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Egyptian HealthCare

ccreditation Program

Survey Process Guide

For

Hospitals

DRAFT

April 2015

Ministry of Health

Minister Office Sector

Accreditation Committee For

Healthcare Organizations Egyptian Accreditation Committee

For Healthcare Organizations




2

Contents

The mission , vision and values 3

Egyptian Accreditation committee Surveys:

General Information

5

Which Hospital is Eligible for the Egyptian Standards AccreditationSurvey?

5

Survey Scheduling, Postponements, and Cancellations 10

Accreditation Decision Rules (Effective 1 April 2015) 15

Tracer Methodology 17

The Accreditation Decision 22

Survey Agenda 24

Sample Survey Agenda 25

Detailed Description 29

Opening Conference and Agenda Review 25

Orientation to the Hospital’s Services and the Quality Improvement

Program

32

Surveyor Planning Session 34

Document Review 37

Daily Briefing 42

Leadership for Quality and Patient Safety Interview 44

Department/Service Quality Measurement Tracer 47

Individual Patient Tracer Activity 49

Facility Tour 52

Appendix 56




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Egyptian Accreditation Program for Healthcare Organization

The mission of Egyptian Accreditation program for Healthcare Organization is

to empower Egyptian healthcare facilities and increase public demand to deliverquality health services and continuous quality improvement through theaccreditation approach.

The vision is to enable all Egyptians to receive equitable and quality health care.

Hence, Accreditation is to be used by the government as a contribution towardsregular & public accountability.

The values of the program are integrity, quality, accuracy, transparency, honestyand cost-effectiveness.

The Code of conduct of the program includes the following four principles: Legalcompliance, confidentiality, conflict of interest.




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Introduction

The Egyptian Standards Hospital Survey Process Guide, first Edition is designed tohelp hospitals learn about and be better prepared for the accreditation surveyprocess. This guide provides hospitals and academic medical center hospitals with

important information about, the hospital standards manual, eligibility foraccreditation, how to request accreditation, survey preparation, the on-site survey,and the accreditation decision.

Hospitals should not hesitate to contact the Egyptian Accreditation committee

Office by telephone or e-mail using the contact directory for any other information.

Contact Egyptian Accreditation Committee

Questions about Accreditation

• For general inquiries regarding accreditation services, to schedule an

accreditation survey or ask about the application process please emailEgyptian Accreditation committee at [email protected] or call+(202) 27948901 . Fax. (202) 27948901.

• To comment about quality or safety at an accredited organizationplease email

• For general inquiries regarding advisory and educational services,please email.

mailto:[email protected]





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Egyptian Accreditation Surveys:

General Information

Which Hospital is Eligible for the Egyptian Standards AccreditationSurvey?

Any hospital may apply for Egyptian Accreditation committee to get any level of theEgyptian Accreditation if it meets all the following criteria:

• The hospital is currently operating as a health care provider in the country, islicensed to provide care and treatment as a hospital (if required), and, at minimum,

does the following:- Provides a complete range of acute care clinical services —diagnostic,

curative, and or rehabilitative.

- In the case of a specialty hospital, provides a defined set of services, such aspediatric, eye, dental, and psychiatry, among others.

- For all types of hospitals, provides services that are available 365 days per

year; ensures that all direct patient care services are operational 24 hours perday, 7 days per week; and provides ancillary and support services as neededfor emergent, urgent, and/or emergency needs of patients 24 hours per day,

7 days per week (such as diagnostic testing, laboratory, and operatingtheatre, as appropriate to the type of acute care hospital).

• The hospital provides services addressed by the EGYPTIAN AccreditationStandards.

• The hospital assumes, or is willing to assume, responsibility for improving thequality of its care and services.

• The hospital is open and in full operation (see below), admitting and

discharging a volume of patients that will permit the complete evaluation ofthe implementation and sustained compliance with the Egyptian Standardsfor Hospital Accreditation.

The applicant academic medical center hospital must meet each of the criteria above

in addition to the following criteria:1) The applicant hospital is organizationally or administratively integratedwith a medical school or an educational authority2) At the time of application, the applicant hospital is conducting

academic and/or commercial human subject's research under multipleapproved protocols involving patients of the hospital.




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Full Operation

Full operation means the hospital accurately identifies the following in its electronicapplication (E-App) at the time of application:

• All clinical services currently provided for inpatients and outpatients.(Those clinical services that are planned and thus not identified in the

application and begin operations at a later time will require a separateextension survey to evaluate those services.)

• Utilization statistics for clinical services showing consistent inpatientand outpatient activity levels and types of services provided for at least

four months or more prior to submission of the application.• All inpatient and outpatient clinical services, units, and departments

identified in application form are available for a comprehensive

evaluation against the Egyptian Accreditation Standards for Hospitalsthrough normal survey process for the size and type of organization,such as

- patient tracer activities, including individual patient and systemstracers;

- open and closed medical record review;

- direct observation of patient care processes;- interviews of patients and interviews with medical

students/trainees.

Note: Contact Egyptian Accreditation Committee prior to submitting an applicationform to discuss the criteria and validate whether the hospital meets the above

criteria for ―in full operation‖ at least four months or more prior to submittingits application and at its initial survey.

Egyptian Accreditation Standards may request documentation of the hospital’sutilization statistics prior to accepting the application or conducting the on-

site survey. In addition, Egyptian Accreditation Standards will not begin anon-site survey, may discontinue an on-site survey, or may cancel a scheduledsurvey when it determines the hospital is not "in full operation."

Licensure, scope and volume of patient services, and types of patient carefacilities, among other factors. When any of these factors change, EGYPTIAN

Accreditation Committee must make a deliberate determination if the changeis within or outside of the scope of planned initial survey or the scope of acurrent accreditation award. Thus, the hospital notifies Egyptian Accreditation

Committee before the change or within 15 days of changes in such coreinformation from the hospital’s profile, including, but not limited to, the




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following:

- A change in hospital ownership and/or name- The revocation or restriction of operational licenses or permits, any

limitation or closure of patient care services, any sanctions of

professional or other staff, or other actions under laws andregulations brought by relevant health authorities

- Alteration or changes in use of patient care buildings, construction

of new or expansion of patient care buildings, or the occupation ofbuildings in new locations in the community, to expand the types

and volume of patient care services 25% or more than was statedin the hospital’s profile or was not reported as a patient carelocation in the Application form, or was not included in the scope of

the previous accreditation survey- The addition or deletion of one or more types of health care

services, such as addition of a dialysis unit or discontinuation of

trauma care- The hospital has merged with, consolidated with, or acquired an

unaccredited site, service, or program for which there are

applicable Egyptian Accreditation Standards.

Egyptian Accreditation Committee may conduct an additional survey for all or

a portion of the hospital again or for the first time in the case of new facilities orservices. Egyptian Accreditation does not automatically extend accreditation to newservices and facilities without an on-site evaluation.

Evaluation begins during the application process and continues as long as thehospital is accredited by or seeking accreditation by EGYPTIAN Accreditation

Committee. Changes reported may be evaluated off-site or by a focused survey.

If the hospital does not provide notification to the EGYPTIAN AccreditationCommittee in advance or within 15 days of these changes, the hospital will beplaced At Risk for Denial of Accreditation and a focused survey will be conducted.




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How to Request an EGYPTIAN Accreditation Survey

Hospitals that wish to be accredited by EGYPTIAN STANDARDS can obtain anapplication for survey by accessing the application form on the EGYPTIAN

Accreditation Committee icon on MOH website.

To begin the accreditation process as a new applicant, fill the application form andsend it by mail to Egyptian Accreditation Committee for Healthcare organization.

Egyptian Accreditation Committee requires organizations to submit one applicationfor each hospital to be surveyed at minimum three months prior to the hospitalsrequested survey dates. This allows the Egyptian Accreditation Committee the

flexibility to assign the most appropriate team of surveyors to your organization.

From the information your hospital submits, Egyptian Accreditation Committee willdevelop an accreditation contract specifying cost, number of surveyors, number ofsurvey days and other details.

The application for survey is valid for six months from the date it is submitted; this

means a hospital can submit its application and have time to finish surveypreparations before the on-site survey takes place. Hospitals should request surveydates when the hospital is confident it will be able to demonstrate a four-month

track record of compliance with the standards at the time of the on-site survey (readmore in Accreditation Preparation).

In its Application, hospitals must indicate three months when it would like thesurvey to take place. EGYPTIAN Accreditation Committee will make every effort to

accommodate these time requests. The earlier the request is submitted, the morelikely the specific requests can be accommodated.

After the application for survey is received, the EGYPTIAN Accreditation Committeerepresentative will contact the hospital. EGYPTIAN Accreditation Committeerepresentative will answer the hospital’s questions about survey preparation and

help guide individuals through each step of the accreditation process.

EGYPTIAN Accreditation Committee schedules on-site surveys based on informationprovided in the application for survey, determines the number of days required for asurvey, the composition of the survey team, and the services to be reviewed.

Three to six months before the survey, the accreditation survey contract agreementwill be sent to the hospital. Until the signed contract agreement and the downpayment of at least 50% of the survey fees are received, the scheduled survey




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cannot be confirmed. The hospital will also receive notification of the surveyor’s(s’)name(s) before its survey. The survey team leader will contact the person

responsible for the hospital’s survey approximately four to eight weeks before thesurvey to finalize the agenda and to coordinate the availability of certain staff forkey survey activities, as well as to provide information regarding the surveyor’s(s’)

travel arrangements and logistics. For governmental ministry of health hospitalsfinancial arrangement may be different.

As noted in the Accreditation Participation Requirements, EGYPTIAN AccreditationCommittee collects core information regarding each hospital’ s profile in its

Application to understand ownership.




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Survey Scheduling, Postponements, and Cancellations

Initial Schedules for Surveys

Egyptian Accreditation Committee schedules surveys systematically and efficiently to

keep accreditation fees to a minimum. Therefore, hospitals are encouraged toaccept scheduled survey dates. Initial surveys (a hospital’s first full accreditation

survey) should be scheduled within six months from the time Egyptian AccreditationCommittee receives the hospital’s application for survey.

Egyptian Accreditation Committee tries to honor specific requests for times duringwhich a hospital prefers not to be surveyed. The hospital should include thesespecific dates in the completed application for survey, when possible. There may,

however, be circumstances that prevent Egyptian Accreditation Committee from

accommodating these dates.

