary Resuscitation Policy No: P a g e

29 COP.3.3 HANDLING, USE, AND ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS Blood must be administered in accordance with standards of practice and in a consistent manner in order to ensure the safety of the recipient Clinical guidelines and procedures describe the process for (a) procurement of blood from the blood bank or blood storage area, (b) patient identification, (c) blood administration, (d) monitoring of the patient, and (e) identification and response to signs of potential transfusion reactions. D. BLOOD TRANSFUSION SERVICES AVAILABLE IN PSMMC Blood is a living tissue that has wide therapeutic benefits when its components are handled and used in an appropriate manner. However, it is a bio-hazardous fluid that is associated with untoward reactions in as many as 10% of transfusion recipients. What is the process of Blood and Blood Products Ordering? It is the Physician s responsibility to order/prescribe blood and blood products by completing Blood Bank Request Form (MSD ). The Physician or designee must inform the Blood Bank for emergency requests through telephone. The degree of urgency must be accurately conveyed. Patients, who are candidates for blood transfusion, must have a cross-match wristband applied by the person taking the sample of blood and must be in place for ninety (90) hours or until any possible transfusion related to that sample are completed. The validity of a Group or Cross-match Sample is seventy-two (72) hours from the date and time the sample was taken. All patient expected to receive blood must be consented. The receiving Physician or nurse is responsible for verifying that the blood or blood products arrived within thirty (30) minutes of leaving the Blood Bank. If transportation takes longer than thirty (30) minutes, the Blood Bank must be contacted immediately. The receiving Physician or nurse is also responsible for making sure that red cell units are set up for infusion or placed in a monitored satellite blood refrigerator immediately. Blood must be kept refrigerated because of the risk of hemolysis and bacterial proliferation. Because of this, the infusion of red cells must be started within thirty (30) minutes of the unit being removed from the refrigerator. Only medical, anesthetists and nursing staff are allowed to remove blood units from the satellite blood refrigerator, and this person is responsible for documenting the exact date and time that blood units are taken out of the refrigerator on the Dispense Report. How do you ensure safe and efficient Pre-transfusion Preparation of Blood and Blood Products? The bedside pre-transfusion check is vital for preventing fatal errors. Patient should be identified correctly as per Patient Identification Policy. For each unit of blood to be administered, the following control checks must be carried out before infusion by TWO (2) responsible staff where one of whom is the person performing blood transfusion: Check the doctor s prescription on the Medication Administration Record and verify that all the requirements are met

30 Check the blood unit as follows: The unit number & blood group on the unit must match that on the attached compatibility label & the Blood Bank Dispense Report. The patient and the unit must be ABO and Rh (D) compatible. Check the unit expiry date and examine the unit for any signs of discoloration, hemolysis or abnormal appearance. Check the cross match expiry date and time on the compatibility label. Check the unit for leaks by squeezing gently but firmly. Perform a full patient assessment including note any rashes or complaints of headaches and recording the patient s vital signs: temperature, pulse, blood pressure (BP) & respiratory rate How do you ensure safe and efficient during Blood and Blood Product Transfusion? DURING TRANSFUSION: Check the patient s vital signs every fifteen (15) minutes twice for the first half an hour. Then, hourly until one (1) hour after completion of transfusion (For platelet transfusion the observation may be extended until six (6) hours post transfusion). Adjust the flow-rate to achieve infusion over the prescribed time period. The maximum infusion time for red cell units is four (4) hours, with most transfusions being completed within two (2) hours. The first ml should be infused slowly under close supervision to detect early signs of an acute transfusion reaction. Throughout the transfusion, the responsible transfusing staff must observe the patient for any sign or symptom of incompatibility or adverse reaction. POST TRANSFUSION: The date, time, and signature of both persons checking and administering the blood must be written on the Dispense Report DO NOT return the empty unit or compatibility label to the Blood Bank. Empty bags should be kept attached to the patient until the one (1) hour post transfusion check has been completed. If no signs of transfusion reactions, empty unit bags should be disposed in infected waste bins. How do you manage Acute Blood and Blood Product Transfusion Reactions? Acute transfusion reactions are defined as reactions that occur during a transfusion or within twenty four (24) hours of completion the transfusion. In the event of an acute transfusion reaction: If the transfusion is still in progress, STOP THE INFUSION IMMEDIATELY, flush the IV cannula and keep the line open with 0.9% saline. Check vital signs. Verify all documentation to make sure that the correct unit has been given to the correct patient. Notify the responsible Physician and the Blood Bank immediately. The attending Physician must assess the patient s condition and take appropriate clinical action, see back copy of dispense form. 30 P a g e

31 PSMMC Pain Management Process Any action or treatment must be fully documented in the medical record. For mild localized allergic reactions such as hives, or mild febrile reactions, the physician may continue the transfusion after medication is given provided the signs and symptoms subside. Circulatory overload and mild reactions that do NOT result in the final termination of the transfusion do NOT need to be investigated by the Blood Bank. For all reactions that result in the transfused unit being discontinued, the Blood Bank must receive a request for transfusion reaction investigation. For more information, please read Blood Transfusion, Dispense, and Administration of Blood Products Policy (No ) COP.6 PAIN MANAGEMENT Patients in pain have the right to appropriate assessment and management of pain. Patients are informed about the likelihood of pain when it is an anticipated effect from treatments, procedures, or examinations and what options for pain management are available E. EFFECTIVE PAIN MANAGEMENT PROCESS Step ASSESSMENT AND REASSESSMENT PAIN MANAGEMENT Description Refer to PAIN SCREENING, ASSESSMENT/REASSESSMENT PROCESS of Assessment of Patient Section D of this manual, Page 23. Pain care plan as part of overall care plan should be formulated by the MRP within 24 hours of admission for inpatients, before seeing next patient for outpatients The pain management interventions, whether pharmacological or non-pharmacological shall continue until the effective outcome of pain reduction is achieved to the satisfaction of the patient and health care provider Patients are informed of their right to appropriate assessment and care of pain and are assured that their report of pain is taken PATIENT EDUCATION seriously Education regarding pain, its management, and the patient's role in assessment and management are provided on an ongoing basis For more information, please read policy No COP.7 END OF LIFE CARE The organization establishes an End-Of-Life Care process where all staff are made aware of the unique needs of patients at the end of life. Concern for the patient s comfort and dignity should guide all aspects of care during the final stages of life. F. MANAGING END-OF-LIFE CARE PROCESS How are patients approaching the end-of-life cared for at PSMMC? Staff are trained on how to carry out End-of-Life Care Processes (beliefs, values, cultural, religious, emotional and psychosocial) through the following focus areas; Focusing on End-of-Life Decision Making Focusing on Palliative Care Focusing on Pain Assessment and Care Focusing on Psychiatric Assessment and Care Focusing on Religious and Cultural Factors

