JCI Training Booklet 2020 C PDF

JCI Survey Readiness Handbook 6th Edition Standards for Hospitals

Purpose This Handbook has been developed with support of our JCI Champions and Co-Champions to serve as a quick reference for you to understand the requirements of JCI standards and how to comply with the measurable elements.

Why is JCI Accreditation Important to Us? Through effective implementation of JCI Standards, Al SKMC aims to provide safe and effective care of the highest quality and value to our patients.

Contact Us If you need any further clarifications on this handbook, please feel free to contact the JCI Champions and Co-Champions or Quality Department. For better understanding, you may refer to policies mentioned in the Handbook at SKMC Portal.

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Contents

TIPS ON HOW TO ANSWER SURVEYOR QUESTIONS ............... 3 INTERNATIONAL PATIENT SAFETY GOALS (IPSG) .................. 5 ACCESS TO CARE AND CONTINUITY OF CARE (ACC) ............. 9 PATIENT & FAMILY RIGHTS (PFR) ................................................ 13 ASSESSMENT OF PATIENTS (AOP) ............................................... 18 CARE OF PATIENTS (COP) ............................................................... 25 ANESTHESIA AND SURGICAL CARE (ASC) ............................... 32 MEDICATION MANAGEMENT AND USE (MMU) ..................... 36 PATIENT AND FAMILY EDUCATION (PFE)................................. 46 QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS) ...... 49 PREVENTION AND CONTROL OF INFECTIONS (PCI): ............ 56 GOVERNANCE, LEADERSHIP AND DIRECTION (GLD) .......... 65 FACILITY MANAGEMENT AND SAFETY (FMS) ......................... 68 STAFF QUALIFICATIONS AND EDUCATION (SQE) ................. 88 MANAGEMENT OF INFORMATION (MOI) ................................. 91

2

TIPS ON HOW TO ANSWER SURVEYOR QUESTIONS Kindly keep the following points in



someone else’s responsibility.” Instead,

mind, when approached by a JCI

you can say “I don’t know, but I’ll find

Surveyor/ Consultant: 

the

RELAX…when



surveyor

first 

Practice

rules

of

courtesy

Don’t attempt to hide, ignore, avoid or



responding. In other words, continue



 

Instead

talk

about

our

Show

them

you

are

interested,

NEVER argue with the surveyors. If after your interview with the surveyor.



Stay confident and highlight your strengths or the strength of your

you know the answers better than

practice and what you would actually

their

you disagree, let your manager know

Respond to questions with confidence –

concisely, based on your everyday

to

knowledgeable, & proud of your work.

surveyor to rephrase the question if you

Answer each question clearly and

answers

procedures.

question before you answer. Ask the



the

your practice based on our policies and

talking with surveyors.

Keep the conversation professional.

in

organization’s standard practices or

your patient to a co-worker if you are



Avoid using the words “always” or questions.

Perform a hand-off communication of

anyone.

more

An apology for not knowing an answer

“never”

afternoon…).

do not understand what is being asked.

give

or Manager.

Surveyor/ Consultants (Good morning/

Always make sure you understand the

Don’t

who knows such as your Charge Nurse

your work and be certain to greet the

not able to attend to your patients while

specific.

is not sufficient. Refer them to someone

would prohibit you from immediately

do in each scenario.

In your response to the question, be

only the question asked.

involved in a patient care activity that



VERY

information than they ask for. Answer

run from them, unless of course you are



IS

Always answer honestly…if you don’t

very and

confidentiality.



you”

surveyor the answer you think.

begin to gather your thoughts.



for

know, don’t guess. Don’t try to give the a

approaches you, take a deep breath and 

answer

ACCEPTABLE ANSWER. ID badges must be worn at all times and at eye level.



DO NOT say, “I don’t know’ or ‘that is

unit/department. 

Know the location of policies, fire exits, Material Safety Data Sheets (MSDS), meaning of RACE and PASS.



Refer to this JCIA Handbook, JCIA Standards and Policy Management System as reference tools. 3



You do not have to memorize SKMC

understanding of SKMC practice with

Mission/Vision Statement; but know

implementing the JCI Standards.

where to find it and read it out to the 



surveyors.

International

Support your co-workers…. If you are

(IPSG),

present

Measures/KPIs,

when

someone

is

being

questioned, feel free to add any relevant



Patient

Department and

Safety

Goals

Performance Performance

Improvement Projects. 

information. 

To tell about your unit compliance with

If asked, how do your work and your

Managers, …please do not volunteer to

department contribute to the SKMC

answer

staff.

Mission Statement, answer it based on

Surveyors primarily want to interact

the service you provide and scope of

with staff….not the managers

service for the Department you work.

If the surveyors or consultants ask for

(Refer also to SKMC Strategic Plan).

on

behalf

of

your

your name and employee ID, Do Not



Be ready to show Plan of Care, Pain

Panic. This is done during tracers for

Assessment and Reassessment, General

employee file review later in the SQE

Consent, Patient Education, Admission

session.

History and Notes etc. on Salamtak. Learn how to navigate with ease.

Be Prepared: 

To show documents in Portal such as: Policies, Guidelines etc. Make yourself familiar with how to access policies. Please also read the polices mentioned in the handbook on portal for better

4

INTERNATIONAL PATIENT SAFETY GOALS (IPSG) The purpose of the IPSG is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and describe evidence- and expert-based consensus solutions to these problems. Joint Commission International and the WHO conjointly promoting the following six international patient safety goals for increasing awareness about these goals and ensure safe delivery of care.  Prior to any treatments, procedures, or

IPSG 1:

diagnostic procedures, such as taking blood

Identify Patients Correctly

or other specimens, POCT, and radiology

Use 2 patient identifiers – For inpatients, ED

procedures.

patients, and patients attending for procedures in the outpatient specialty clinics 3 and 4, the two identifiers are, the patient’s full name and medical record number. For all other outpatients, the two identifiers

 Prior to medication administration.  And prior to delivering restricted dietary trays. [Ref. Doc.: Patient Identification Policy]

are, the patient’s full name and a government issued ID, preferably, the Emirates ID. The patient’s room, bed number or location

IPSG 2:

must NEVER be used

Effective communication, which is timely,

for identifying

Improve Effective Communication accurate,

patients.

complete,

unambiguous,

and

Patients arriving in

understood by the recipient, reduces errors,

the

and results in improved patient safety.