Definition of Postponement

Egyptian Accreditation Committee also allows the postponement of initial surveys or

re-surveys. A postponement is a hospital’s request to alter an already scheduledsurvey date or to push back the survey date before it is actually scheduled. Ahospital should submit a request for a postponement via email to the committee. A

new survey application may be required when a new date is established if theoriginal application is older than six months.

Acceptable Reasons for Postponement

A hospital may postpone scheduled surveys when one or more of the followingevents occur:

• A natural disaster or another major unforeseen event that totally orsubstantially disrupts operations

• A major strike that causes a hospital to cease accepting patients andto transfer patients to other facilities

• Patients and/or the hospital are being moved to another buildingduring the scheduled survey

Egyptian Accreditation Committee reserves the right to conduct an on-site survey if

the hospital continues to provide patient care services under such circumstances.Prior to postponing a scheduled survey, it is recommended that hospitals contactEgyptian Accreditation Committee.






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Introduction to Egyptian HealthCare Accreditation Organization Standards

The Egyptian HealthCare Accreditation program is designed to encourage allhospitals and clinics to become accredited over time. There are three programs:

Hospital, Ambulatory, and Primary Healthcare Clinics/Family Health Units, each

program with it’s own manual. Clinics and ambulatory units associated with ahospital will be surveyed under the hospital standards at the same time the hospital

is surveyed.

Process of Standards Development

The previous accreditation standards were reorganized into a format that wassystem based and easily understood. Many new standards were developed and

included to cover multiple areas that were needed but not present. The standardswere then classified as A, B or C. This enabled the development of structures first (Astandards) and then gradual success through implementation of the B standards

then the C standards. The standards underwent multiple reviews by various

stakeholders. Recommendations for changes were reviewed and, if appropriate,were accepted and incorporated into the final manuals.

ISQua Accreditation Awarded: As a final step, the standards were submitted for assessment by The International

Society for Quality in Health Care (ISQua the ―Accreditors of the Accreditors‖).ISQua Accreditation for the three standards manuals was awarded June 29, 2007.This accreditation is in effect for 4 years. Reassessment and ISQua reaccreditation

of the hospital standards was achieved in 2013 (seventh edition). The seventhedition of hospital standards includes a total of 777 standards.

Standards Structure:The rating system is designed to maximize inter-rater reliability. The system uses A,

B and C labels. B and C standards require a specific number of observeddeficiencies. To provide transparency for scoring and enable frequent self-assessment, the scoring has been added to each standard in the manuals as shown

below. The first column indicates if this is an A, B or C standard. This is followed bya series of 4 boxes which are used for scoring. The letters in the boxes are M forMet, P for Partially Met, N for Not Met and NA for Not Applicable. Since the A

standards are essential structures they cannot be partially met. Therefore, a P box(box is grey) does not exist as these standards can only be scored Met, Not Met or

NA. The B and C boxes are scored based on the number of deficiencies observedand therefore can be scored P for Partially Met.

A standards

The A standards are structures and are scored as M= Met (totally present) or N=Not Met (not totally present) or NA as Not Applicable. Structures include policy andprocedures, plans, bylaws, required committees and other specified items. ―A‖

standards with numbered elements (example PR.1 with elements 1 through 10)




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require all elements to be present in order to be scored as Met. If any one of thenumbered elements were lacking or is inadequate this standard will be scored as

―Not Met‖. The A standards are therefore scored all or none. The A standardsrepresent 25% of the total hospital accreditation standards.

B & C standardsThe B and C standards are implementation standards. These standards are scoredeither based on the number of observations, documentation of deficiencies, or non-

compliance with the standard. The scoring is M (Met) = 0 – 1 observations and/ordocumentation deficiency; P = (Partially Met) = 2 observations and/or

documentation of deficiencies; and N = (Not Met) = 3 or more observations and ordocumentation of deficiencies.

The difference between the B and C standards is:(a) the increasing difficulty in the implementation process of C standards, (b)

achieving compliance with the C standards, or (c) a standard that is not applicable

on an initial survey which requires a 4 month track record (example an annualreport that requires 12 months to complete it). The B and C standards represent75% of the total hospital standards.

Staging – Levels:The design of the accreditation process is flexible. An organization may choose to

seek full accreditation or they may choose to achieve accreditation over a period oftime by making incremental improvements in the development and implementationof processes and systems. Changes in the seventh Edition: The foundation level

standards include fixed specific standards to comply with. These represent 40% of

the total standards. It includes A and B standards. ( table 1) .

These changes were done for the following reasons:a) Reduce variability in the choice of standards by the organizations

b) includes 45%of the B standards that will show improvement in patient carec) shorten the duration of achieving the foundation level

Achieving the foundation level means compliance with 90% of the total

foundationstandards and 75% of the patient safety standards.

There are three levels of achievement:

• Foundation level –(136 A standards+179 B standards )• Basic Quality – Level 2 (181 A standards+ 252 B standards + 35 C standards)• Accreditation Level - Final level- (compliance at least 82% of the totalstandards )




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Scoring Standards – Summary

• A – structures – policy/procedures, plans, required committees(all or none scoring) Met

Present – all elements

Not MetNot present with all elements

• B & C – implementation - frequency based - observations of deficiencies Met

Zero to 2 observed or documented deficiency Partially Met

3 observed or documented deficiencies

Not Met4 or more observed or documented deficiencies

B versus C standards

B standards are to be implemented first (easier)C standards are more difficult to implement or not needed for an initial survey

Accreditation Process:The accreditation process begins with an initial self-assessment.

The foundation level of accreditation is the least level required for contracting withthe new Egyptian insurance Program.

A +B Standards

Foundation Level

Basic Quality Level

A+B+C

Standards Accreditation

A+B+C

Standards

Pyramid of Excellence in Egyptian HealthCare Accreditation

Application




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• After Achieving the Foundation level: it is valid for 18 months and theorganization will be legible for resurvey after 18 months.

• After achieving the Basic Level: it is valid for 18 months and theorganization will be legible for resurvey after 18 months.

• Accreditation Level: it is valid for 3 years and the organization will be

legible for resurvey after 3 years.

Request for Survey/Assessment:

*A request is to be sent on by mail to Egyptian Accreditation committee*The organization has to complete the application for survey

*Application for survey: the organization can apply for evaluation againstany level of accreditation

1-Foundation level:a) Initial assessmentb) Mock survey

c) Final survey

2-Basic level :

a) Initial assessmentb) Mock surveyc) Final survey

3-Full Survey for Accreditation (against all the standards):a) Initial assessment

b) Mock survey

c) Final survey

The organization that requests survey against all the standards and achieved a scorethat is matching with the foundation/basic /final survey. The organization will be

granted the level of accreditation irrespective of the types of the standards in eachlevel.

Other Considerations

The Look-Back Period for New Standards

The effective date of new standards is published with the standards. Hospitals are

expected to be in compliance with the standards on the published effective date.The look-back period for new standards can go back only to the effective date of the

standard. Thus, for a new first edition standard, the look- back period on a 1 Julytriennial survey is 3months back for existing standards. Similarly, example a 1 Julyinitial survey, the look-back is 3 months rather than 4 months.




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Accreditation Decision Rules

The Egyptian Accreditation committee considers all information from the initial,mock or full survey and any required focused survey in making its decision regarding

accreditation. The outcome is that the hospital meets the criteria for any of thethree levels of accreditation or does not meet the criteria and is deniedaccreditation.

Denial of Accreditation

Conditions that place a hospital At Risk for Denial of Accreditation are as follows:

• An immediate threat to patient/public health or staff safety exists within the

hospital (An individual who does not possess a license, registration, orcertification is providing or has provided health care services in the hospitalthat would, under applicable law or regulation, require such a license,

registration, or certification and that placed the hospital’s patients at risk fora serious adverse outcome

• EGYPTIAN Accreditation Committee is reasonably persuaded that the hospitalsubmitted falsified documents or misrepresented information in seeking toachieve or retain accreditation.




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The Egyptian Accreditation Scores (updated 2014)

The total standards=777

Total A standards: 213 Total B standards: 389 Total C standards: 175

Level of

AccreditationNumber

of A

standards

% of A

standards

Number of

B

standards

% of B

standards

Number of

C

standards

% of C

standards

Total

number of

standardsRequired

score

Foundation

Level136 64% 179 46% - - 315

40% of

total

standards

90% and

PS 75%

Basic Level 181 85% 252 65% 35 20% 471

60.6% of

total

standards

90% and

PS 90%

Accreditation

Level203 95% 330 85% 105 60% 638

82% of

total

standards

82% and

PS 100%




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Tracer Methodology

Tracer methodology is the tool to be used in the on-site survey and accomplishesthe following:

• Incorporates the use of information provided in the accreditationsurvey application and previous survey and monitoring reports• Follows the experience of care for a number of patients through the

hospital’s entire health care process• Allows the surveyor(s) to identify issues in one or more steps of the

patient care process or the interfaces between processes

The Role of Staff in Tracer Methodology

Staff will be asked to provide the surveyor(s) with a list of patients presently in thehospital, including the patients’ names, current locations in the hospital, and

diagnoses, as appropriate. The surveyor(s) may request assistance from hospitalstaff for selection of appropriate tracer patients. As the surveyor(s) moves aroundthe hospital, he or she will converse with a wide variety of staff involved in the

traced patient’s care, treatment, and services. This staff could include nurses,physicians, residents/trainees, therapists, case managers, aides, pharmacy staff, labpersonnel (as appropriate), and support staff. If those staff members are not

available, the surveyor(s) will ask to speak to another staff member who wouldperform the same function(s) as the member who has cared for or is caring for thetracer patient. Although it is preferable to speak with the direct caregiver, it is not

mandatory because the questions that will be asked are questions that any caregiver

should be able to answer in providing care to the patient being traced.