32 Focusing on the Role of Family Members Focusing on Geriatric, Pediatric, End-of-Life Care Focusing on Education and Training of Staff Caring for terminally ill patients carried out by multiple disciplines are made aware of the unique needs of patients that is/are integrated into the end-oflife process by asking questions, providing information and making appropriate referrals. Palliative care is provided inclusive of appropriate treatment of symptom and in accordance to the desire of the patient and/or responsible family member. Respect in patient/family s decisions and dignity ensured Alleviate from pain Assess and manage psychological, social and spiritual/religious beliefs. Continuity of care offered Access to any therapies to improve patient s quality of life Ensure access to palliative care Respect physician s professional judgment and recommendations with respect to patient/family s preferences. Promote clinical and evidenced-based approach For more information, please read; Care of End of Life and Dying Patients Policy ( ) Patient and Family Rights and Responsibility ( ) Spiritual Care for Inpatients ( ) 32 P a g e Anesthesia and surgical Care (ASC) ASC.3 SEDATION CARE The hospital must develop specific guidelines for how and where sedation may be used. Standardization of procedural sedation is supported by policies and procedures and identifies (a) areas in the hospital where procedural sedation may occur, (b) special qualifications or skills of staff involved in the procedural sedation process, (c) the differences between pediatric, adult, and geriatric populations or other special considerations, (d) availability and use of specialized medical technology, and (e) obtaining informed consent for both the procedure and sedation. What is the process of ensuring Safe Sedation Care in PSMMC? -ASC.3 Sedation services are available 24/7. Pre-sedation assessment is performed by a qualified/certified healthcare professionals for each patient within thirty (30) days prior to sedation and updated for any changes on the day of the procedure and will be documented. Risks, benefits and alternatives related to the procedural sedation will be discussed with the patient and/or his family or those who make decisions for the patient prior to patient signing the consent. Pre-induction assessment is performed for each patient just before induction of sedation. A Time-Out will be conducted immediately before starting the procedure (after the induction) A qualified/certified healthcare professional will assess the patient s status immediately after administration of moderate/deep sedation and after the procedure.

33 A dedicated RN will be responsible for providing uninterrupted monitoring of the patient physiological parameters before and after sedation as well as recovery. ASC.4 5 ANESTHESIA CARE The hospital establishes a well-planned anesthesia care. Only qualified healthcare provider performs anesthesia care including preanesthesia assessment and preanesthesia induction. Anesthesia care is carefully planned, monitored, and documented in the anesthesia record. Postanesthesia discharge criteria is established and performed by a qualified anesthesiologist or other individual authorized by the individual(s) responsible for managing the anesthesia services. The patient is discharged (or recovery monitoring is discontinued) by a nurse or similarly qualified individual in accordance with postanesthesia criteria developed by hospital leadership, and the patient s record contains evidence that criteria are met. What is the process of ensuring safe Anesthesia Care in PSMMC? Anesthesia services are available 24/7. Pre-anesthesia assessment is performed by a qualified anesthetist for each patient within thirty (30) days prior to surgery/procedure. All patients undergoing anesthesia will have their anesthesia care planned before giving anesthesia by a qualified anesthetist and documented in the patient s clinical file. Risks, benefits and alternatives related to anesthesia will be discussed with the patient and/or his family or those who make decisions for the patient prior to patient signing the consent. Pre-induction assessment is performed for each patient just before induction of anesthesia drugs. Patient s physiological status is monitored and documented intra and post anesthesia. Post anesthesia patient will be discharged from recovery room according to Aldrete Scoring Criteria performed by a qualified individual of the service (anesthesiologist or a nurse. ASC SURGICAL CARE Procedure selection depends on the patient s history, physical status, and diagnostic data as well as the risks and benefits of the procedure for the patient. The risks, benefits, and alternatives are discussed with the patient and his or her family or those who make decisions for the patient. Information about the surgical procedure is documented in the patient s record to facilitate continuing care. Patient care after surgery is planned and documented. What are the essential information should the patient or family should receive prior to surgery? the risks of the planned procedure; the benefits of the planned procedure; the potential complications; and the surgical and nonsurgical options (alternatives) available to treat the patient. What are the essential post-operative/procedure information that should be present in a patients records? postoperative diagnosis; name of operative surgeon and assistants;

34 procedures performed and description of each procedure findings; perioperative complications; surgical specimens sent for examination; amount of blood loss and amount of transfused blood; registry number of all implantable devices; and date, time, and signature of responsible physician. Medication Management and Use (MMU) MMU.1 ORGANIZATION AND MANAGEMENT The hospital ensures efficient and effective medication management and use Do we have a Medication List (Drug Formulary) and How it is managed? Yes, we have PSMMC Formulary that can be found in PSMMC ego Portal. PSMMC Formulary is updated annually based on safety and efficacy information. Pharmacy and therapeutic committee (PTC) maintain and monitor medication formulary. MMU.3 STORAGE Strategies are set to ensure appropriate storage of medications. In all locations where medications are stored, the following is evident: (a) Medications are stored under conditions suitable for product stability, including medications stored on individual patient care units, (b) Controlled substances are accurately accounted for according to applicable laws and regulations, (c) Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates, and warnings, (d) Concentrated electrolytes are not stored in care units unless clinically necessary, and when stored in care units there are safeguards in place to prevent inadvertent administration, (e) All medication storage areas, including medication storage areas on patient care units, are periodically inspected according to hospital policy to ensure that medications are stored properly, (f) Medications are protected from loss or theft throughout the hospital How do you ensure the safety of your medications in your department/area? All medication products are stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, safety and security. Medications are stored securely (in Pyxis MedStations and Safety Cabinets with locks). Temperatures for medication storage are monitored and documented twice daily by the responsible staff in the unit. Are you aware of the approved High Alert Medications? Yes. There is a list of all PSMMC approved High Alert Medications and Safety Strategies to ensure safe handling and storage of High alert Medications. 34 P a g e