Emergency

Service area, which

Verbal or telephone orders

are

and

Verbal and telephone patient care orders,

(such

verbal and telephone communication of critical

as Trauma Patient in ED), comatose or

test results, and handover communications,

confused/disoriented and cannot be properly

are instances that are impacted most by poor

identified, identification is made by ED staff or

communication.

unknown

unresponsive

accompanying

family

member

identification

wristband

will

and be

an

issued

containing: 

Temporary Name (e.g. Unknown A, unknown B etc.)



Medical Record Number

Patient identification must be done:  At

the

time

of

admission,

discharge, and time of handover.

Verbal or telephone orders are discouraged at transfer,

SKMC, unless during emergency situations, where access to electronic record is not feasible. When there is a need, the appropriate form should be used.

5

The verbal order must be written down, read

During handovers, nurses use the SBAR tool,

back

while physicians use their standardized tool.

and

confirmed

to

the

person

communicating the information by the person receiving the order. Physicians need to co-sign

[Ref. Docs.: Critical Results, Observations

their

and

verbal

or

telephone

orders,

or

acknowledge the critical results of patients within 24 hours.

Findings

Communications

Policy, Policy,

Hand-off Verbal

or

Telephone Orders Policy]

The complete order or test result (s) is written down in Doctors order form / Critical result

IPSG 3-Improve the safety of high alert

form as received and verbally read-back to the

medications

person communicating the information to



High alert medications, are drugs that

confirm.

possess a narrow margin of safety. When

Physicians are also expected to document their

these drugs are involved in an error, they

recommendations or actions following the

often result in serious harm. 

receipt of their patient’s critical result.

SKMC has a list of high alert medications, as well as a list of look-alike, sound-alike

Hand-Off

medications. Strategies to mitigate risks The objective

primary of

associated with these medications, such as

a

independent double checks of clinicians,

“hand off” is to provide

accurate

are also available. 

Do

not

mix

high-alert

medications

information about

together, such as insulins and heparin.

a

patient’s care,

They must also be stored in red bins,

treatment and services, current condition and

labelled with a clear, red, High Alert

any recent or anticipated changes. The

sticker.

information communicated: during a hand off



Concentrated electrolytes are stored in

must be accurate in order to meet patient safety

pharmacy only, except perfusionist OR

goals. Hand offs are interactive communications

trays, for cardiac surgery. 

If look-alike, sound-alike medication pair

allowing the opportunity for questioning

is present in the unit, store in yellow bins

between the giver and receiver of patient

segregated with each other. In addition,

information.

Tall Man lettering is used in the medical

Hand offs include up-to-date information

record, and medication and bin labels for

regarding the patient’s/ client’s/resident’s care,

these drugs.

treatment and services, condition and any



For all High Alert Medications including

recent or anticipated changes

concentrated electrolytes,

Interruptions during hand offs are limited to

double check process must be followed

minimize the possibility that information

before dispensing and before medication

would fail to be conveyed or would be

administration.

independent

forgotten.

6

[Ref. Docs.: High Alert Medications, Look-

team. Once the time-out is complete, no one

Alike, Sound-Alike (LASA) Medications,

from the team should leave the room.

Concentrated Electrolyte Injections]

The Pre-op checklist is used to verify that all documents and equipment needed for surgery

IPSG 4- Ensure Safe surgery

are on hand and correct and functioning

Significant patient injuries, and adverse and

properly before surgery begins.

sentinel events can be

prevented from

occurring, by following essential elements, as required by the standard. These are: 

Having

a

preoperative

verification

process. 

Marking the surgical site.



Conducting

a

time-out

immediately

And conducting a sign-out in the area where the procedure was performed, before the patient leaves.

laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine) with “Arrow” prior to the start of any surgical or invasive procedure, with the participation of the patient. A final verification process is conducted, such as a “time out,” to confirm the correct patient, procedure and site, using active communication. surgical

or

invasive procedure site

marking,

is

done by the person who will perform the procedure. At SKMC, an arrow is used to mark the site, except

for

ophthalmology

Operation Theatre and for all invasive procedures in any another clinical area just For Neonates and Dental procedures, we have separate site verification forms.

IPSG 5-Reduce the risk of health careassociated infections. Hand hygiene is the single most effective

The site is marked in all cases involving

The

“Time-Out” and “Sign-Out” must be done in

before the procedure conducted.

before the start of the procedure. 

[Ref. Docs.: Safe Surgery and Procedures]

and

dental

procedures. The Time-Out is conducted in the location at

means of preventing healthcare associated infection. The term hand hygiene refers to actions intended

to

microorganisms

decrease on

the

the

number skin,

of

thereby

minimizing the risk of the transmission of infections from staff to patients, from patient to staff, and between patient and visitors. Effective hand hygiene is achieved through hand washing with soap and water or hand decontamination with the use of a waterless alcohol based hand rub. At SKMC, we are in compliance with the current CDC guidelines for hand hygiene, and follow the WHO five moments of hand hygiene. 1. Before touching a patient. 2. Before doing an aseptic procedure. 3. After a body fluid exposure risk. 4. After touching a patient.

which the procedure will be done, and it involves the active participation of the entire

7

5. And, after touching the patient surroundings.

When a patient is determined to be at risk for falls, the patient is flagged. For inpatients:

A yellow Fall Risk wristband is placed next to the patient's ID band. And a Lamp or look at me please sign, is placed on the patients’ door. Wash hands with liquid soap and water when

Examples of interventions done to prevent

hands are visibly soiled and using gloves does

patients from falling are:

not replace hand washing.