Individual Patient Tracer Activity

The Individual Patient Tracer Activity is an evaluation method that is conductedduring the on-site survey and is designed to ―trace‖ the care experiences that apatient had during his or her stay in the hospital. Tracer methodology is used to

analyze a hospital’s system of providing care, treatment, and services using actualpatients as the framework for assessing international standards compliance. Duringan individual tracer, the surveyor(s) will perform the following:

• Follow the course of care, treatment, and services provided to thepatient by and within the hospital using current records whenever

possible• Assess the interrelationships between and among disciplines and

departments, programs, services, or units, and the important functions

in the care and services being provided• Evaluate the performance of relevant processes, with particular focus




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on the integration and coordination of distinct but related processes• Identify potential concerns in the relevant processes

Using the information from the application, the surveyor(s) will select patients froman active patient list to ―trace‖ their experiences throughout the hospital. Patients

typically selected are those who have received multiple or complex services andtherefore have experienced more contact with various parts of the hospital. Thisinteraction will provide the opportunity to assess continuity-of-care issues Egyptian

accreditation Standards for Hospitals irrespective of the level.To the extent possible, the surveyor(s) will make every effort to avoid selecting

tracers that occur at the same time and that may overlap in terms of sites within thehospital.

Individual Patient Tracer Selection Criteria Patient tracer selection may be based on, but not limited to, the following criteria:

• Patients in the top five diagnoses groups for that hospital

• Patients related to system tracers, such as infection prevention or

control and medication management

• Patients who cross programs. Examples include the following:

• Patients scheduled for a follow-up in outpatient care .

• Patients receiving care by a specialty resident

• Patients on a research protocol

The surveyor(s) will follow the patient’s experiences, looking at services provided by

various individuals and departments within the hospital as well as handovers(handoffs) between them.

This type of review is designed to uncover systems issues, to look at the individualcomponents of a hospital, and to examine how the components interact to providesafe, high-quality patient care.

• The surveyor(s) may start a tracer where the patient is currentlylocated. He or she can then move to where the patient first entered

the hospital’s systems; to an area of care provided to the patient thatmay be a priority for the hospital; or to any areas in which the patientreceived care, treatment, and services. The order will vary.




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Number of Patients and Other Elements The number of patients followed under tracer methodology will depend on the size

and complexity of the hospital and the length of the on-site survey. As appropriate

to the provision of care being reviewed, the tracer will include the followingelements:

• Review of the patient record with the staff person responsible for the

patient’s care, treatment, or service provided. If the responsible staffperson is not available, the surveyor(s) may speak with other staffmembers. Supervisor participation in this part of the tracer should be

limited. Additional staff involved in the patient’s care will meet with thesurveyor(s) as the tracer proceeds. For example, the surveyor(s) willspeak to a physiotherapist if the patient being traced has

rehabilitation issues.

• Observation of direct patient care• Observation of medication processes• Observation of infection prevention and control issues• Discussion of data use in the hospital. This includes quality

improvement measures being used, information that has been learned,

improvements made using data, and data dissemination

• Observation of the impact of the environment on safety and staff roles

in minimizing environmental risk• Observation of maintenance of medical equipment .

• Interview with the patient and/or family (if it is appropriate andpermission is granted by the patient and/or family). The discussion willfocus on the course of care and, as appropriate, will attempt to verify

issues identified during the tracer.• Address emergency management and explore patient flow issues in

the emergency department. Patient flow issues may also be explored

in ancillary care areas and other patient care areas as relevant to thepatient being traced. For example, if the patient received a bloodtransfusion, the surveyor(s) may visit the blood bank.

Other Records

The surveyor(s) may select and review two to three additional open or closedrecords to verify issues that may have been identified. The surveyor(s) may ask staffin the unit, program, or service to assist with the review of the additional records.The following criteria can be used to guide the selection of additional records

depending on the situation:

• Similar or same diagnosis or tests




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• Patient close to discharge

• Same diagnosis but different physician/practitioner• Same test but different location• Same age or sex

• Length of stay• Interview with staff

Links to Other Survey Activities Issues identified from the individual patient tracer activities may lead to further

exploration in the system tracers or other survey activities, such as the Facility Tour(and the Leadership for Quality and Patient Safety Interview. Findings from tracervisits provide focus for other tracers and may influence the selection of other

tracers. They may also identify issues related to the coordination andcommunication of information relevant to the safety and quality of care services.

System Tracer Activity

System tracers look at a specific system or process across the hospital. When

possible, this activity will focus on the experiences of specific patients or on activitiesrelevant to specific patients. This differs from the individual tracers in that duringindividual tracers, the surveyor(s) follows a patient through his or her course of

care, evaluating all aspects of care rather than a system of care. During a systemtracer, the surveyor(s) will perform the following:

• Evaluate the performance of relevant processes, with particular focus

on the integration and coordination of distinct but related processes• Evaluate communication among disciplines and departments

• Identify potential concerns in relevant processes

An individual-based system tracer includes unit/department visits to evaluate theimplementation of the system process and to review the impact on patient careservices and treatments. The tracer also includes an interactive session that involves

a surveyor(s) and relevant staff members and that will utilize information fromunit/department visits and individual tracers. Points of discussion in the interactivesession include the following:

• The flow of a process across the hospital, including identification andmanagement of risk points, integration of key activities, and communication

among staff/units involved in the process• A baseline assessment of international standards and IPSG compliance• Education by the surveyor(s), as appropriate




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Medication Management System Tracer The medication management individual-based system tracer explores a hospital’s

medication management process while focusing on sub-processes and potential riskpoints. This tracer activity helps the surveyor(s) evaluate the continuity ofmedication management from the procurement of a medication through the

monitoring of its effect on patients.

Infection Prevention and Control System Tracer

The Infection Prevention and Control System Tracer explores a hospital’s infectionprevention and control processes. The goals of this session are to assess a hospital’s

compliance with the relevant Prevention and Control of Infections (PCI) and FacilityManagement and Safety (FMS) standards, to identify infection prevention andcontrol issues that require further exploration, and to determine actions that may be

necessary to address any identified risks and to improve patient safety.

Facility Management and Safety System Tracer

The focus of this system tracer is the process the hospital uses to evaluate thehospital’s facility management and safety (FMS) system and performance inmanaging risk. The surveyor(s) will evaluate the strengths in the hospital’s FMS

processes, review the action(s) taken to address any identified areas of concern,and determine the hospital’s actual degree of compliance with relevant standards.

Operating Theatre Tracer The focus of this tracer is the process the hospital has implemented to ensure thesafety and quality of care that the surgical patient receives throughout the

perioperative period. The surveyor may commence the tracer in the pre-admission

area observing the handoff process and review of documentation for patientidentification and complete documentation, including consents and surgical-site

marking. In the operating theatre, the surveyor will observe the process the hospitalhas implemented to ensure correct site, correct procedure, and correct patient

surgery (time-out). Other areas of focus include medication management by bothnursing and anesthesiology; the hospital’s compliance with the relevant Preventionand Control of Infection (PCI) and Facility Management and Safety (FMS) standards,

as implemented in the operating theatres, and a review of staffing qualifications andexperience of the operating theatre staff. The surveyor may follow the surgicalpatient to the post-anesthesia care unit to observe the care processes, including

handoff communications, monitoring, and medication management.

Central Sterile Supply Department (CSSD) Tracer

The focus of the Central Sterile Supply Department (CSSD) Tracer is the processesthe department has implemented to ensure the appropriate disinfection, cleaning,and sterilization of supplies and equipment. The surveyor will review the

transportation and cleaning processes for instruments and equipment both from theoperating theatres and satellite clinics; review the checking and packing process for




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supplies and instruments; and review the biological tests, documentation of testresults, and tracking process for sterile supplies. The surveyor will also review the

safety measures in place for hospitals that use non-steam sterilizers, such asethylene oxide. Other areas of focus include compliance with the relevant Preventionand Control of Infection (PCI) and Facility Management and Safety (FMS) standards

as implemented in the CSSD.

Endoscopy Tracer

The focus of this tracer is the process the hospital has implemented to ensure thesafety and quality of care that the endoscopic patient receives throughout the

procedure. The surveyor will review the patient’s documentation for the procedure,including patient identification and appropriate consents and pre-procedureassessments. The surveyor may also observe the time-out process. Other areas of

focus include medication management, monitoring of the patient under sedation,and the unit’s compliance with the relevant Prevention and Control of Infection (PCI)and Facility Management and Safety (FMS) standards. The surveyor will also

evaluate the unit’s process for the cleaning and high-level disinfection and storageof the endoscopes. The surveyor may also trace the patient to the recovery areaand review the documentation of the recovery period and the patient and family

education .Staff qualifications for sedation administration may also be reviewed.

The Accreditation Decision The final accreditation decision is based on the hospital’s compliance with Egyptian

Accreditation standards. Hospitals do not receive a numeric score as part of the final

accreditation decision. When a hospital successfully meets the accreditation

requirements, it will receive an award of Accredited. This decision indicates that ahospital is in compliance with applicable standards to the level at the time of the on-

site survey.

Promoting Accreditation

After a hospital receives official notification of the accreditation decision, it can

publicize its national accreditation achievement by notifying patients, the public, thelocal media, third-party payers.




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The Continuing Accreditation Cycle

The accreditation process does not end when the on-site survey is completed. In the

three years between on-site surveys, Egyptian accreditation committee requestshospitals to report any changes to the Egyptian Accreditation committee , as well assubmission of ongoing evidence of compliance and corrective actions, such as a self

-assessment, periodic submission of compliance data, root cause analyses, and/orresponse to complaints.

Continuous survey compliance means that hospitals can focus less on ―ramping up‖for survey every three years and, instead, can (and should) focus on continually

improving their systems and operations, thereby eliminating the need for intensesurvey preparation. Continuous compliance with national Egyptian standards directlycontributes to the maintenance of safe, high-quality care and improved

organizational performance.