35 All high alert medications are labeled with special label both in the pharmacy and patient care areas. High alert medications requires double checking before dispensing and administration, How do you manage medications that are brought-in by your patients? All medications brought-in by patients upon admission should be approved by the Main Responsible Physician to outline those that can be used by the patient during hospital stay. Do you have a Medication Recall System? All medications that is recalled by the Saudi Food and Drug Authority, Drug Manufacturer or other international health authority will be pulled-out from medication stations and in the pharmacy by the responsible staff from Pharmacy Department. Recalled medications will be isolated until returned to the manufacturer or destroyed as per manufacturer s instructions/guidelines. MMU.5.1 MEDICATION PRESCRIPTIONS The hospital defines what patient-specific information is required for the appropriateness review of the order or prescription What elements should be considered to ensure that the physician s medication prescription is appropriately correct? PHARMACIST: the appropriateness of the drug, dose, frequency, and route of administration; therapeutic duplication; real or potential allergies or sensitivities; real or potential interactions between the medication and other medications or food; variation from hospital criteria for use; patient s weight and other physiological information; and other contraindications. NURSES: The safe administration of medications includes verifying the following; patient whom the order is intended medication with the prescription or order; time and frequency of administration with the prescription or order; dosage amount with the prescription or order; route of administration with the prescription or order PFE.1-4 Patient and Family Education (PFE) PATIENT AND FAMILY EDUCATION SUPPORT, NEEDS ASSESSMENT, METHODS, AND COLLABORATIVE APPROACH The hospital educates patients and families so that they have the knowledge and skills to participate in the patient care processes and care decisions.

36 Educational needs of the patient and family are assessed. Education by hospital staff is provided to patients and families to support decisions in the care process. The hospital selects educators and educational methods consistent with the patients and families values and preferences and to identify the families roles and the instruction method. What are the essential parameters in planning and providing education to your patients/family in your unit? Each healthcare team member is responsible to identify education needs of the patient and provide education pertinent to their scope of service. Learning needs assessment must be conducted prior to giving education and teaching content, evaluation and action plan must be documented in the Multidisciplinary Patient and Family Education Record. Health education materials will be provided to the patients/family during the course of awareness. Patient understanding must be checked and education must be provided based on easy terms (understandable language, clear, and action-specific). Patients and families are encouraged to participate in care process. What health education empowerment methods/process is available for patient and family in PSMMC? Structured Patient and Family Education Policy is established to regulate the processes of health education through different mechanism; Development and distribution of health educational materials Referral to patient education Health awareness day campaigns 36 P a g e Health Care Organization Management Standards Quality Improvement and Patient Safety (QPS) QPS.2-6 Measure Selection, Data Collection, Analysis, Validation The quality and patient safety program described in QPS standards plays an important role in helping these departments/services agree on a common measurement (KPI) approach and facilitates the data collection of the measure(s) selected. The quality and patient safety program is also in the position to integrate all measurement activities in the hospital, including measurement of the safety culture and adverse event reporting systems Current scientific and other information supports patient care, clinical education, research, management and Information is provided in a time frame that meets user expectations What is/are the purpose/s of Key Performance Indicators and its use? The purpose of having Key Performance Indicators/Measures is to have a baseline data in which a certain department/unit performance is monitored such as percentage of hand hygiene compliance, Adult Smoking Counseling HF, patient fall rate, hospital acquired pressure ulcers rate, and more. It provides a picture of how the department/unit performance compliance is held for a specific period of time. Data are used and analyzed to serve as a basis for areas of improvement.

37 Each department in PSMMC must select and measure at least one Key performance indicator to measure the service that it provides. Criteria for selecting a KPI should include at least one of the following: Alignment with PSMMC strategic objectives. Those hospital wide measurement and improvement priorities set by hospital leadership that relate to their specific department or service. The measures associated with specific department/service priorities to reduce variation, improve the safety of high-risk procedures/treatments, improve patient satisfaction, or improve efficiency. JCI International library of measures Related Policy for Performance Measurement Performance Measurement Policy( ) QPS.7 IDENTIFYING AND MANAGING SENTINEL EVENTS. The hospital has a well-structured process of identifying and managing sentinel events. What is sentinel event and its criteria? Any unexpected occurrence involving death or serious physical or psychological injury. Serious injury that includes loss of limb function. SENTINEL EVENT CRITERIA in PSMMC: Unexpected death of any patient receiving care, treatment that is unrelated to the natural course of illness. Suicide of any patient receiving care treatment and services in a staffed around-the-clock care setting or within seventy-two (72) hours of discharge. Unanticipated death of a full-term infant Major permanent loss of function unrelated to patient s natural course of illness or underlying condition Abduction of any patient receiving care, treatment and services. Wrong site, wrong procedure, wrong-patient surgery Infant sent home with the wrong parents Rape Adverse drug reaction that leads to death, life-threatening hospitalization or prolonged, disability significant, persistent or permanent change, impairment, damage or disruption in the patient s body function/structure, physical activities or quality of life. QPS.9 NEAR-MISS DEFINITION, IDENTIFICATION AND ANALYSIS The hospital establishes a definition of a near miss and what types of events are to be reported. A reporting mechanism is put into place, and there is a process to aggregate and to analyze the data to learn where proactive process changes will reduce or eliminate the related event or near miss