Placing the bed side rails in up position.



Placing the call bell within the patient’s

[Ref. Docs.: Hand Hygiene Policy]

reach. 

IPSG 6-Reduce the risk of patient harm resulting from falls

Educating the patient and the family members and asking for their cooperation.



Supervising

the

patients

during

mobilization and ambulation. 

And

limiting

the

patient’s

activity

whenever possible. If FALL occurs, it must be mandatorily reported

through

the

hospital

Safety

Intelligence system. [Ref. Docs.: Falls Prevention and SKMC has a process for assessing and

Management for Adult and Paediatric

reassessing patients’ falls risk – using the

Patients]

Morse Falls Risk Assessment tool for adults, and the Humpty Dumpty tool for pediatrics. In certain outpatient locations where nurses are not present, such as in radiology and laboratory, the patient access staff conducts a visual screening process to determine a patient’s falls risk.

8

ACCESS TO CARE AND CONTINUITY OF CARE (ACC) SEHA and SKMC are in pursuit of a more comprehensive and integrated approach toward delivering health care. The continuum of care, made up of the following ― integrated system of services, health care professionals, and different levels of care, are things that we consider in SKMC when providing care for our patients. Our goal is to correctly match the patient’s health needs with the service available, to coordinate the services provided to the patient in the organization, plan for discharge, followup care and transfers between services and hospitals, whenever necessary. Patient Triage Policy - D-NUR-ED-01-021, for specific details) 

Whenever required, patients are assessed and stabilized within SKMC’s capacity, before they are transferred.

Screening for Admission to the Hospital

Delays

Patients attending SKMC…

Services





Are screened and assessed appropriately,

and/or Treatment

All patients will be informed, and their clinical needs taken into account when a

scope of services of the hospital.

procedure and/or treatment is cancelled or

Are transferred, referred, or assisted to

delayed for more than 12 hours. 

Patients will be informed of the reason for

applicable.

the delay, and provided with information

Get specific screening tests or evaluations,

on available alternatives consistent with

and results are made available, prior to

their clinical needs.

patients’ admission, transfer or referral. 

Diagnostic

and are accepted when they fall under the

appropriate sources of care, whenever 



in

Refer to Admission/Care & Discharge of ED Patient Policy - C-NUR-ED-01-012



Discussions are documented in the patient’s EMR.



Refer to Delay in Diagnostic and/or Treatment Services Policy - C-NUR-ED-01019)

Patients in the Emergency Department 

Triaged

and

prioritized

using

the

Emergency Severity Index (ESI) Criteria (Refer to the Emergency Department

Admission to the Hospital 

SKMC

has a standardized admission

process (refer to Patient Admission Policy 9

C-MD-GEN-01-023)



and

registration

process (refer to Outpatient Appointment

information

Scheduling Process Policy - D-FIN-PAS-01-

treatment). It is easy to access and is

008 )

automatically updated after each visit.

Physicians who has authority to admit



and

In the clinics and emergency department, all



Consultant Grade Physicians

assessment is completed. Patients are then



Designated Specialists with admitting

evaluated based on their chief complaint. 

The Nurse and the Physician assess all

(Refer to Most Responsible Physician (MRP)

inpatients on admission. In addition, they

Policy - C-MD-GEN-01-005)

receive assessments from the dietician and

Patient needs for preventive, palliative,

other services based on needs identified

curative, and rehabilitative services are

from on-going assessments. 

at the time of admission Upon patient admission, the patient and 

education

All of these assessments are documented or recorded in the patients’ medical record.



family receive:

During all phases of inpatient care, there will be an assigned Most Responsible

and

orientation

to

the

Physician (MRP) designated as responsible

inpatient ward

for the patient’s care. (Refer to Most



information on the proposed care

Responsible Physician (MRP) Policy - C-



information on the expected outcomes

MD-GEN-01-005) 

of care  

problems

patients are seen by a nurse and an

prioritized based on the patient’s condition 

(Diagnosis,

patients to SKMC are:

privileges



record, it contains updated patient medical

When a transfer of MRP is required, the

information on any expected costs

current MRP is responsible for personally

related to the proposed care

notifying the other physician of the

There is a patient flow process being

intended transfer of care. All requests and

followed at SKMC including patients who

acceptance

are boarded in the ED (Refer to the

documented in the patient’s medical record.

of

patient

transfer

is

following policies: Emergency Department



Referral, Transfer and Admission - D-MD-

Discharge, Referral and Follow-up

ED-01-001 and General Case Management



The plan for discharge and referrals, as

Policy - D-NUR-CM-01-001)

required, is initiated upon admission and is

Admission, transfer, and discharge to

revised throughout the patient’s hospital

inpatient units providing intensive or

stay. Appropriate clinical referrals and

specialized

care

their

follow up appointments must be made

established

admission

discharge

before the patient is discharged from the

to

inpatient

criteria

is

documents

guided and (refer

by

these

documents for details)

setting.