24

Survey Agenda:

o Sample survey agenda

o Detailed Descriptions




25

Sample Survey Agenda

(4 surveyors for 4 days)

DAY ONE

09:00 – 09:15 Opening Conference

09:15 – 09:45 Hospital’s Overview of Organizational Structure

Surveyor 1 Surveyor 2 Surveyor 3 Surveyor 4

09:45 - 12:00 Document Review Document Review Document Review DocumentReview

12:00 - 13:00 Break

13:00 - 14:30 ES* EmergencyServices Visit and

Interview

Managementinterview

Patient Tracer

14:30 – 16:00 ES* Patient Tracer Operating Room

Recovery Room

Patient Tracer

16.00 – 16.30 Surveyors Meeting

Data Entry

DAY TWO

09:00 – 09:30 Debriefing


09:30 – 11:30 ES* Outpatient Visit andInterview

Medication Tracer NurseManagement

Interview

11:30 - 13:30 Radiology Visit

(Employee Health)

ICUs Visits M.M SystemTracer

Patient tracer

13:30 - 14:30 Break

14:30 - 16:00 CommunityInvolvement

Patient tracer Patient tracer Patient Tracer

16.00 – 16.30 Surveyors Meeting

Data Entry

DAY THREE





26


09:30 - 11:30 Infection Control

System Tracer

Blood bank visit PerformanceImprovement

Human Resources

11:30 – 13:30 Infection Control

System Tracer

Closed MR Review Medical staff Patient tracer

13:30 – 14:30 Break

14:30 – 16:00 Patient Tracer Patient Tracer Patient tracing Patient Tracer

16:00 - 16:20 Survey's Meeting

Data Entry

DAY FOUR

09:00 - 09:30 Debriefing


09:30 - 11:30 InformationManagement &

Closed MR Review Pathology andclinical lab visit

Hemodialysisvisit

Nutrition

Tracer

11:30 - 13:30 Patient Tracer Patient Tracer

Patient Tracer Patient Tracer

13:30 - 14:30 Break

14:30 - 15:30 Staff Interview of any additional standards

15:30 - 16:00 Integrate findings

16:00 - 16:30 Exit Summary

* Environmental safety




27

Sample Survey Agenda

(4 surveyors for 3 days)

DAY ONE

09:00 – 09:15 Opening Conference

09:15 – 09:45 Hospital’s Overview of Organizational Structure


09:45 - 12:00 Document Review Document Review Document

Review Document

Review

12:00 - 13:00 Break

13:00 - 14:30 ES Operating Room,

Post- Anesthesia

Recovery Room

Management

Interview Blood Bank

Visit

14:30- 16:00 ES Patient trace Patient tracer Patient tracer

16:00 – 16.30 Surveyors' Meeting

Data Entry

DAY TWO


Surveyor1 Surveyor2 Surveyor3 Surveyor4

09:30 – 11:30 ES Emergency Services

Visit and Interview

Infection Control

System tracer

Medication

Management

System tracer

11:30 - 13:30 Radiology Visit

Employee's health

program

Medical staff Infection Control

System tracer Medication

Management

System tracer

13:30 - 14:30 Break

14:30 - 16:00 Patient tracer Patient tracer Patient Tracer Patient Tracer

16.00 – 16.30 Surveyors' Meeting

Data Entry

DAY THREE




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Surveyor1 Surveyor2 Surveyor3 Surveyor4

09:30 - 11:30 Pathology and

Clinical Laboratory Outpatient Visit

Nutrition

Management of

Information

Closed Medical

Records Review

11:30 – 13:30 Nursing Management

Interview

Community

Involvement

Human Resources Performance

Improvement

Intensive Care

Unit

13:30 – 14:00 Break

14:00 - 15:00 Interview of any additional standards not yet evaluated

15:00 - 15:30 Integrate findings

15:30 - 16:00 Exit Summary




29

Survey: Detailed Descriptions

Opening Conference and Agenda Review

Note: The survey team leader will conduct a brief meeting prior to the OpeningConference and Agenda Review with the CEO, survey coordinator, to discuss the

logistics and expectations for the on-site survey. If there will be any approvedobservers, hospitals must provide a list of their names, titles to the survey teamleader.

PurposeDuring the Opening Conference and Agenda Review, the surveyor(s) describes the

structure and content of the survey to the hospital.

Location At any suitable venue of the hospital

Hospital Participants

• Chief executive officer and the hospital leadership team

• Individual responsible for coordinating the hospital’s survey agenda,such as a survey coordinator• Others, including and not limited to middle managers

Surveyor(s) All surveyors

Standards/Issues AddressedIntroduction of the surveyors and key hospital leaders and coordination of the

survey

Documents/Materials Needed

Final survey agenda

What Will Occur

• Surveyor(s) and any preceptors will be introduced.• Hospital leadership will be introduced.• Agenda will be reviewed and modified.• Surveyor(s) will answer questions about the survey agenda.• Surveyor(s) will explain the use of tracer methodology during thesurvey process activities, and that it is important for them to be able to ask




30

questions to the hospital’s front line staff who are directly taking care ofpatients. It is acceptable for a small group (4-5 persons) to accompany each

surveyor, but questions should not be answered by these staff membersunless specifically requested. Surveyors will also not interrupt patient care inany way.

• Surveyors will try as best as possible to put staff at ease with theirquestions. In addition, all patient-specific information will remain confidential

• Surveyor(s) will advise leaders that the only presentation allowedduring the survey is scheduled on the survey agenda for the session entitled

―Orientation to the Hospital’s Services and the Quality Improvement Program.This session should last less than 30 minutes and is intended to give thesurveyors an introduction to the hospital and to update the data presented on

the hospital’s application. Topics covered include the following:

o History of the hospital (1 or 2 slides) as well as missiono Vision, organization structure ( chart)

o Number of buildings, area (square meters)

o Total number of beds and type of units (ICU, CCU, general wards, andso forth)

o Number of employees, contracted staff, staff physicians, visitingphysicians, residents, medical students, and trainees

o Top-five procedures and diagnosis

o Average length of stay .o Number of the outpatient visits

o Number and type of surgeries performed .

o Number of visits in the ER

o Type of contracted services

o Clinical guidelines, pathways, or protocols implemented.

o Strategic plan (services or areas the hospital is planning to

increase or open during the next three years)

o The Quality Committee structure and its relationship with othercommittees (1 or 2 slides)

• The surveyor(s) will follow the planned survey agenda when

conducting the tracer activities. Staff should be prepared to answer questions.The surveyor(s) will also obtain pertinent information through various other




31

methods.

• Surveyor(s) will explain the concept of ―drilling down‖ as aninterviewing technique/approach that aims to gather specific informationabout a process or outcome. Staff members involved in drilling down inquiries

should not perceive this approach as personal or necessarily an indication ofnoncompliance. It is an indication that the surveyor(s) is evaluating theestablishment of systems to support a process.

• Surveyors will explain the staff involvement in the various quality

activities, such as the Department/Service Quality MeasurementTracer), Quality Program Interview, and other quality sessions.

• Surveyor(s) will explain the purpose of and the leaders’ involvement in

the Daily Briefing sessions.• Hospital staff will be encouraged to ask questions and seek clarification

from the surveyor(s) throughout the survey process.

Hospital staff will introduce the surveyor(s) to the staff member who will provideassistance throughout the day. This staff person will help the surveyor(s) move

quickly between hospital locations and maintain the planned schedule. This staffperson is usually a leader of the hospital or the survey coordinator.

How to Prepare

• Set up a meeting or conference room large enough for the surveyor(s)

to meet with key hospital leaders and survey coordinators.• Notify hospital receptionists, so they can direct the surveyor(s) to the

room when he or she arrives.

• Have copies of the survey agenda available for all participants in theconference.

• Prior to the survey, decide which hospital leader or staff member willaccompany each surveyor throughout the survey day.

• Arrange for the surveyor(s) to be served a break..

• Notify hospital staff of the survey agenda.

• The surveyor(s) will wear a name badge that will identify him or her asa Egyptian surveyor(s). If the hospital requires additional hospitalidentification, prepare and make it available to the surveyor(s) in the

conference.




32

Orientation to the Hospital’s Services and the Quality ImprovementProgram

Purpose

The hospital orients the surveyor(s) to the services, programs, and strategicactivities the hospital provides and its quality improvement process. This informationprovides the surveyor(s) with baseline information about the hospital and its quality

and patient safety program that can help focus subsequent survey activities.

Location Same location as Opening Conference and Agenda Review


• Hospital general manager/ Chief executive officer

• Individual responsible for coordinating the hospital’s survey agenda,such as a survey coordinator

• Medical staff leadership

• Nursing leadership

• Staff responsible for the quality improvement and patient safety

program, if applicable

• Others, including trainees, at the discretion of the hospital

Surveyor(s)

All surveyors

Standards/Issues Addressed

• Overview of the hospital’s services

• Overview of the quality improvement and patient safety program and

process• Overview of medical education (for academic medical center hospitals

only)

• Overview of research programs (for academic medical center hospitals

only)




33


• Copy of the hospital’s presentation for each surveyor

• Organizational chart for clinical services

• Quality improvement example

• Organizational chart for medical education and research (for academicmedical center hospitals only)

What Will Occur/How to Prepare

• The hospital will give an overview of its structure, services, and strategicactivities.

• The hospital will include a brief presentation about the structure and methodsof the quality improvement and patient safety program.

• The presentation should show how quality and safety information flows

through the hospital/committee structure.• The presentation should describe the following:• How quality and safety measures were chosen

• How the measures were prioritized for data collection and how data arecollected, aggregated, and analyzed

•

• How findings from data analysis are communicated and used for planningimprovements

• The hospital may choose to present a quality improvement example to

demonstrate the hospital’s methodology and sustained improvement.• The surveyor(s) will ask questions, as needed, to clarify information or to

request additional information for use later.




34

Surveyor Planning Session

Purpose

During this session, the surveyor(s) reviews data and information about the hospital

and plans the survey agenda. The surveyor(s) also selects initial tracerpatients/residents/clients.

Location

The hospital should provide space for this activity, usually the room designated asthe ―surveyor headquarters.‖ This space should have the following items:

• Conference table• Power outlets• Telephone

• High-speed Internet connection/access for each surveyor

• Printer


• Hospital survey coordinator (as needed by team)


What Will Occur, Documents/Materials Needed

This time is set aside for the surveyor(s) to review and discuss pertinent data andplan the survey agenda. The surveyor(s) reviews the following list of references and

resources (as applicable to the setting), and these materials should remain availableto the surveyor(s) for the entire duration of the survey:

• Performance improvement data, including

• A list of system-wide quality improvements;• A list of individual department/service quality measures; and

committee-meeting minutes for 4 months prior to the survey

• Infection prevention and control surveillance data, including committeemeeting minutes for 4 months prior to the survey

• Facility management and safety plan annual reviews. The surveyor(s)will review these documents to prepare for the Facility Tour.

• Facility management and safety multidisciplinary team meetingminutes for the 4 months prior to the survey.