38 What is Near Miss? Any process variation that did not affect an outcome but for which a recurrence carries significant chance of a serious adverse outcome (Sentinel Event) When an incident occurs, what is the process of reporting? All employees are required to report all incidents that jeopardize patient safety even if the incident almost happen or if it occurred but didn t reach the patient. Reporting of incidents should be done through one of the following: Online PSMMC incident reporting system Manual incident reporting form Calling extension # What events/incident should be reported? The following incidents are mandatory to be reported: Unanticipated death, including, but not limited to: Death that is unrelated to the natural course of the patient s illness or underlying condition (for example, death from a postoperative infection or a hospital-acquired pulmonary embolism); Death of a full-term infant. Suicide. Major permanent loss of function unrelated to the patient s natural course of illness or underlying condition; Wrong-site, wrong-procedure, wrong-patient surgery; Transmission of a chronic or fatal disease or illness as a result of infusing blood or blood products or transplanting contaminated organs or tissues; Infant abduction or an infant sent home with the wrong parents; and 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. In-patient falls. All confirmed transfusion reactions, if applicable to the hospital All serious adverse drug events, if applicable and as defined by the hospital All significant medication errors, if applicable and as defined by the hospital All major discrepancies between preoperative and postoperative diagnoses Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use Other adverse events; for example, health care associated infections and infectious disease outbreaks QPS.10 GAINING AND SUSTAINING IMPROVEMENTS Effective changes are incorporated into standard operating procedure, and any necessary staff education is carried out How do you make sure that Quality and Patient Safety information and education reaches the frontline staff? 38 P a g e

39 Orientation and information drive/campaign are provided to all staff regarding quality and patient safety activities hospital wide. Leaders, seniors and middle management teams are trained and provided with quality and patient safety related information that serves as a baseline in building internal capacity that facilitates the unit/department quality improvement and patient safety implementation. Related Policies for Quality and Patient Safety Standards Departmental Key Performance Indicators (KPI) Policy ( ) Performance Measurement ( ) Incident Reporting and Investigation ( ) Prevention & Control of Infections (PCI) PCI RISK-BASED APPROACHES AND TRACKING OF INFECTION RISKS, INFECTION RATES, AND TRENDS Each hospital must identify those epidemiologically important infections, infection sites, and associated devices, procedures, and practices that will provide the focus of efforts to prevent and to reduce the risk and incidence of health care associated infections. A risk-based approach helps hospitals identify those practices and infections on which they should focus their programs. A risk-based approach uses surveillance as an important component for gathering and analyzing the data that guide the risk assessment What Infection Control approved bundles were implemented in PSMMC? Infection Control Bundles: A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices generally three to five that, when performed collectively and reliably, have been proven to improve patient outcomes. All healthcare providers shall abide by the official PSMMC infection control bundles and guidelines that include: 1. Central line bundle 2. Ventilator bundle 3. Urinary catheters bundle 4. Multidrug resistant organisms PCI.7 RISK (INFECTION) REDUCTION STRATEGIES Infection risk is minimized with proper cleaning, disinfection, and sterilization processes. A policy identifies the process for ensuring proper handling of expired supplies. Single use devices utilization must be in accordance with national laws and regulation and professional standard. Hospital has a process of efficient waste management process and proper disposition of sharps and needles. What is the process of disinfecting and sterilizing your medical/surgical instruments? Disinfection and Sterilization: All hospital staff must be aware of the proper management of sterile items for patient care.

40 Before use on each patient, critical medical and surgical instruments must be sterilized. All reusable critical and semi-critical medical and surgical instruments should be precleaned and transport to CSSD or other designated sterilization area and processed by trained staff. Critical items include objects and items entering the vascular system and sterile tissue. Examples of critical items are surgical and dental instruments, cardiac and blood catheters, implants and needles, blood compartments of hemodialysis equipment, laparoscopes, arthroscopes, and other scopes that are introduced into sterile tissues. These items present a high risk of infection and require sterilization after each patient use. All reusable items in this category must be processed by the CSSD or designated area. Semi-critical item include objects and items that come in contact with intact mucous membranes and non-intact skin but do not penetrate body tissues or the vascular system. Examples of semi-critical items are non-invasive medical equipment, flexible and rigid fiberoptic endoscopes, respiratory therapy and anesthesia equipment, endotracheal tubes, and cystoscopes. These items may require either medium or high level disinfection after each patient use. Any reusable items in this category must be processed by CSSD or Endoscopy or designated area. Non-critical items include items and objects that come in contact with intact skin only. Examples of non-critical items are bedpans, blood pressure cuffs, tourniquet cuffs, and crutches. These items could potentially contribute to secondary transmission of microorganisms to healthcare workers hands; therefore, they require cleaning with hospital-approved disinfectant at the point of use. These items do not require CSSD service. Disinfection and sterilization of medical equipment is only allowed to be conducted in CSSD with exception of the following: Endoscopes: Semi-critical patient-care equipment (e.g., gastrointestinal endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment) should undergo high-level disinfection in Endoscopy Unit Bronchoscopes: Semi-critical patient-care equipment should undergo high-level disinfection in GICU bronchoscope processing room. Dental instruments: (except cassettes) will be sterilized in the Dental Department All sterile equipment should be appropriately stored 40 P a g e

41 What is the process of storing your medical supplies in your unit/department? All sterile patient care supplies and equipment must be stored appropriately to prevent moisture, extremes of heat or cold, dust and dirt, or tearing. What is your process in maintaining disinfection of surfaces and medical equipment/machines in your department? All staff must ensure that low level disinfection of clinical surfaces (whether inpatient or out-patient areas) and non-critical patient care equipment (blood pressure cuffs, glucometer, stethoscopes, mattresses, etc) are done when visibly dirty and on a regular basis in coordination with the housekeeping. After discharge of any patient, the housekeeping will conduct thorough cleaning of patient rooms and beds prior to admission of the next patient. How do you manage your supplies storage and expired consumables in your unit/department? Head nurses will conduct weekly rounds within their units/departments to ensure that all ward stocks are properly tagged, well-organized and not expired. NEAR EXPIRED ITEMS: Items/supplies that is about to expire within Six (6) months, a GREEN Circle Sticker will be indicated in the corresponding items/bins. Items/supplies that is about to expire within One (1) month, an ORANGE Circle Sticker will be indicated in the corresponding items/bins. EXPIRED ITEMS/SUPPLIES: Shall be pulled out from the bins, separated from other non-expired supplies and clearly labeled with the phrase EXPIRED DO NOT USE and sent to PSMMC supply department. Do you have a process for Reusing Single-Use-Devices? It is PSMMC policy that single use devices shall not be reused under any circumstances. What is the process of waste segregation and collection mechanism in your unit/department? All clinical waste moderately or heavily contaminated by patient fluids shall be discarded in yellow bags in designated trash bins. General waste such as medical supplies wrapper, papers, food foils will be disposed in black bags. Waste will then be collected by a designated person and brought to the waste designated area outside the clinical area. Yellow bags and black bags shall not be mixed under any circumstance. Sharps and needles must be disposed of in the sharp containers. Heavily contaminated or infected linens shall be placed in an alignate bags for laundry pick up. Any material contaminated by chemotherapy shall be discarded in special chemo bags.