(Refer

to

General

Discharge Policy - C-MD-GEN-01-024) 

SKMC has a process for patients being

Continuity of Care

permitted to leave the hospital during the



A patient’s clinical summary is the first

planned

page when opening the patient’s medical

approved pass for a defined period of time.

course

of

treatment

on

an

10

Ensure

that

appropriate

discussion,

frequently and who require the input of

assessment and documentation was in place

services from different practitioners in

before patient is allowed to do so. (Refer to

multiple settings. Their profile may be

Approved

viewed through the “Ambulatory Tab” in

Inpatient

Leave

from

the

Hospital - C-MD-GEN-01-036). 

Patients

are

provided

the patients EMR and it contains their upeducation

(Refer

to

needs identified in the assessment, and are

Complex Care - C-MD-OSC-01-010) 

The

hospital has a

process for the

learning needs, which includes discharge

management and follow-up of patients who

planning. The assessment for learning

notify hospital staff that they intend to leave

needs is ongoing.

against medical advice. For further details,

A complete discharge summary is prepared

refer to the LAMA / DAMA / AWOL section

to all inpatients and it includes the

of the General Discharge Policy - C-MD-



Reason for admission, diagnoses and

GEN-01-024. Transfer and Transportation of Patients

comorbidities



SKMC will transfer patients as appropriate,



Significant physical and other findings

from referring facilities or to outside



Diagnostic and therapeutic procedures

organizations. There must be written orders

performed

and accepting physician for transfers into

  

Significant

medications,

including

SKMC or from SKMC to another facility, for

discharge medications

the consistent handling of patient transfers

The patient’s condition/status at the

from/to outlying facilities, in accordance

time of discharge

with legal and regulatory requirements.

Follow-up instructions

(Refer to Management of Transfers to and

(Refer to the General Discharge - C-MD-

from Sheikh Khalifa Medical City Policy - C-

GEN-01-024,

MD-GEN-01-022)

and

Discharge

Summary

Content and Completion - C-MD-GEN-01-



All transfers into SKMC (including Critical

042 Policies)

Care) must be coordinated through the

Follow up instructions are given by the

Admission/Transfer Center (ATC) to ensure

nursing team, in a format that the

the appropriate assigned bed and resource

patient/family understands. It will include

allocation is available to meet patient needs.

instructions to return for follow up care,



care.

Documentation for Outpatients Requiring

following:



medical

immediately after admission and based on given specific education based on identified



to-date



The

ATC

will

ensure

that

all

and where and when to obtain urgent or

communication between facilities must be

emergent care. As required by the patient’s

clearly documented to include, but not

condition, families are likewise provided

limited to:

instructions and education on how to



The agreement of transfer

provide competent care.



The reason for transfer

care



Medical report/ Referral letter

outpatients are patients whose conditions



Inter Hospital transfer form

SKMC

has

defined

complex

require complex care continuously and 11

  

Any other relevant and pertinent



clinical documentation and reports

been handled in an appropriate way or

Any special conditions in direct relation

deviated from the standards set by SKMC

to the transfer

policy, a Safety Intelligence report will be

DOH

Feedback

Form/Hospital

submitted. Furthermore, the case may be

Discharge Summary 

Inter-facility

Hospital

referred to the medical director, nurse Transfer

supervisor or charge nurse, who will

Documentation Form 

If a patient transfer or transportation has not

document the situation and report it to

The patient is assessed prior to transport to ensure

the

appropriate

personnel,

Quality Department for review. 

The Ambulance medical items are checked

equipment and mode of transport is

by the ED team every morning and upon

provided to ensure patient safety in

the ambulance return from workshop.

accordance with the SKMC Transport Grid.

(Refer to Ambulance and Vehicle Service Request Policy - C-OP-HS-01-063)

12

PATIENT & FAMILY RIGHTS (PFR) Health care organizations work to establish trust and open communication with patients and to understand and protect each patient’s cultural, psychological, social, and spiritual values. This starts by defining patient rights, then educating patients and staff about them. The goal of the Patient and Family Rights chapter is to improve care, treatment, services, and outcomes by recognizing and respecting the rights of each patient and by conducting business in an ethical manner. All standards related to this chapter are coded “PFR.”

How are your patients protected from harm? 

Security personnel are always present in SKMC and they observe everyone who enters and leaves the facility.

How are patients informed of their rights



monitored by both Security staff and SEHA

when they seek care in the OSC, ED, or

Operation Command Center.

admission to the hospital? 

Yes. PFR posters are located throughout



emergency operations plan codes, as

Arabic and English.

defined

The patient’s rights and responsibilities

receive

the

responsibilities



patient

rights

information

and

pamphlet,

in

the

EOP

Annexes

and

Departmental Action Cards.

Posters are posted throughout the facility in Arabic and English. Patients/Families

Additionally, Security Services, and other staff are trained to respond to specific

the hospital and it is available in both 

There are CCTVs throughout the hospital

How do you know that only authorized personnel

have

upon admission. It is also be available in

information?

waiting areas of the hospital.



access

to

patient

All staff members wear a badge that

Information about patient rights and

identifies them by name, department and

responsibilities is provided to each patient

Position. Staff is taught to stop/question

in a language and manner the patient

those who seek information they are not

understands.

entitled to.

Familiarize yourself with the patient’s rights



Computer access is limited to those who

and responsibilities and be prepared to tell the

have been given access to information

JCI surveyor about this process.

based on their assigned job and area.

13



All staff sign confidentiality statements

recommended treatment or procedure, the

upon employment and at re-contracting,

risks and complications, benefits and

agreeing to honor the privacy rights of

alternatives.”

patient’s, and agreeing never to share their

known risk factors that increase the

computer passwords.

likelihood of a poor outcome must also be

An

individual

patient’s

part of the discussion. What is SKMC’s policy on Consent? General Consent:

What is the adult age in UAE?

For Treatment shall be obtained from the all

18 Years old.

patients when they present for treatment: • Each ED visit

What is the validity of informed consent

• Each admission

forms?