• The surveyor(s) will review these documents to prepare for the FacilityTour)




35

• A list of departments/units/areas/programs/services within the hospital(if applicable)

• An organizational chart and map• A daily list of inpatients, including their names, diagnoses, ages,

admission dates, physicians, and units/services

• A daily list of the operative and other invasive procedures scheduledfor the day, including surgeries in the operating theatre(s), daysurgeries, cardiac catheterizations, endoscopies/colonoscopies, and in

vitro fertilizations• The name of key contact person (such as a supervisor or scheduler)

who can assist the surveyor(s) in planning tracer selection• A list of contact telephone numbers in case the surveyor(s) needs to

reach key staff

• A list of all employees (providing direct and indirect patient care), withname, date of hire, job title, and primary location of work in thehospital

• A list of all independent clinical practitioners (physicians and others,such as dentists, psychologists, and others) privileged by the medicalstaff, with the name, clinical department or specialty and date of

appointment or reappointment to the medical staff• A list of clinical guidelines, pathways, or protocols selected• A sample of the forms used in the medical record

• Copies of the Strategic Improvement Plans• A list of approved/unapproved abbreviations (one list for each

surveyor)

• A list of students/trainees assigned to the hospital and their associated

academic program• The name of a key contact person (such as a supervisor or scheduler)

who can assist the surveyor(s) in planning tracer selection




36

Selection of Individual Tracers

• Surveyor(s) reviews the information from the survey application and

the list of patients currently receiving care in the hospital to guide his

or her selection of patients to trace.• Surveyor(s) identifies a clinical/service group and some general

information about the patient population receiving care and services.• Surveyor(s) describes to the hospital the type of patient that he or she

is seeking to trace and requests staff’s assistance in identifying anindividual.

• In surveys longer than one day, the surveyor(s) informs the hospital

during the Daily Briefing about the types of tracers he or she wants toperform that day to facilitate activity planning. This does not meanthat the surveyor(s) will identify a specific patient from the list supplied

by the hospital. For example, the surveyor(s) may choose to trace the

following types of patients:

o A hospital orthopedic surgery patient who is receiving physicaltherapy

o An ambulatory patient who visited the internal medicine clinicand had laboratory services

o An intensive care patient who is receiving blood gas testing

o A patient with developmental disabilities

o A patient who is receiving sedation and/or anesthesia

• Surveyor(s) will trace patients in all intensive care units and

sedation/anesthesia areas of the hospital, as well as all sites/buildingsin which patient care is delivered.

• In team surveys, tracer selection should be coordinated when possible

to avoid overlap of visits to various units.• In hospitals with multiple sites, individual tracers will include patients

who move between locations and services addressed by the

represented accreditation programs.




37

Document Review

Purpose The objective of the Document Review session is to survey standards that require

some written evidence of compliance, such as an emergency preparedness plan or apatient’s rights document. In addition, this session orients the survey team to thestructure of the hospital and management.

Location

A meeting room or office that will be used throughout the duration of the survey asa meeting place and work area for the survey team

Hospital Participants Participants should include hospital staff members who are familiar with thedocuments that will be reviewed, can translate these, and are able respond to

questions the surveyor(s) may have during the session. At the discretion of theteam, the surveyor(s) may designate a limited number of staff members to attendand participate in the Document Review session. The session may be conducted as

an interview of staff about the documents. This approach has been very effectivewhen language barriers exist and the survey activities necessitate the use ofprofessional interpreters.


Standards/Issues Addressed Almost all standards chapters make reference to plans, policies, and procedures that

are to be written. The following section and the ―Survey Planning Tools" section willassist staff members in understanding the particular documents that are a part of

the accreditation survey.


The documents that should be available to the survey team for their review orreference during the survey process are listed in the ―Survey Planning Tools‖section. The list of documents includes the following:

• A list of hospital wide priority improvement measures

• A list of department/service quality measures

• All measurement information is to include data from the past 4 months

(initial surveys) and/or 12 months for triennial surveys• A list of clinical practice guidelines




38

• Required hospital programs

• Required policies and procedures, written documents, or bylaws• Minutes of the key committees for the past year, such as Performance

Improvement, Infection Prevention and Control, Safety,

Leadership/Management Team Meetings, and Medication Systems• An accurate list of the patients currently receiving care in the hospital• A list of the operative and other invasive procedures scheduled for the

day, including surgeries in the operating theatre(s), day surgeries,cardiac catheterizations, endoscopies/colonoscopies, and in vitro

fertilizations• A sample action plan for a root cause analysis for a sentinel event or a

near miss

• A sample failure mode and effects analysis (FMEA) action plan• A current map of the hospital campus .• A sample of all medical record forms

• A list of the five clinical practice guidelines and any associated tools,such as clinical pathways and/or clinical protocols the hospital selectedto guide clinical care

In addition, the hospital should complete the Laws and Regulations Worksheet andhave it available for the survey team.

What Will Occur

• The documents should be made available to the survey team in the

meeting room that has been designated for their use throughout theduration of the survey.

• At the beginning of the session, one staff person should briefly orientthe survey team to the organization of the documents.

• During the remainder of the session, a staff member who can respondto any questions the surveyor(s) may have should be readily available(in person or by telephone).

• The materials should remain available to the survey team throughoutthe survey for reference purposes. However, if documents are requiredfor use by hospital staff, they can be removed. The surveyor(s) may

schedule a second Document Review session during the course of the

survey. A second review is generally scheduled for hospitals that havea survey of longer than three days but may be scheduled on surveys of

a shorter duration based on need. The survey team may also requestadditional documents throughout the survey to clarify or becomeknowledgeable about the hospital’s policies and procedures or

performance. Hospital staff should be as proactive as possible incomplying with requests for documents.




39

• Some of the documents may need to be translated into English,

whereas other documents may require an interpreter to be madeavailable.

How to Prepare

It is highly probable that many of the required documents will be part of larger

documents. Hospitals do not need to remove or photocopy pertinent sections ofthese documents. Instead, hospitals can identify these sections using bookmarks or

tabs. Guidelines for cross-referencing this information are provided in the nextsection.

Other documents, such as minutes and reports, may be freestanding or individualdocuments. Hospitals should decide whether to provide the original document or aphotocopy. It is always beneficial to have several examples of these documents,

such as committee minutes from the last few meetings.

If the hospital has a large quantity of examples or a large volume of materials on a

given topic, it should select the most representative or the most pertinent examples.There will not be time for the surveyor(s) to review large amounts of material onany given topic.

Organization of the MaterialsBecause the issues identified in the Document Review list may be addressed in

different documents depending on the hospital, the following guidelines for

organizing the documents to be used by the surveyor(s) are provided.

Group the freestanding or individual documents according to the followingthree lists provided in this guide:

• Required quality data• Required hospital programs

• Required policies• Hospital scope of services documents

Note: When possible, please indicate the standards that the document addresses.The documents may be grouped in binders or folders, or other means may beused to separate major topical areas.

Gather the documents in one place. Identify the location in the document where thespecific information that is required by the standard may be found. The hospital mayuse methods such as the following to identify the information:




40

• A guide• An index

• Bookmarks• Tabs

Note: When information is provided using computer monitors rather than paper, thefollowing conditions should be met:

• Each member of the survey team should be provided with a monitor.

• A printer should be available in case a member of the survey teamwishes to print a paper copy of a given document.

• Staff may be needed to assist the surveyor(s) in locating the

documents in the computer.

Printed copies of bylaws and longer documents that may require extensive reading

or scanning by the surveyor(s) should be available.

Evaluation of the Policies and Procedures by the Survey Team

The documents reviewed by the survey team provide an overview of what theyexpect to see in actual practice during the survey process. For example, they wouldexpect to find the following when a new procedure on the disposal of infectious

waste is developed:

• That appropriate staff have been educated about the new procedure

• That any special skills or other needed training has taken place

• That waste is actually being disposed of according to the newprocedure

• That any documentation required by the procedure is available forreview

The survey team will look for evidence that the practice related to the policy orprocedure is well implemented, as appropriate, throughout the hospital and thus is

sustainable. In the event the implementation appears incomplete to the surveyteam, or the implementation occurred in a manner that is not sustainable, thesurvey team will make a recommendation that more time be allowed for better

evidence of sustainable implementation and for incorporating the recommendation

into the survey follow-up requirements.

As there is now one standard that addresses development and implementation ofpolicies for all standards requiring a policy, the survey team will look for theexistence and implementation of all policies as a whole. The absence of one policy

or the lack of full implementation of one policy will likely not be scored. However, ifthe surveyor(s) identify multiple missing policies or have evidence that several of the




41

policies have not been fully implemented, this can be an indication of a system-wideproblem related to policy management.

In general, the length of time a policy has been implemented is referred to as a

―track record.‖ The survey team will look for a 4-month track record for policy-related standards during an initial survey and for a 12-month track record during atriennial survey. For policy- related standards to be scored ―fully met,‖ the track

record requirement must be met. When the track record period has not been met,but the survey team finds that the policy has been implemented in a sustainable

manner, the team has the prerogative to score the standard as ―fully met.‖




42

Daily Briefing

PurposeTo facilitate understanding of the survey process and the findings that contribute to

the accreditation decision

Location

At the discretion of the hospital


• Hospital survey coordinator (as needed by team)

• Chief executive officer• Designated leaders (as determined by the hospital)• Staff members from areas visited by the surveyor(s) the previous day,

at the discretion of the leaders

Surveyor(s)

All surveyors

What Will Occur

The daily briefing occurs every morning of a multiday survey with the exception ofthe first day. The session is intended to be brief; 60 minutes is suggested dependingon the number of surveyors on the team. When multiple surveyors are on site, the

briefing is conducted jointly, with the survey team leader serving as the facilitator.

During the daily briefing with the hospital, the surveyor(s) will perform the following

actions:

• Offer a concise summary of the survey process activities completed onthe previous day

• Make general comments regarding significant issues resulting from theprevious day’s activities

• Note any specific positive findings (although because of time

limitations, the session is not intended to review most or all issues thatwere in full compliance with standards).

• Emphasize patterns or trends of significant concern that could lead tononcompliance determinations. The surveyor(s) may report minor,one-time, or single observations that might not impact final scoring.