42 Nurses shall clearly label infected cadavers and ensure that they call the mortuary to inform them of the infectious risk of the patient. How could you prevent a needle-stick injury? Prevention Strategies: Health care providers shall practice extreme caution when handling sharps and needles. Do not recap / manipulate / disassemble, (use one-handed method or mechanical device), discard sharps at point of use, pass instruments on a tray, verbalize actions when passing sharp items, handle sharps as little as possible. Inspect the sharps containers prior to disposing of sharps to ensure that the box is not filled up to 3/4, this step helps to prevent accidental injury while disposing. Close and remove sharp container that are 3/4 full Sharp Injury/Body Fluid Exposure: In the unfortunate incident of a exposure do the following: First Aid: Percutaneous Injury (ex. Needle Stick Injury/ Sharp Injury): Wash generously with soap and water, cleanse with alcohol wipes, and cover with appropriate bandages. Mucocutaneous & non-intact skin (ex. Splashes of Blood or body fluids to eyes and mucous membranes): Remove contaminated clothing and irrigate affected area with copious amounts of water. Report to Supervisor Fill out an SRS: Report for medical assessment at Clinic 104 or ER, and comply with follow up recommendations. PCI.8 BARRIER PRECAUTIONS AND ISOLATION PROCEDURES The hospital develops policies and procedures that establish the isolation and barrier procedures/precautions. What are the components of Standard Precautions? The basic practices needed to prevent or reduce the transmission of germs during healthcare-personnel-patients interactions. These work practices should be applied to all body fluids, wounds and mucous membranes. These must be used for all patient care regardless of diagnosis or presumed infectious status. These practices include: Strict hand hygiene according to the WHO 5Moments Alcohol-Based hand rubs Hand washing with soap and water Use of PPEs (personal protective equipment): Gown used to protect your skin and clothing during procedures or activities where contact with blood or body fluids are anticipated. Gloves are worn when there is potential contact with blood, body fluids, mucous membranes and non intact skin or contaminated equipment. Facemasks- when there is potential contact with respiratory secretions and sprays of blood and body fluids. 42 P a g e

43 Goggles/Face shields- wear eye protection for potential splash or sprays of blood, respiratory secretions, or other body fluids. Respirators (N95)- for potential exposure to infectious agents transmitted via the airborne route (e.g. pulmonary Tuberculosis) Use of aseptic techniques for all invasive procedures and any procedure requiring asepsis Use of Resuscitation devices Proper handling of contaminated equipment/patient care devices Appropriate handling, segregation and disposal of infectious wastes and sharps Safe injection practices Collection and handling of lab specimens Respiratory Hygiene and Cough Etiquette Do you know how to put on and remove PPEs? Use PPEs to prevent exposure or contact with infectious substances. Put on in this order: Perform Hand hygiene Gown: Select appropriate type and size, opening is in the back, secure at neck and waist Mask: Place over nose, mouth and chin, fit flexible nose piece over nose bridge, secure on head with ties or elastic, adjust to fit Eye and Face Protection: Position goggles over eyes and secure to the head using the ear pieces or headband, position face shield over face and secure on brow with headband and adjust to fit comfortably Gloves: Put on gloves last, select correct type and size, insert hands into gloves, extend gloves over gown cuffs Remove PPEs in this order: Example 1 1. Gloves 2. Hand hygiene 3. Goggles or Face Shield 4. Gown 5. Mask or Respirator 6. Wash Hands or use an alcohol-based hand sanitizer immediately after removing all PPE

44 Remove PPEs in this order: Example 2 1. Gown and Gloves (together) 2. Hand hygiene 3. Goggles or Face Shield 4. Mask or Respirator 5. Hand hygiene Why should you perform hand hygiene? Hand Hygiene is the most effective measure to prevent healthcare associated infections (HAI) 1. To protect the patient against harmful germs carried on your hands or present on his/her own skin. 2. Protect yourself and the health care environment from harmful germs When should you perform hand hygiene? 1. Where ever health care is given, there are 5 moments (indications) when it is essential that you perform hand hygiene (see IPSG.5 in this manual) 2. At the bed side, in ambulatory clinics and non in-patient care area (Emergency, dental, ENT, hemodialysis, etc) 44 P a g e

45 How should you perform hand hygiene? 1. Perform hand washing when hands are visibly soiled 2. Perform hand washing with patient having Clostridium difficile 3. The use of gloves does not replace the need for hand hygiene by either hand rubbing or hand washing. What can we do to prevent the transmission of MDROs and other infectious diseases? Isolation Precautions: are extra measures, based on the mode of transmission, used when infectious status of patient is known or suspected with epidemiologically significant organism (e.g. highly transmissible or multidrug resistant germs). This must be used in conjunction with Standard Precautions. Contact Isolation: To prevent the spread of infection by contact route. Requires a single room, used for patients known or suspected to be infected or colonized with resistant, epidemiologically important or highly transmissible germs such as MRSA, VRE, etc. Droplet Isolation: To prevent the spread of infections spread by droplet contact route to mucous membranes, conjunctiva, nose and mouth. Droplets generated by coughing, sneezing and suctioning. Requires close contact ( 3ft) for transmission of diseases such as Pertussis, Mumps, Rubella, Invasive Neisseria meningitides. Airborne Isolation: To prevent the spread of infections by airborne route. Requires a single room with negative pressure ventilation, used for patients known or suspected to be infected by Measles, Varicella, Pulmonary Tuberculosis. Nurses on the Isolation Ward will test the negative pressure rooms on a daily basis. If Negative Pressure Room (NPR) is not available, what alternatives are available? NEWLY ADMITTED PATIENT: If no NPR is available in the Isolation Ward, the admission coordinator will facilitate in evacuating any NPR in the ward if there is any patient eligible for discharge.