• Yearly for outpatients

30 days for informed consent. Correct and complete consent (Informed Consent) must contain the following: 

To take consent you must have sole management privileges of that operation (MRP and specialist only).



The patient’s MRP if going to do the operation

should

take

the

consent

personally or he can delegate to one of the privilege specialist who is fully aware about the said procedure. 

Informed Consent: 





Informed consent is a way to involve the

other than MRP, the privileged specialist

patients/family with the plan of care. It is a

should have the approval of MRP to

medical/legal document which needs to be

perform

completed following the SKMC consent

documented

policy.

performing the procedure. (Best practice)

The purpose of informed consent is “to



that

procedure in

and to

patient

file

be

before

A delegated physician cannot further

honor the patient’s right to make decisions

delegate (sub-delegate) activity to a third

about

physician

health

care,

ensure

patient

without

having

specific

understanding and prevent allegations of

direction and authority from the consent

lack of informed consent.”

giver and attending physician.

The informed consent discussion must be held when the patient is alert and has the ability to make a rational decision.



If the operation is to be done by someone

Informed consent begins with a discussion between discussion

doctor

and

includes

patient. the

“The

condition,



GPs and Residents should not take consent.



Use black or blue ink only and write legibly.



Procedure must be written in full without using abbreviations. 14



Procedure

description

matched

the



description in the clinical notes.

timely manner.



There must be no abbreviations.



The side where the procedure will be



conducted must be spelled out in full and



The dates of all the signatures must all be Any alteration to a completed consent form

must

intervention

 

be

made

commences

before

the

and

the



assault. 

To receive visitors, unless it would compromise treatment.



To be informed about their medical condition(s), treatment plan, anticipated

consent giver and the attending physician

outcomes in a

both or by the physician as indicated.

family/caregiver

Patient’s sticker is correct (this is the

including:

correct patient information).

associated with treatment and a plan for

General and specific complications are

continuity of care following discharge. 

Any procedure intervening with fertility must be signed by patient and her

the

way they or their can Risks

understand and

Benefits

To know the names/ titles of their healthcare providers.



Husband or father if Patient is Single. 

To be free from all forms of harassment or

alteration must be signed and dated by the

listed. 

To an interpreter and/or translation services.

the same (patient, doctor, nurse witness). 

To access spiritual care services available in the community if needed.

match the clinical notes. 

To have pain assessed and managed in a

To request for a change of provider or second opinion.

For emergency Cases (E1), there is no need



to obtain consent only Document in the

their medical record as permitted by law. 

Cerner in Plan of care.

To request a medical report and access To be informed about their financial responsibilities.



Patients’ rights and responsibilities All patients have the following rights: 

To

receive

information

about

against doctor’s advice as permitted by the

availability of care, services and how to access these appropriately. 

To

receive

protection

vulnerable: i.e.: 





To refuse, discontinue treatment or leave law.



To provide prior consent for use before the making of recordings, films, or other

if

they

are

images.

children, elderly, and

patients with special needs.

How the staff is made aware of the patient’s

To receive care regardless of race, creed,

unique needs at the end of life? What is End

color, national origin, gender, age, or

of Life care?

disability.

End of life is an anticipated death and the end

To have personal dignity, privacy, culture,

stage of a fatal medical condition. End of life

psychosocial & personal values, beliefs

care starts, when the patient becomes so

and preferences respected.

debilitated, confined to bed, and death is

To a clean, safe environment.

imminent.

15

Palliative Care is a multidisciplinary approach



Involving the patient and family in every

seeks to prevent or relieve the Physical, social,

aspect of care, including the decision

Spiritual,

making process for end of life issues. Responding to the psychological, social,

Distress

psychological Produced

and

by

a

Emotional

life-threatening



medical condition or its treatment, to help patient with such conditions and their

emotional, spiritual and cultural concerns

families, to live as normally as possible, and to

children and teens affected by the death,

provide them with timely and accurate

prior to, and at the time of the patient’s

information and support in decision making:

death. Assuring that all staff caring for the



By providing relief from pain and other

patient are aware of the patient’s wishes

distressing symptoms.

and respectful of their decision.

  

of the patient and family, including

By integrating psychological, social and spiritual aspects of patient care.

How do you obtain an interpreter for a

To help patients live as actively as possible

patient or family member?

until death.



There is an Interpreter Services under

To maintain the personal dignity and self-

Nursing Division available on SKMC

respect of the patient

Portal. 

Interpretation Services is available during the normal working hours.

If a patient or family member has a complaint, how do you assist them? 

The goal is managing patient complaints as early and immediate intervention and resolution.

 End of Life Care includes 



Managing

Pain

Complaints should be resolved at the level closest to the patient whenever possible.

aggressively

and

If the complaint is not resolved. Then the

effectively. Through assessing, managing,

Patient Experience Officer will escalate it to

and reassessing technique. Providing Treatment of

complaint office. Senior patient Symptoms

experience

will arrange family meeting if needed.

according to the wishes of the patient family, through assessing, managing and

Complaint office will deal with all internal

reassessing technique. 

complaints to ensure that they are assessed,

Respecting the patient’s privacy, religion

investigated, and resolved within 7 working



and cultural values. Communicating and Coordination is

days. If the complainant is dissatisfied with

important between the caring team, in a

complaints manager for further investigation.

feedback, the complaint will be escalated to the

patient centered approach, and between family and medical team.

Following are the 5 main steps for Service Recovery: 16



Hear the Story



Empathize with the patient

Patients and Families Responsibilities



Apologize for not meeting the patient



To bring their insurance card and

expectation

Emirates Identity Card with you every



Respond to the concern and what you can

visit.



do in a timely manner Thank the patient for giving him the



To keep scheduled appointments, arrive on time or let the facility know in advance

chance to resolve the concern.

if they would like to reschedule. 