• Inform the hospital that final findings for any given standard will be




43

possible only when all activities are complete and results areaggregated

• Allow the hospital staff to provide information that may have beenmissed or misunderstood during the previous survey day

• Review the agenda for the survey day ahead (including the

identification of individual patient tracers) and make any necessaryadjustments based on hospital needs or the need for more intensiveassessment of any issue during the survey

Do not expect the surveyor(s) to perform the following actions:

• Repeat observations made at a previous Daily Briefing unless it is in

the context of identifying a systemic issue• Discuss, in detail, each survey activity, specific records, suggestions,

and conversations held with individuals during tracers

• Delay scheduled activities for the current day to have an in-depthdiscussion of issues from the previous day

Special Situations There may be instances when a surveyor(s) will be scheduled to survey an activitythat is not taking place at the same location where a Daily Briefing would normally

occur; this may take place particularly when surveying with a team. There may alsobe situations in which a surveyor(s) is brought in for a day or two and departsearlier than the rest of the team. If a surveyor(s) cannot be physically present for

the daily briefing, the surveyor(s) will do the following:

• Try to make arrangements to join via conference call

• Share details of the previous day’s activities and findings with anothersurveyor for the daily briefing presentation, even if a conference call is

anticipated




44

Leadership for Quality and Patient Safety Interview

PurposeThe purpose of this session is to identify how hospital leadership selects the

approach to be used to measure, assess, and improve quality and patient safety andthe process for identifying hospital wide strategic priority improvements.

Location At the discretion of hospital leaders


• Chief executive officer

• Medical director, when applicable

• Nurse executive

• Leader responsible for quality improvement

• Other senior leaders, at the discretion of the hospital

To foster an interactive process, a larger group than described above is notrecommended for this conference.



• Documents identifying system wide priority improvements

• Quality improvement and patient safety program reports provided togovernance

•

• Action plans for improvements resulting from strategic prioritymeasurement

•

• Minutes from governance meeting relating to quality reports•

• Information about the impact of hospital wide improvements onefficiency and resource use




45

What Will OccurThis session is organized to better understand how hospital leadership establishes

and supports an organizational commitment to the quality and safety program andensures that the program has adequate resources to be effective. Hospitalleadership also implements a structure and process for the overall monitoring and

coordination of the program throughout the hospital. It is important to understandhow coordination occurs among all the departments and services in measurementand improvement efforts.

The surveyor(s) will ask questions related to leadership activities and the decisions

that have been made related to development of the quality improvement andpatient safety program. Everyone present should participate in answering thequestions. This is designed to be an interactive session.

How to Prepare

Hospitals should identify the participants in the Leadership for Quality Improvementand Patient Safety Interview. Although hospital leadership should be familiar with allthe standards, leadership should read organization management chapter prior to

survey. In preparation for this session, it would be useful to turn the standards intoquestions.

Sample questions include the following:

• Who makes up the governing body of the hospital and how are they

evaluated?

• What is the process for approving the hospital’s strategic plan andoperating budget?

• What are your strategies and programs for health care professionaleducation and research?

• What is the structure and process developed for the qualityimprovement and patient safety program and how was this developed?

• Please provide an example of a sentinel event that lead to

improvements in a safety issue. How is information about the qualityimprovement and patient safety program communicated to staff?

• What are the hospital-wide collective priorities for system

improvements? Give us an example of how you assessed the impact ofthese improvements on efficiency and/or resource use.

• What is your process for identifying, in writing, the services provided

by each department? How do you know the documents are current?

• How do you involve your contracted services in the quality




46

improvement and patient safety program?

• How are the services of independent practitioners monitored for

quality as part of the quality improvement and patient safety program?

• How were the hospital’s system-wide priorities chosen? Which Library

measures were chosen related to the system-wide priorities?• What involvement does leadership have in the leaders' selection of

department/service measures? How are results of department/servicequality improvements communicated to leadership?

• How have the leaders communicated within the hospital yourcommitment to protect human research subjects and support the code

of ethical professional behavior?




47

Department/Service Quality Measurement Tracer

PurposeThe purpose of this tracer is to identify how individual department/service leaders use

quality measurement to improve patient care and services being provided by their area.In addition, the surveyors will evaluate how clinical guidelines are selected andimplemented for use in areas providing clinical care.

Location

Selected patient care settings, inpatient and ambulatory units, treatment areas, andother areas, including, but not limited to, admitting, pharmacy, radiology and diagnosticimaging department, clinical laboratory, and others. The surveyor(s) will be talking with

the department or service leader as well as a variety of staff to understand themeasurement priorities for that particular department or service and their participationin the hospital-wide strategic priorities.


• Department or service leader of area being traced• Quality program person responsible for supporting the department or

service area being traced

• A variety of staff involved in the activities of the department or service.Staff could include nurses, physicians, medical students, trainees,therapists, case managers, aides, pharmacy and lab personnel, and

support staff.

Surveyor(s)

Nurse, physician, or administrator surveyor(s)


• The measurement plan for the department/service area being traced

• Copies of data collection tools, definitions, and the like• Any documentation of communication of measurement activities for the

area being traced

What Will OccurThe surveyor will have an interactive discussion with the department or service leader

and other staff about their participation in the quality improvement and patient safetyprogram. In particular, the participants should be able to discuss their involvement inthe hospitalwide strategic improvements as well as what department specific measures

are being collected. The surveyor may ask to review the measurement activities beingdone, documentation of data analysis and any improvements that were a result of their




48

specific measurement. Staff will be asked to discuss how the specificdepartment/service improvement project has affected patient care.

How to Prepare

Although department/service leaders should be familiar with all the standards, thehospital’s leaders should review the performance improvement standards chapter priorto survey. In preparation for this session, it would be useful to turn the standards into

questions. Mock discussions could then be conducted with participants so they feelmore comfortable with possible questions.

Sample questions include the following:

• How do the department's measures align with hospitalwide prioritieschosen by the leaders? What was the impact of department improvementson efficiency and resource use at the department level?

• What measures do you collect that are specific to your department/servicearea?

• How did you pick your measures?

• Do any measures from the Library relate to your department/service? Ifyes, have you selected any measures from the Library?

• Are there any measures you currently collect that are applicable to

physician and/or professional staff evaluations?• How are staff involved in quality decisions and the resulting quality

activities?

• How do you communicate quality information to staff?

• How does the quality staff support you in your quality improvementprogram?

• How do you integrate the department/service –specific measures withother department/service initiatives?

• Which clinical guidelines are used in your area and how were theyselected?

• What was the process for implementing the guidelines? How was the

information communicated? How was staff trained?• How are the guidelines evaluated? Do you have data to show that use of

the guidelines improved resource utilization or patient outcomes?




49

Individual Patient Tracer Activity Purpose

An individual patient tracer follows the experiences of an individual patient to evaluate

the hospital’s performance against international standards. One approach to conductinga tracer is to sequentially follow the course of care, treatment, and services received by

the patient from preadmission through postdischarge. During an individual tracer, thesurveyor(s) will do the following:

• Follow the course of care, treatment, and services provided to the patientby and within the hospital using current records when possible

• Assess the interrelationships between and among disciplines anddepartments, programs, services, or units and the important functions inthe care, treatment, and services being provided

• Evaluate the performance of relevant processes, with particular focus on

the integration and coordination of distinct but related processes• Identify potential concerns in the relevant processes

Hospital ParticipantsDuring a tracer, the surveyor(s) will converse with a wide variety of staff involved in the

patient’s care, treatment, and services. Staff could include nurses, physicians, medicalstudents, trainees, therapists, case managers, aides, pharmacy and lab personnel, andsupport staff.

Surveyor(s)

Nurse, physician, or administrator surveyor(s)


All standards chapters may be addressed during this visit.


The clinical records of patients currently receiving care in the unit/setting

What Will Occur

Using the information from the application, the surveyor(s) will select patients from anactive patient list to trace their experience throughout the hospital. Patients typically

selected are those who have received multiple or complex services and therefore havehad more contact with various parts of the hospital. This contact will provide theopportunity to assess continuity of care issues. To the extent possible, the surveyor(s)will make every effort to avoid selecting tracers that occur at the same time and that

may overlap in terms of sites within the hospital.




50

The surveyor(s) will follow the patient’s experience, looking at services provided by

various individuals and departments within the hospital, as well as at ―handoffs‖between them. This type of review is designed to uncover systems issues, looking atboth the individual components of a hospital and how the components interact to

provide safe, high-quality patient care.

The number of patients followed under tracer methodology will depend on the size and

complexity of the hospital, the number of surveyors, and the length of the on-sitesurvey. The tracer starts in the patient care setting or unit where the patient and the

clinical record are currently located. This is where the surveyor(s) begins to trace theentire care, treatment, or service process from preadmission through postdischarge.The surveyor(s) has approximately two hours to conduct a tracer, although it may be

shorter or longer depending on its complexity and other circumstances. Multiple patientrecords may be reviewed during a single designated tracer activity.

As appropriate to the provision of care being reviewed, the tracer will includethe following elements:

• Review of the record with the staff person responsible for the patient’scare, treatment, and services. If the responsible staff person is not available, thesurveyor(s) may speak with other staff members. Supervisor participation in this

part of the tracer should be limited. Additional staff involved in the patient’s carewill meet with the surveyor(s) as the tracer proceeds. For example, thesurveyor(s) will speak to a dietitian if the patient being traced has nutritional

issues.

• Observation of direct patient care• Observation of medication processes

• Observation of infection prevention and control issues• Observation of care planning processes

• Discussion of data use in individual departments/services. This discussionmay include quality improvement measures being used, analysis of dataidentifying improvement opportunities, information that has been learned,

improvements made using data, and data dissemination.• Observation of the impact of the environment on safety• Staff roles in minimizing environmental risk

• Review of emergency equipment, supplies, and processes

• Interview with the patient and/or family (if it is appropriate andpermission is granted by the patient and/or family). The discussion will

focus on the course of care and, as appropriate, will attempt to verifyissues identified during the tracer.

• When visiting the emergency department, the surveyor(s) will alsoaddress emergency management and explore patient flow issues. Patient




51

flow issues may also be explored in ancillary care areas and other patientcare units as relevant to the patient being traced. For example, if the

patient received a blood transfusion, the surveyor(s) may visit the bloodbank; or if patients are sent to a holding area to wait for admission, thesurveyor may visit the holding area.

• The surveyor(s) may pull and review two to three additional records toverify issues that may have been identified. The surveyor(s) may ask staffin the unit, program, or service to assist with the review of the additional

records

Tracer Selection CriteriaPatient tracer selection may be based on, but not limited to, the followingcriteria:

• A patient on dialysis• A pediatric and/or neonatal patient

• A maternity patient• A patient receiving imaging services• A patient receiving rehabilitation services

• Patients related to system tracers, such as infection prevention andcontrol or medication management

• Patients who cross programs (for example, patients scheduled for a

follow-up in ambulatory care or home care)• Patients received from another hospital, long term care patients

transferred from another organization, mental health care clients receiving

ambulatory services, and patients receiving home care services

• Patients due for discharge that day or the next day

Links to Other Survey Activities

Issues identified from the tracer activities may lead to further exploration in the systemtracers or other survey activities, such as the Facility Tour and Leadership for Qualityand Patient Safety Interview.