46 TRANSFERRING IN-PATIENTS TO ISOLATION WARD: Call admission coordinator will facilitate in evacuating any NPR in the ward if there is any patient eligible for discharge. In rare cases that Isolation Ward is filled with patients with airborne infection (suspected/confirmed), call A&E Team Leader and liaise with him/her to transfer the patient to NPR in A&E Area E. If no NPR is available in A&E, the staff will coordinate with the admission coordinator and place the patient in a single room with door closed. Staff must wear N-95 mask before entering the room. Patient will be transferred to NPR in isolation ward or A&E once room is available. PATIENTS IN A&E DEPARTMENT: Patients with suspected airborne infectious disease (pulmonary TB, Chicken pox, Measles, etc) will have a priority usage of NPR in A&E Area E. CONFIRMED CASES: Admit to Isolation Ward IF no NPR in Isolation Ward, place patient in NPR in A&E Area E. SUSPECTED CASES (Paedeatric and Adult): Place patient in NPR in A&E Area E and initiate appropriate investigations. IF no NPR in A&E Area E, transfer patients to isolation ward for screening and assessment. Transfer must not be delayed for any reason. When NPR Is not available in the hospital for suspected or confirmed Open Pulmonary TB, the patients will be Placed in a single room in A&E Department, doors are closed and use portable HEPA Filters (if available). N-95 mask is required before entering the room. Arrange for patient transfer to MOH Hospital (King Saud Chest Hospital) (ph.# ) IF NPR becomes available before transferring the patient, place him/her immediately in the NPR Room. When NPR is not available in the hospital for suspected or confirmed Not Open Pulmonary TB, the patients will be Placed in a single room in A&E Department, doors are closed and use portable HEPA Filters (if available) until NPR is available. N-95 mask is required before entering the room. Discharge the patient if he/she is medically fit to go home. Transfer the patient to NPR in A&E or Isolation ward when NPR room becomes available. OUTPATIENTS: SUSPECTED/CONFIRMED CASES (Pediatric and Adult): Admitted to Isolation ward. If NPR is not available in Isolation Ward, call A&E Team Leader and liaise with him/her to transfer the patient to NPR in A&E Area E. If no NPR is available in Isolation ward and A&E, place the patient in a single room in OPD or in A&E in liaison with team leader, use portable HEPA Filter if available. Staff must wear N-95 mask before entering the room. Initiate test and confirm diagnosis. For patients with OPEN PULMONARY TB (Suspected/Confirmed), arrange for patient transfer to MOH Hospital (King Saud Chest Hospital) (ph.# ) 46 P a g e

47 Discharge patients with NOT OPEN PULMONARY TB, if patient health condition and home situation allows. PCI.11 STAFF EDUCATION The hospital must have an effective infection prevention and control program, and must educate staff members about the program when they begin work in the hospital and regularly thereafter Infection Prevention and Control activities/trainings/orientation. Infection Control and other department coordinate in terms of staff education and awareness. Education on the principle and practices of infection control is important to the prevention of hospital acquire infection (HAI). This education can be in general orientation program, Infection Control department yearly activities, lectures given on the units, handouts, consultations, etc. Applying this infection control knowledge during daily patient care activities will reduce and prevent transmission of infections to our patients, staff, and visitors. This education is empowering can allow staff recognized infection risks and apply prevention strategies. Did you attend any of the following: TB Day activities Annual IC Education HW MERS-CoV education (English, Arabic, Tagalog) JCI Accreditation Education -PCI Standards HW HH Campaign Related Policies: Infection Prevention and Control Risk Assessment and Plan ( ) Management of Exposure to Blood Borne Pathogens Policy ( ) Prevention of Central Line-Associated Blood Stream Infections (CLABSI) 9415 policy ( ) Prevention of Central Line- Associated Blood Stream Infections (CLABSI) in Neonates and Young Infants (2 months) Policy ( ) Management of Multidrug Resistant Organisms (MDRO) Policy ( ) Standard Precautions Policy ( ) Contact Isolation Precautions ( ) Droplet Isolation Precautions ( ) Airborne Isolation Precautions ( ) Admitting Patients to Negative Pressure Rooms ( ) Governance, Leadership, and Direction (GLD) GLD.1.2 GOVERNANCE OF THE HOSPITAL The governing entity has important responsibilities that must be carried out for the hospital to have clear leadership, to operate efficiently, and to provide high-quality health care services. Approving and periodically reviewing the hospital s mission and ensuring that the public is aware of the hospital s mission

48 What is the Mission and Vision of PSMMC? Mission: Vision: PSMMC Management is committed in providing the best expectations; full commitment to the Principles of Continuous Quality Improvement; providing the optimum support to all employees through effective training; improving the management operations efficiency; and to ensure a continuous improvement work culture. Prince Sultan Military Medical City is inspired to be the premier hospital in providing the highest standards of healthcare services for its patients, to be the benchmarked hospital in the kingdom, and to achieve Excellency in all specialties in the Middle East. GLD DEPARTMENT/SERVICE SCOPE OF SERVICE AND QUALITY AND PATIENT SAFETY The department/service leaders collaborate to determine the uniform format and content of the department-specific planning documents. In general, the documents prepared by each clinical department define its goals, as well as identify current and planned services. The Department/service leaders engage their staff in improvement activities that reflect the hospitalwide priorities and address the clinical or nonclinical activities specific to the department or service. What is your department s/unit s Scope of Services? The department/unit staff should describe their Unit Description, Function, Services (eligible to avail the service), hours of operation, staff-patient ration, staff professional and developmental growth support, mode of communication and quality programs implemented within the department/unit. What quality and patient safety program is/are implemented in your department/service? The staff being asked should specify the quality and patient safety programs implemented within the department such as; Six (6) IPSG s Prevention of Hospital Acquired Infection Prevention of Hospital Acquired Pressure Ulcers Prevention of Patient Fall Program Patient and Staff Safety (Fire and Environmental Safety) Periodic Maintenance and Management of Medical Equipment What approved Key Performance Indicators (KPI) are being measured/monitored in your department? Show the surveyors of what indicators are being monitored in your department/unit and its current compliance status. Example; Hand Hygiene Compliance with compliance rate up to present Fall Prevention Rate up to present Others. 48 P a g e