To Sign a general consent for treatment

Organ Donation

after having the scope and limits fully

This process shall be performed through the

explained. Children under 18 years old

administration office of organ donation unit.

should be accompanied by a consenting,



adult family member.

The hospital supports patient and family choices to donate organs and other tissues.







and

accurate

medical history and medications 

To let the healthcare providers know if

The hospital provides information to the

they don’t understand the information

patient and family on the manner in which

given to them about their condition or

organ procurement is organized.

treatment

The

hospital

ensures that

adequate



To inform the medical team of changes in

controls are in place to prevent patients

their condition or symptoms, including

from feeling pressured to donate.

pain

The hospital defines the organ- and tissue-



To

follow

regulations

regarding

donation processes and ensures that the

patient/visitor conduct, no smoking and

process is consistent with the region’s

visitation timings 

The

hospital

To show respect and courtesy to staff and other patients

identifies

consent



To take responsibility for the outcome(s) if

requirements and develops a consent

they decide not to follow the health care

process

provider instructions and/or treatment

consistent

with

those

requirements.

plan and recommendations

Staff are trained in the contemporary



To speak up and communicate their

issues and concerns related to organ

concerns to any employee as soon as

donation

possible

and

the

availability

of

transplants. 

complete

patients and families on the donation

cultural values.



provide

information about their health, including

laws and regulations and its religious and 

To

The hospital provides information to process.







To pay their bills or make arrangements to

The hospital cooperates with relevant

meet the financial obligations arising from

hospitals and agencies in the community

their care

to respect and to implement choices to donate.



To leave their valuables at home or entrust to Security Department.

17

ASSESSMENT OF PATIENTS (AOP)

What is an Effective Patient Assessment Process? The goal of assessment is to determine the care,

How soon after admission does the doctor

treatment, and services that will meet the

need to complete the Admission Assessment?

patient’s initial and continuing needs. Patient

The doctors must complete the admission

needs must be reassessed throughout the

assessment documentation within 24 hours of

course of care, treatment, and services.

admission.

Reassessment is key to understanding the patient’s response to the care, treatment, and

How are patients with frequent Outpatient

services

visits assessed?

provided

identifying

whether

and

is

care

essential decisions

in are

patient

assessments

Nurses must do regular assessment at each visit.

appropriate and effective. Are

 

in

SKMC

Physicians - The medical history must be updated

and

physical

examination

interdisciplinary?

repeated if patient is scheduled for

Yes; Patients visiting the ED and OSC, or

admission, or booked for Outpatient

admitted as an inpatient receive an assessment

procedure or if medical assessment is older

from various disciplines, as indicated. The

than 30 days.

physician and nurse assess patients seen in the clinics and physicians refer them to other

What are the two mandatory elements to be

disciplines including allied health as indicated.

documented when an Emergency Surgery is to be performed?

Are assessments from outside facilities

The

two

Mandatory

elements

to

be

accepted in SKMC?

documented by the physician before the

No, SKMC policy requires that all patients

surgery are: A brief assessment note & a

transferred from other facilities be assessed

preoperative diagnosis.

again when presenting to our facilities for treatment.

How are the needs of patients known or identified?

How soon after admission does Nursing

Information about the patient’s physical,

complete the Admission Assessment?

psychological, social, functional and cultural

Written documentation must be completed

status is obtained during assessment. A review

within 12 hours of admission

of the patient’s medical record, including other 18

discipline’s

notes

(Salamtak

Document

Viewing and Results Review), can help

When are your patient’s nutritional and

identify patient needs. How are the patient’s needs prioritized?

functional

Patient’s needs are prioritized as per the

This is assessed upon admission and as part of

assessment findings using all disciplines

the ongoing assessment daily for inpatients

involved data and using a Multidisciplinary

and for outpatients upon each clinical visit. The

approach.

findings are documented in the medical

(activity

and

rehab)

needs

assessed? Where are they documented?

record/ Salamtak. What is the frequency of the Nursing Assessment & Re assessment?

What do Nurses do for patients with

Within 12 hrs of admission and every 12 hr

Nutritional needs?

shifts and before any transfer or discharge.

Once the nutritional need is identified, the nurses notify the doctor. The doctor then refers

What are the assessment criteria for Patient

the patient, as necessary, to the clinical

who are deemed chronic or a lower level of

Dietitian.

care? 





When the multidisciplinary health care

How would nutritional services know about

team determines the patient has reached a

patients who are at nutritional risk?

maximum level of functioning and has an

If the patient meets any nutritional risk criteria

established routine pattern of care, a

as per the screening tool, nurses notify the

patient may be designated for LTC if he/she

doctor and the doctor then refers to the

no longer requires acute care. (Refer to

dietician as needed. The dietetics then assess

policy C-NUR-CLI-16-007: Long Term

the patients for, such as certain lab values or

Care).

height/weight ratios.

Physicians: each patient will be assessed by a member of the medical/specialty group at

Why do we do a daily Nutritional and

least weekly and appropriate progress

Functional screening for all our patients?

notes will be recorded. (Refer to policy C-

As per SEHA mandate a minimum of every 24

NUR-CLI-16-007: Long Term Care)

hours screening is required.

Nurses: Nursing care will be recorded each shift & after relevant events. (Refer to

How would you know what is restricted in a

policy C-NUR-CLI-16-007: Long Term

patient’s diet order?