The surveyor(s) will use time scheduled as ―Undetermined Survey Activity‖ on theagenda to conduct additional activities to clarify issues, to gather additional information,and to evaluate standards compliance that is not directly related to a patient tracer.

Findings from tracer visits provide focus for other tracers and may influence theselection of other tracers. They may also identify issues related to the coordination and

communication of information relevant to the safety and quality of care services.




52

Facility Tour

Purpose

The purpose of the Facility Tour is to address issues related to the following:

• The physical facility

• Utility systems

• Fire safety

• Medical technology and other nonmedical equipment

• Patient, visitor, and staff safety and security

• Infection prevention and control

• Emergency preparedness

• Hazardous materials and waste

• Staff education

Location Selected patient care settings, inpatient and ambulatory units, treatment areas, andother areas, including, but not limited to, admitting, kitchen, pharmacy, central storage,

laundry, morgue, and power plant (if applicable). The tour is designed to cover high-risk areas for safety and security. Any and all areas of the hospital’s campus may besurveyed, so the hospital must be prepared to provide JCI surveyors with access to any

area(s) upon request.


• Chief engineer• Supervisory engineer(s) (electrical, HVAC, civil)• Safety officer and/or facility manager• Fire safety officer

• Infection control practitioner (as appropriate to the area being toured)• Nursing leadership (as appropriate to the area being toured)




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Surveyor(s) Administrator surveyor(s) (physician and/or nurse surveyor[s] when team does not

include an administrator)


• Facility Management and Safety• Prevention and Control of Infections


• Documents, such as plans, policies and procedures, and test and

maintenance reports• A documented, current, accurate inspection of the hospital's physical

facilities

• Documentation related to the clinical laboratory and radiology/diagnosticimaging departments

Laboratory safetyo Laboratory equipmento Radiology and diagnostic imaging safety

Radiology and diagnostic imaging equipmentWhat Will Occur

Prior to the facility tour, the surveyor(s) will have reviewed the documented, current,accurate inspection of the hospital's its physical facilities (described in FMS.4 through

FMS.4.2) and the safety program(s) described in FMS.2. They will then visit differentareas of the facility to check the implementation of these programs. The surveyor(s)will also review selected portions of the facility inspection report prepared by thehospital.

The surveyor(s) will visit patient care areas as well as non –patient care areas of thefacility. In all areas, the surveyor(s) will observe the facility and interview staff to learn

how the hospital manages the facility to accomplish the following:

• Reduce and control hazards and risks

• Prevent accidents and injuries

• Maintain safe conditions

• Maintain secure conditions

• Implement emergency response plans




54

Note: In some survey agendas, two surveyors will visit separate sections of the facility

at the same time. The hospital should be prepared to have staff available to guide andassist each surveyor on the tour of the facility.

The non –patient care areas visited by the surveyor(s) include the following:

• The boiler room

•

• The emergency power generator

•

• The loading/receiving dock•

• Central storage areas or warehouse•

• Central sterile supply department

•

• Laboratory•

• The IT control room•

• The laundry, if applicable

•

• Food service/kitchen•

• Medical gas storage areas

• • Oxygen storage rooms

•

• Hazardous materials storerooms

•

• Areas designated as hazardous, such as locker rooms, clean and soiledlinen rooms, and oxygen storage rooms

• The bottoms of laundry and garbage chutes•

• The morgue

•

• Heating and air-conditioning equipment rooms to evaluate storagepractices and utility systems maintenance

• The roof•

• Helipad

• Outside assembly areas•




55

• Radiology services•

• Patient wards•

• Automobile parking garages

• • Ongoing construction and renovation sites•

• Biological waste collection sites outside the main hospital

How to Prepare

Prior to survey, hospital leaders and the facility manager(s) should carefully read therelevant standards.

• The facility manager(s) should tour the facility, conduct an inspection

according to the standards, and attempt to address any deficiencies priorto survey.

• FMS standards require that the hospital conduct its own inspection of thefacility. This information should be available to the surveyor(s). Allbuildings in which patients are housed or treated are included in the

inspection and the report.•

• The hospital is aware of relevant laws, regulations, and facility inspections

and will share as much information as possible with the surveyor(s)(FMS.1) and provide necessary information to the relevant sections of the

relevant sections of the Laws and Regulations Worksheet as completely asis possible.•

• Representatives of the hospital should be prepared to show thesurveyor(s) how their facility management plans are implemented. Forexample, they should demonstrate how hazardous materials are stored

and disposed of.•

• Representatives of the hospital should be prepared to explain or

demonstrate how potable water and electrical power are available 24hours a day .

• The hospital should have the following items available for the surveyor(s)to use when conducting the facility tour:

o Flashlighto Master key

• Ladder (to look above ceiling tiles




56

Appendix

Required policies and procedures

StandardCodeSerial

Patient Rights and Responsibilities

Policy and procedure defines patient rightsPR.1

Policy and procedures define patient rightsPR2

Policy and procedures define patient & family responsibilityPR.7

Policy and procedures defines informing patient and family

about their rights and responsibility in refusing treatment

PR.9

Policy and procedures defines the process for patients to make

oral or anonymous written complaints or suggestions

PR.13

Consent

Policy and procedures guides the process of informed consent

PR.16

Organization Ethics

The organization has a system to inform patients and families ofall services available and how gain to access these services.

PR.23

A system to inform patients and families of any expected costs.PR.24

Policy and procedures defines the organization's responsibilities

regarding patients’ belongings

PR.26

There is a defined process for informing patients and families of

the outcome of care and treatment.

PR.29

Policy and procedure defines how the organization informspatients and families about choosing to donate organs and other

tissues.

PR.30

Policy and procedure defines the process for obtaining

performing and documenting the results of an autopsy

PR.32




57

StandardCodeSerial

Research

Research Policy and procedures is available and includes

eligibility for enrollment in research projects or protocols

PR.35

Patient Access and Assessment of Patient

Policy and procedure defines access and admission to servicesPA.2

Policy and procedures that defines access and admission to

services

PA.3

Continuity of Care and Consultations

Policy and procedures defines the coordination between multiple

disciplines (including nurses and physicians) and differentclinical settings across inpatient, outpatient and community

services

PA.7

Policy and procedures defines the criteria for getting

consultation for patients including the time frame &the process,

both internally and externally, as needed

PA.10

Transfer, Discharge, Referral

Policy and procedures defines the process and responsible stafffor transfer, referral and discharge of patients.

PA.13

Assessments and Reassessment

Policy and procedure defines:

-Scope and content of initial assessment by each discipline

- Time frame for completion of initial assessments,

- Frequency of reassessment of patients by diagnosis and/or

level or need

AP.2

Policy and procedure defines the screening criteria for furtherassessment of all patients for the following:

AP.4

Nutritional risk and needs

AP.4.1

Functional/rehabilitation risk and needs AP.4.2




58

StandardCodeSerial

Social and psychological services and discharge needs AP.4.3

Policy and procedures defines the screening criteria of patients

against abuse and neglect

AP.5

Pain

Policy and procedures defines and guides screening, assessment,reassessment and management of pain

AP.15

Medical Staff Assessments and Documentation

Policy and procedure of the comprehensive history and physicalexamination for inpatient admission .

AP.20

Policy and procedures defines the minimum frequency and

content of reassessment

AP.24

Policy and procedures defines the minimum scope of assessment

(history and physical exam) for short-stay (less than 24 hours)patients.

AP.27

Policy and procedures defines the minimum acceptable scope of

the history and physical examination for outpatient surgery andinvasive procedures.

AP.28

Policy and procedures defines the minimum content of

outpatient medical records for new and returning patients formedical assessment.

AP.29

Policy and procedures defines the organization's vulnerablepatients, and the specific assessment required for each.

AP.31

Providing Care

Nutritional Care

Policy and procedure defines the role of all care givers inassessment, follow up and monitoring of patients according to

their nutritional needsPC.20

Policy and procedure of food servicesPC.22

Policy and procedure describes how to manage and store foodbrought in by family members.

PC.28




59

StandardCodeSerial

Policy and procedures governs the preparation, storage and

administration of feeding tube nutritional therapy.PC.30

Terminally Ill Patients

Policy and procedures guides the management of terminally illpatients

PC.32

Restraint and Seclusion

Policy and procedures defines the appropriate and safe use ofrestraint and seclusion

PC.39

Resuscitation

Policy and procedures defines the response to medicalemergencies in the organization for both adult and ped

iatric patients

PC.47

Radiology

There is a quality control program covering the inspection,

maintenance, and calibration of all equipment

DS.5

There is a radiation safety programDS.14

Laboratory and Pathology

Policy and procedures for receiving the lab tests orders,collecting, identifying, processing, and disposing of specimens

DS.20

Policy and procedures covers inspection, maintenance,

calibration, and testing of all equipment

DS.22

Quality control program for all laboratory equipmentDS.26

Policy and procedures covers management of reagents and

supplies, including availability, storage, labeling and testing foraccuracy

DS.29

There is a Laboratory and pathology safety programDS.43

Point of Care Testing

Policy and procedure specifies:

-Which tests can be performed in the organization outside of the

DS.47




60

StandardCodeSerial

laboratory

-Which individuals may perform the test

-The training/competence required of staff who perform thepoint of care tests

-Monitoring for calibration of equipment and controls areoverseen by the laboratory

Blood Bank and Transfusion

Policy and procedures describes the following:

- Selection of blood donors in accordance with the nationalselection criteria.

- Procedures to be followed for all blood bank tests including

screening of specified communicable diseases, blood type andRh.

BB.2

Policy and procedures for safe collection, handling and storageof blood and blood products.

BB.4

Policy and procedures defines safe administration andmonitoring of blood transfusions.