49 Do you have an approved clinical practice guidelines in your department/service that guides clinical care practices? On an annual basis PSMMC administration shall develop hospital wide evidence based guidelines. Clinical staff must be aware about any PSMMC guideline that is related to their department. Guidelines shall be disseminated though CQI department and a copy can be found on the PSMMC intranet under the CQI website. Staff must ensure compliance with any PSMMC guideline. Show the surveyors the approved clinical practice guideline (either hardcopy filed in the unit/department or soft copy via intranet). Know the current compliance data of your respective department and emphasize that the compliance monitoring data will be used to improve the performance Patient safety through implementation of the Clinical Practice Guideline. GLD.13 CULTURE OF SAFETY The hospital leadership implements, monitors, and takes action to improve the program for a culture of safety throughout the hospital. Hospital leadership encourages teamwork and creates structures, processes, and programs that allow this positive culture to flourish. How do you ensure that a culture of (patient) safety is being implemented in your department/service? Policies and Procedures, Protocols, and Guidelines are enforced and empowered to all staff within the department/unit. Reporting incidents/events in CQI and PS Department Staff must be comfortable in reporting any issue related to safety without the fear of retribution Collaboration across ranks and disciplines to seek solutions to patient safety problems Improvement initiatives are initiated to optimize Patient Safety Programs implemented in the department/unit. Organizational commitment of resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns. Culture of Safety survey is monitored by Continuous Quality Improvement and Patient Safety Department. Facility Management and Safety (FMS) FMS SAFETY AND SECURITY The hospital develops and implements a comprehensive, proactive risk assessment to identify areas in which the potential for injury exist. The hospital must have a security program to ensure that everyone in the hospital is protected from personal harm and from loss or damage to property. Staff, vendors, and others identified by the hospital, such as volunteers or contract workers, are identified by badges (temporary or permanent) or other form of identification. Others, such as families or visitors in the hospital, may be identified depending on hospital policy and laws and regulations

50 How do you ensure safety and security of your patients and protect them from harm? All employees, patient families, visitors, contractors will have identification badge issued by the security department. All visitors will obtain permission from the security office at Building 54. Sales/Service representatives shall obtain a visitor s ID badge from the security office worn in PSMMC premises. Security staff on duty will stop and question unidentified individuals in any areas. FMS HAZARDOUS MATERIALS A hazardous materials program is in place that includes identifying and safely controlling hazardous materials and waste throughout the facility Information regarding procedures for handling or working with hazardous materials in a safe manner must be immediately available at all times and includes information about the physical data of the material (such as its boiling point, flashpoint, and the like), its toxicity, what effects using the hazardous material may have on health, identification of proper storage and disposal after use, the type of protective equipment required during use, and spill-handling procedures, which include the required first aid for any type of exposure. (Material Safety Data Sheets [MSDS]) What procedure will you follow in case of a chemical/cytotoxic spill? Spilled liquid will be identified first through MSDS and follow its indicated instructions. Notify the people in the immediate area, the supervisor and Environmental Health and Safety Department (EHSD). For Major Spills, evacuate all staff from the area and close all doors. Wait by the spill area (out of danger) until help arrives. Obtain appropriate PPE in reference to MSDS. Complete incident report on spill/leaks. What is your process on safe handling and storage of chemicals used in your department/unit? All hazardous materials (HazMat) are stored in a designated supply closet for chemicals only, well identified through proper labeling with hazard description. How do you handle and manage your infectious waste in your department/unit? Staff are oriented and empowered to use appropriate PPE s when handling wastes. All infectious wastes are disposed according to its classification whether if it is a medical (YELLOW BAG) or non-medical (BLACK BAG) wastes. There is a designated waste bins available in all clinical areas. Conracted service personnel collect hazardous and infectious wastes in our department/unit to bring it to the waste storage area located in a separate building. FMS FIRE SAFETY A hospital establishes a program in particular for the prevention of fires through the reduction of risks, such as safe storage and handling of potentially flammable materials, including flammable medical gases such as oxygen; hazards related to any construction in or adjacent to the patient-occupied buildings; safe and unobstructed means of exit in the event of a fire; 50 P a g e

51 early warning, early detection systems, such as smoke detectors, fire alarms, and fire patrols; and suppression mechanisms, such as water hoses, chemical suppressants, or sprinkler systems. What are the PSMMC Codes/Hotlines in case of emergency situations? Code Implication Hotline CODE F Fire 555 Cardiac Call (Adult/Pediatric) Cardiac Arrest 444 Stroke Call Stroke 555 CODE E Evacuation Security IN CASE OF EMERGENCY Aggressive Patient Armed Incidents Child Abduction Missing Patient/Child Others Main Hotline: Alternate Hotlines: Morning Security Supervisor 1 Bravo: Evening Security Supervisor 2 Bravo: EXTERNAL DISASTER ANNOUNCEMENT Code Yellow Stand By Code Red Full Alert Code Green Stand Down What would you do in case of fire? (RACE) R Rescue A Activate the Alarm C Confine the Fire E Evacuate In case of fire, who is responsible to shut off the medical gas valve in your unit? The unit Head Nurse is responsible for shutting the medical gas valve. In the absence of the HN, the Charge Nurse may turn it off (especially at night shift). Portable oxygen cylinder must be with the patient needing oxygenation prior to shutting off the valve.