Care)

Doctors and Dietetic staff can place diet orders. Nurses have access to the approved Diet order

What is the assessment requirement of a

which is available in patient’s electronic

patient receiving blood/ blood products?

medical record and is auto printed to Food

Assessment of patients receiving blood and

Services section for diet delivery to patients.

blood products will be done as per the Blood Transfusion Policy. (SKMC/ C-MD-LAB-02-

How do you assess a special population

006-F-001/ Transfusion Guidelines).

group? 19

Special population groups will have their



Refer to Assessment and Care of Patients

assessment individualized based on their

who are Vulnerable and/or at High Risk (C-

unique needs and characteristics, so that their

MD-GEN-01-010).

needs are identified and addressed. Specific assessment elements are integrated into the

Do you base your assessment of the patient’s

assessment documentation in Salamtak.

needs on their age and special needs? Yes. Nursing assessments are based on age-

Who are the patients identified as special

specific criteria and identified special needs.

population (vulnerable / at risk)? 

Children and adolescents (up to 18 years)

What



Frail/ elderly

served) assessment mean and how do you



Terminally ill/dying patient

know about these needs?



Patients with intense or chronic pain





Pregnant or in labor women



Women



experiencing

Different

“age-specific”

age

psychosocial spontaneous

groups

(populations

have

different

and clinical needs.

For

example, a 2-year old patient requires an

abortions

appropriate paediatric blood pressure cuff

Patients with mental and/ or substance use

rather than an adult size. 

disorders 

does

Also, for example, when administering an

Suspected/ alleged victims of abuse and

IM medication, an appropriate gauge and

neglect

length of needle would need to be



Prisoners or those in police custody

considered in the case of a frail elderly



Patients in emergency department

person who may have decreased muscle



Patients who are comatose

mass.



Patients on life support



Patients with infectious or communicable

When patient Discharge plan start?

diseases

The discharge plan starts from admission time



Patients who are immunosuppressed

to identify the needs.



Patients receiving dialysis



Patients in restraints



Patients



receiving

Laboratory Services chemotherapy

or

Are you sending lab tests to other facilities?

radiation therapy

Yes, all laboratory tests which are not done at

Patients at risk for suicide

SKMC & sent to other referral labs either in UAE or outside UAE are done in the stipulated

Who are considered as frail/elderly as per

time as per agreed contract and mentioned in

SKMC Policy and how do you assess them?

the test catalogues of the offsite referral labs.



Vulnerable elderly patients are those who as a result of ageing and/or disease, the

What is the Turnaround Time (TAT)?

individual has become vulnerable to

Lab TAT is the time from receiving the

environmental and self-generated hazards

specimen in the laboratory reception until the result is verified.

20

Do you have a Critical tests list? Where can

A- Ordering physician.

you find it?

B- Senior on call physician.

Yes. It can be found in the following lab policy/ies: (D-MD-LAB-01-011, Critical Result

C- Chief of Service /Head of Department of

Notification)

D- Lab COS.

the concerned department. E- CMO. Who is authorized to order laboratory test? Only physicians are authorized to order laboratory test. What is Point of Care Testing (POCT)? Point-of-care testing (POCT) refers to any testing conducted outside a lab, near the site where the patient is located by non-lab staff.

What is a Critical result or a Panic Value?

How frequently must the POCT Competency

Panic Value is a laboratory result that indicates

be reassessed? Does it mean staff training?

that a patient may have a life threatening

Annually.

medical condition that requires immediate action by a physician.

How often is the Correlation study done between POCT devices?

What

must

the

caller

say

when

Annually.

communicating Critical result? 

Identify

himself/herself

by

Name

&

What is IQC and PT? Who runs IQC/PT

Employee ID. 

sample for POCT?

Take receiver’s Name & Employee ID.



IQC is Internal Quality control and PT is

State purpose of call.



Proficiency Testing. PT is performed by POCT

Identify patient by full name & MRN.



coordinator.

Communicate result with units clearly.



Ask receiver to read back the result.



What is your POCT critical result policy?

Confirm its correctness.



A result is considered critical if listed in the

Document conversation in CERNER.



POCT critical results table.

Verify the result on CERNER/ Salamtak.

Critical results shall be communicated by the Nurse/Respiratory Therapist/ phlebotomist

Is

there

any

documentation

of

communication of Critical result? Where? Yes, in CERNER/Salamtak system.

who performed the analysis immediately upon test verification. Concerned

physician

must

be

informed

immediately. Who can receive Critical results for Inpatients? In sequence: 21

All Critical results & their communication to

Blood/ Blood products should only be picked

physician must be recorded in Patient’s

up by a medical staff (nurse or physician) by

records in Salamtak system.

using blood bank transport boxes.

Where can you find the POCT policies &

Can blood bank transport boxes be used to

records?

store blood/blood component?

In

SKMC

Policy

Management

System

categorized on departments- lab policies- lab

No. These boxes are meant only to transport blood/blood component not to store.

General- POCT policies. Records are also Who is responsible to order emergency

available with POCT coordinators.

blood/blood component? What precautions must you use while

The

performing POCT?

emergency blood/blood component by filling



Universal

precautions

for

infection

control. 

physician

is

responsible

to

order

and signing an “Emergency Transfusion Requisition Form”

Specific precautions like cleaning the devices after using them for each patient.

During the downtime is there any delaying on patient results?

What is the type of patient specimens with high-risk category?

No, Lab is processing all the samples offline and send a hard copy results till the system

Blood from patients with Hepatitis B, Hepatitis

back.

C, HIV, or Viral Haemorrghic Fever, Sputum samples from MERSCoV, H1N, TB patients,

During the planned

stools

receiving all the samples (Stat & Routine)?

from

patients

with

Typhoid,

downtime

is

lab

Parathyphoid, C. difficille or Dysentery.

Lab receive only STAT.

What is a transfusion reaction?

Is it possible to find the patients result in

A transfusion reaction is any signs and

Cerner after the downtime?

symptoms that occurs during or after a patient

Yes, all the results will be uploading to Cerner

receives transfusion of blood/blood products.

when system back.