BB.10

Surgical and Invasive Procedures

Policy and procedures defines the process of preoperative,

operative and postoperative patient surgical care

IP.1

Anesthesia and Moderate Sedation

Policy and procedures of anesthesia care including pre –anesthesia assessment, monitoring during anesthesia and postanesthesia care of patients

IP.18

Patient education

Policy and procedure defines the screening criteria foreducational needs (including family) (Refer to standards PE.3.4

and PE.5)PE.1

Policy and procedures for patient and family education includingthe responsible disciplines is available

PE.2

Policy and procedure guides patient and family educationPE.3




61

StandardCodeSerial

Medication Management

Policy and procedures defines the selection and procurement of

medications, including when the pharmacy is closed, and how toaccess medications and information when the pharmacy isclosed

MM.7

Policy and procedures define how sample medications arestored, inventoried, dispensed and safely used both in outpatient

and inpatient

MM.13

Policy and procedures defines the appropriate storage ofmedications

MM.15

Policy and procedure defines the appropriate storage oftherapeutic parenteral nutrition (TPN).

MM.16

Policy and procedures defines the storage, distribution andcontrol of narcotics in compliance with law and regulations.

MM.20

Policy and procedure defines safe prescribing/ordering of

medications in the organization

MM.29

Policy and procedures defines safe prescribing/ordering andtranscribing includes

MM.30

Policy and procedure defines the use of verbal and/or telephone

orders

MM.31

Policy and procedure defines the use of weight basedcalculations, at least for pediatrics, chemotherapy, andcompromised patients.

MM.33

Policy and procedure defines the use, review and updating ofpreprinted order sets.

MM.34

Policy and procedures defines the safe preparation and

dispensing of medications.

MM.37

Policy and procedures defines who can prepare medications(compounding and admixing) and the equipment and conditions

required

MM.40

Policy and procedures governs the preparation and distributionMM.42




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StandardCodeSerial

of therapeutic parenteral nutrition (TPN).

Policy and procedures defines safe and accurate administrationof medications

MM.48

Policy and procedures governs the medications that are allowedto be brought from home or by the family

MM.51

Policy and procedure defines the monitoring of the response to

medications including the first dose of a new medication and allhigh risk medications (including TPN).

MM.54

There is a system for reporting medication errors and adversedrug reactions

MM.58

Patient safety, Infection Control and Environmental Safety

General Patient Safety

There are Policies & Procedures related to patient’ s safety in the

organization.

PS.1

Policy and procedures defines Egyptian and WHO Patient Safety

recommendations and solutions

PS.2

Policy and procedures for handling critical values/testsPS.3

Medication Management Safety

Policy & Procedures for Medication Management Safety

PS.18

Policy and procedures to prevent errors from high risk

medications

PS.19

Policy and procedures to prevent errors from look-alike, sound-alike medications

PS.20

Operative and Invasive Procedure Safety

Policy and procedures for operative and invasive procedures

safety

PS.29

Infection Control, Surveillance and Prevention




63

StandardCodeSerial

There is a continuous program to reduce the risks of

organization acquired infections that describes the scope,objectives, expectations, and surveillance methods

IC.2

The organization identifies those procedures and processes

associated with increased risk of infection.

IC.10

There are infection control policies and procedures that describe

infection control practices

IC.11

Policy and procedures describe infection control practicesIC.12

Sterilization

There is a procedure that guides each sterilization technique ordevice used, and includes the manufacturer's recommendations.

IC.28

Policy and procedures describes the processes of sterilizationIC.29

There is a policy and procedure for reprocessing guided by the

laws and regulations and manufacturers requirements

IC.31

Policy and procedures defines laundry and linen services andincludes at least

IC.36

Policy and procedure for laundry and linen services are approvedby the infection control committee.

IC.37

The organization has an infection control surveillance policy andprocedure which includes all areas of the organization (Refer to

standards IC.2)

IC.41

Facility and Environmental Safety

Medical equipment

Policy and procedures defines the monitoring of refrigerators

and freezers Available in the organization.ES.58

Information management




64

StandardCodeSerial

Confidentiality & security

Policy and procedures defines the confidentiality and security ofdata and information and protection from loss or damage

IM.2

Policy and procedures defines the requirements for developing,

approving, tracking and revising policies and procedures.

IM.6

A policy on the retention time of records, data, and informationthat is consistent with law and regulation.

IM.11

Patient specific information

Policy and procedures defines a uniform/consistent structure of

the medical record

IM.17

Policy and procedures defines the types of verbal/telephoneorders that can be received, the type of individuals who canreceive these orders, and the time frame to be authenticated.

IM.24

The organization has a policy for review of medical records at

least quarterly that includes the following

IM.38

Performance Improvement

Policy and procedures defines an incident-reporting systemPI.54

Policy and procedures defines the criteria and process forintensive analysis when significant unexpected events andundesirable trends and variation occur.

PI 55

Organizational management, Human Resources, Nursing andMedical Staff

There is a formal orientation program for all employees,volunteers and contract workers.

HR.17

There is a continuing education and training program for allemployees, and applicable physicians.

HR.24

Policy and procedure defines the process for performance reviewof employees.

HR.48




65

StandardCodeSerial

The organization has an employee health program that is

provided for all employees.

HR.53

Policy and procedure defines the extent and frequency of the

employee health and physical assessment, testing, actions to betaken including the reporting of occupational hazards for staff.

HR.57

Medical staff

The medical staff reports to the governing body and isaccountable to the governing body.

MS.2

Medical staff bylaws address the following:MS.4

The structure of the entire medical staffMS.4.1

The structure and function of the medical staff committeeMS.4.2

The appointment process including the process for validatingrequired licensure, education, registration and/or certification of

all medical staff, other staff and visiting consultants andprofessors

MS.4.3

The privileging processMS.4.4

The revision and/or renewal of privilegesMS.4.5

The process to identify those members who may provide carewithout supervision

MS.4.6

The process and criteria for suspensionMS.4.7




66

StandardCodeSerial

The mechanism for a fair hearing and appeal processMS.4.8

The process for peer review and criteria for external peer reviewMS.4.9

Continuing EducationThe organization has a functioning continuous medical educationprogram.

MS.34

Policy and procedure define the scope of student, house officerand resident assessment and treatment of patients.

MS.38

Community Involvement

Policy and procedure guides the public relations process fordealing with at least the following

CI.13

There is a defined process to document and manage communityand external customer complaints

CI.14

Required plans

Safety and security

There is a safety and security plan that addresses the objectives,scope, performance, and effectiveness.

ES.13

Emergency/Disaster Management

There is an emergency/disaster management plan for internaland external emergencies that addresses the objectives, scope,performance, and effectiveness.

ES.23

There is an emergency/disaster management plan to respond tolikely community emergencies, epidemics, natural or other

disasters.

ES.27

Hazardous Materials and Waste

There is a hazardous materials and waste management plan for

the use, handling, storage, and disposal of hazardous materials

ES.33




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StandardCodeSerial

and waste that addresses at least the following

Fire Safety

There is a fire and smoke safety plan that addresses prevention,early detection, response, and safe exit when required by fire or

other emergencies that addresses at least the following

ES.41

Medical Equipment

There is a plan for selecting, inspecting, maintaining, testing,

and safe usage of medical equipment that addresses at least thefollowing

ES.51

Utility Systems

There is a plan for regular inspection, maintenance, testing andrepair of essential utilities

ES.64

The organization has an Information plan to meet informationneeds based on at least the following

IM.8

There is a performance improvement, patient safety and riskmanagement plan that defines at least the following:

PI.2

There is a risk management program(Plan) that includes at leastthe following

PI.53

Governance - Governing Body

The organization's strategic plan and budget are approved bythe governing body

0M.7

Each department has a written staffing plan that defines the

following:

OM.53

Human Resources

Planning

There is a staffing plan for the organization

HR.1




68

StandardCodeSerial

REQUIRED COMMITTEE

Research committee reviewsPR.34

Drug and therapeutic committeeMM.3

Infection control committeeIC.7

Environment of Care committeeES.3

There is a performance improvement, patient safety and riskmanagement committee(s).

PI.4

Medical staff committeeMS.3




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List and criteria

List or Criteria

Code

List of procedures or treatments for which informed consent is requiredPR.17

Criteria for getting consultation for patientsPA.10

Established criteria determine the appropriateness of transfers withinthe organization, including transfer to an appropriate level of careand service

PA.16

screening criteria for Nutritional risk and needsPA.4.1

screening criteria for functional/rehabilitation risk and needsPA.4.2

screening criteria for Social and psychological services and dischargeneeds

PA.4.3

Screening criteria of patients against abuse and neglect.AP. 5

criteria to identify patients who require further nutritionalassessment.

AP.6

criteria to identify patients who require further functionalassessment.

AP.7

criteria to identify patients who require further abuse and neglectassessment.

AP.8

There are written admission and discharge criteriaAP.38

A list of all special diets is available and accommodatedPC.22.1

Physiologic based admission criteria for the intensive care andspecialized units and /or specific conditions defined by the hospital

PC.35

Criteria for the use of restraints or seclusionPC.40

Emergency equipment and supplies as required by law andregulation and organization policy

PC.49

Criteria are developed to determine priority of care. PC.54

List of special techniques or procedures that must be performed underphysician supervision.

DS.8

The organization defines the timeframes for availability of reports forinterpretation of radiology tests and procedures, including both

DS.10




emergency (STAT) and routine reports by types of tests are defined.

List of essential reagents and supplies.DS.28

List of laboratory tests that are performed in the organization.DS.32

The Essential Drug List (EDL) or organization developed medication list(formulary) is approved by the Drug and Therapeutic Committee andMedical staff medications are listed by their generic names

MM.8

List of the high risk and look-alike, sound-alike medicationsMM.12

There is a list of qualified individuals, as per requirements of law andregulations and hospital policy, permitted to prepare and dispensemedications.

MM.36

List of the lab tests that have critical values/test results and the criticalvalues/test results are defined for each test.

PS3.1

List of the radiology tests that have critical values/test results and thecritical values/test results are defined for each test.

PS3.2

List of the clinical findings that have critical values results and the criticalvalues are defined for each clinical finding.

PS3.3

Abbreviations not to be used throughout the organization.PS18.1

The list of high risk medications including concentrated electrolytesPs19.1

current inventory of the types and locations of hazardous materials

and waste including the interventions to take in the case of a splashor spill (material safety data sheets)

ES.36

Inventory of all medical equipmentES.51.1

Indicators are identified and monitored for all significant processes PI.15

list of events that are subject to root causes analysis PI.53.1

list of all current equipment in the organization. ES.54

List of reportable incidents and near missesPI.54.1