52 How do you operate Fire Extinguisher? P Pull the pin A Aim at the Base of the Fire S Squeeze the handle trigger S Sweep nozzle/handle side to Side Where is the nearest exit, fire extinguisher in your area? Is it maintained and managed well? (the staff should point the nearest fire extinguisher to the surveyor) Fire extinguishers should be checked by the responsible staff on a monthly basis with appropriate documentations. How would you know your exact location and where to go in case of fire? (the staff need to show the location of the evacuation map posted within the vicinity of the department/unit) The staff must be fully aware of the nearest fire alarms, evacuation procedures, exits, routes and assembly points designated of the unit. What is the hospital s policy on smoking? PSMMC has a smoke free policy and smoking is not permitted within hospital buildings and grounds. FMS MEDICAL TECHNOLOGY To ensure that medical technology is available for use and functioning properly, the hospital performs and Documents the following; an inventory of medical technology; regular inspections of medical technology; testing of medical technology according to its use and manufacturers requirements; and performance of preventive maintenance. How do you ensure that medical equipment are safe for patient use and well maintained? Do you have evidence? All medical equipment will be evaluated by the Biomedical Engineering prior to its use. Staff training/orientation will be conducted by the vendor (when required) in effect to the endorsement of the Biomedical Engineering Department for the new Medical equipment to the department/unit. Periodic and Preventive Maintenance schedule is conducted by the Biomedical Engineering Department to ensure medical equipment functionality and for safe use to the patients. 52 P a g e

53 What is the process should be followed if a medical equipment malfunctions? All medical equipment that are malfunctioning or having erroneous results will be tagged DO NOT USE, OUT OF ORDER. it will be separated from functioning medical equipment. biomedical engineering will be notified eventually for their action. FMS.11 STAFF EDUCATION Hospital staff needs to be educated and trained to carry out their roles in identifying and reducing risks, protecting others and themselves, and creating a safe and secure facility As a staff, have you received any actual training on how to classify and use fire extinguisher, managing chemical/biological spills, medical equipment management? Yes. All staff are required to attend Fire Safety, Biological and Hazardous Spill Management, and medical equipment handling and management Training conducted by the responsible Department of PSMMC upon joining or during the probationary period as part of our orientation program. As a staff, have you received refreshers training for each component of the FMS programs on an annual basis? Yes. All employees will be educated (in-service) annually in a mandatory continuing education program which include all safety programs (Safety and Security, Hazardous materials, Emergency Preparedness, Fire safety, others) Staff Qualification & Education (SQE) SQE.2 RECRUITING, EVALUATING, AND APPOINTING The hospital provides an efficient, coordinated, or centralized process for recruiting individuals for available positions; evaluating the training, skills, and knowledge of candidates; and appointing individuals to the hospital s staff. How do you ensure that healthcare staff are qualified (By- Law) to care and intervene to patients needs in the clinical area? Saudi commission license: All health care providers must ensure that they are registered from Saudi Commission for Health Specialties and must possess a valid license (up-to-date). In case the license is outdated, they are required to renew their license as soon as possible. Failure to renew their certification will result in suspension of contract renewal and physicians will be subject for withdrawal of their clinical privileges.

54 Healthcare providers that don t have a valid and updated license must work under supervision until their license is renewed SQE.7 ORIENTATION PROGRAM A new staff member, no matter what his or her employment status, needs to understand the entire hospital and how his or her specific clinical or nonclinical responsibilities contribute to the hospital s mission. This is accomplished through a general orientation to the hospital and his or her role in the hospital and a specific orientation to the job responsibilities of his or her position. As a staff, did you receive an Orientation Program upon joining PSMMC? Yes. All new clinical and nonclinical staff members are oriented to the hospital, to the department or unit and to their specific job responsibilities. SQE.8.1 COMPETENCE IN RESUSCITATIVE TECHNIQUES The hospital identifies those staff to be trained in resuscitative techniques and the level of training (basic or advanced) appropriate to their roles in the hospital How do you ensure that PSMMC healthcare providers can provide intervention related to life-threatening emergencies? All health care providers must ensure that their Basic life support certification is valid. Those required to have any type of advance life support must also ensure that certification is valid In case the certification is outdated, they are required to renew their certification. Failure to renew their certification will result in suspension of contract renewal and physicians will be subject for withdrawal of their clinical privileges. How do you ensure that all staff has complied with all necessary requirements to work/practice in PSMMC? All healthcare providers are required to ensure that their employee file is completed and updated to include the following: 1. Copy of their CV 2. Copy of their certificates 3. Copy of their Saudi license 4. Copy of their BLS & other advance live support 5. Copy of work history 6. Copy of job description/ clinical privileges 7. Copy of evaluation 8. Copy of in-service training SEQ.8.2 STAFF HEALTH AND SAFETY PROGRAM A hospital s staff health and safety program is important to maintain staff physical and mental health, satisfaction, productivity, and safe conditions for work 54 P a g e

55 Do you have health insurance services for PSMMC staffing? PSMMC has a staff health program that ensures that his medical record is valid to get his urgent and non-urgent healthcare services within the hospital. It is ensured that he/she get all required vaccination and immunization. Staff is also oriented to contact the preventive health medicine if the staff is exposed to risk of infectious diseases. SQE.9 DETERMINING MEDICAL STAFF MEMBERSHIP Medical Membership requires documents where some of which are required by law or regulation, but some by hospital policy and must be verified from the original source that issued the document. What is the medical credentialing and privileging process in PSMMC? CREDENTIALING: All medical staff are credentialed by the designated and responsible credentialing committee. All staff must have complete credential file that contain Appointment letter. Ensure re-credentialing is done every three (3) years PHYSICIAN CLINICAL PRIVILEGES: Medical staff applies for clinical privileges and submitted to his direct/immediate supervisor of the department for review and recommendation for appointment by the Medical Director. Medical staff must ensure to have copy of his/her granted clinical privileges from credential and appointment team. Medical staff must ensure to practice his profession within his/her approved clinical privileges. Reappointment process will be based on the performance of the medical staff. SQE.11 ONGOING MONITORING AND EVALUATION OF MEDICAL STAFF MEMBERS The process of ongoing monitoring and evaluation is intended to Improve individual practices as they relate to high-quality, safe patient care; Provide the basis for reducing variation within a department/service through comparisons among colleagues and the development of practice guidelines and clinical protocols; and Provide the basis for improving the results of the entire department/service through comparisons with external benchmark practices and published research and clinical results. How does the evaluation of medical staff work in PSMMC? Medical staff evaluation in PSMMC is data driven. Medical staff are evaluated for their behaviors, professional growth commitments and clinical results/outcome related to their scope of clinical privileges. BEHAVIOURS: committed to hospital code of ethics PROFESSIONAL GROWTH: actively participated in continuous medical education activities and updates such as grand rounds, symposiums, forums. CLINICAL RESULTS: patient care outcomes based on clinical privileges.