What should be done in case of a suspected

Radiology Services

transfusion reaction?

Which

Licensing

and

regulatory

body

Call blood bank and send a properly filled

standards in the UAE does SKMC Radiology

“Request for investigation of transfusion

adhere to?

reaction form.

FANR

-

Federal

Authority

of

Nuclear

Regulation Who should pick the blood/blood component from the blood bank and using what?

What is an outside source of imaging? Outside sources are hospitals that cover SKMC Radiology department during breakdowns 22

and for specialized imaging tests (Nuclear

Radiation Safety Officer (RSO) at SKMC

medicine/Vascular intervention)

responsible for radiation safety orientation for all hospital staff, monitoring and protection.

Who are the outside sources of imaging for SKMC?

What are the key measures to be radiation

All SEHA BEs.

safe? Distance from the X-ray source – minimum of

Who is chiefly responsible for imaging

2 meters from the machine. Lead protection

services at SKMC?

devices can be used if proximity to the source

Chair of the Radiology Department

is unavoidable. How is staff exposed to radiation/radiation workers monitored? 

This includes the radiology staff and the staff working in the Operating Theatres where the portable C-arm fluoroscopy machine is used.



A Thermoluminescent Dosimeter (TLD) is provided to the above staff. TLDs are measured every 3 months.



exceed an average of 0.3 mSv (milliseivert)

Can you act on a provisional CT or ultrasound

per month or 3 mSV per year.

report? No. You should only act on a finalized report by the Radiologist. In case of emergencies, verbally verified provisional report by the Radiologist is acceptable provided this is documented – e.g.: Critical results.

What are precautions for the pregnant patient or potentially pregnant?  

procedures

should

last menstrual period.

dosing for patients are decided to obtain the

not

be

images

with

the



If the pregnancy test is positive or the patient is already known to be pregnant,

lowest

the referring physician should be informed and consent obtained.

Who is the key individual assigned by the department

Pregnancy test

should then be performed

practically possible doses.

radiology

Radiation

performed 10 days after the onset of their

As low as reasonably achievable – this is how possible

Last Menstrual Period (LMP) should be obtained prior to the X-ray/CT

What does ALARA stand for?

best

Dose constraint for SKMC – should not

responsible

for



Lead shield is placed over the abdomen during the procedure.

implementing the radiation safety program?

23

What are steps and precautions for the

Biomedical

pregnant staff?

Department



What are measures in place to ensure quality

Inform the Radiation Safety Officer ASAP

department

and

Radiology

of Outside sources imaging services? 

Additional dosimeter provided to place

SEHA BEs are utilized. Records of Quality

over the abdomen/waist level during

Control results performed by the physicist of

pregnancy which is read every month

outside sources are annually received.

(should be < 1msV throughout pregnancy). Minimize exposure where possible. What are time frame for radiology results at SKMC? All STAT orders in 60min All URGENT orders in 24hrs All ROUTINE orders within 5 days Who are primarily responsible for radiology equipment?

24

CARE OF PATIENTS (COP)

A health care organization’s main purpose is to provide quality patient care. The delivery of patient care must be coordinated and integrated by all individuals caring for the patient (clinical, rehabilitation, physical, occupational, respiratory therapists, dietary, nursing, radiology, etc.). Evidence of care planning includes, but is not limited to, the following: Progress or patient care notes, Dictated reports, Patient and family teaching information, MDT documentation, Interdisciplinary plan of care How is a patient’s plan of care determined? Plan of care is determined by collaborative approach among care providers and using data from

initial

assessments,

periodic

reassessments and identified needs. This also involves the patient and family. How and when are the patients reassessed? Patients are reassessed whenever there is a change in the patient’s condition and/or diagnosis and responses to treatment. The plan of care is reprioritized according to the changing needs of the patient. Plan of care is set for each patient as measurable goals. What is evidence of interdisciplinary and collaborative care planning? After a patient’s needs are determined, the health care team develops a care plan.

& Medication Administration Records. Collaborative approach is evident through Communication among treating physicians, Nurses and others. What is the principle of patient care followed in our hospital? The principle is “One level of quality of care” which aims to provide uniform patient care that is available in each day of the week and in all shifts of the day. Do we have a planning process for care for patients? Yes, we collect the data from initial assessment, periodic

reassessment

and

provide

the

treatment and care. Is there a specified period for developing the plan of care? 25 | P a g e

Yes, within 24hours of admission as an

How often is MDT documentation repeated

inpatient.

in critical areas? On a daily basis of earlier if indicated.

How does interdisciplinary and collaborative patient care planning occur?

How is MDT documented?

This happens by participation of the different

It is initiated by the admitting or attending

health care practitioners who work together to

physician

identify the needs of the patient though

(multidisciplinary note)’ from the dropdown

physician – nurse patient rounds, multi-

menu and using “Free Text” in the encounter

departmental patient rounds, contribution of

pathway (until a specific inbuilt template is

nurse managers and through patient & family

made available). The note can be titled

discussions.

appropriately as ‘Clinical Rounds’, “Team

by

selecting

‘MDT

meetings’ or ‘Family meetings’. The content What is a multidisciplinary team?

should mention the ‘Participants’ and the ‘Plan

It refers to a group of healthcare professionals

of care or decisions’.

from a range of disciplines who work together to address as many of the patient needs as

If a physician fails to initiate a MDT note

possible. Can comprise of physicians, nurse

after the rounds due to unavoidable reasons,

practitioners, clinical pharmacists, allied health

how

specialists,

document?

health

educators,

and

social

workers.

do

other

health

care

providers

They need to mention in their respective documentation: “as per MDT rounds with …”

What is MDT Note or documentation? Document recorded in the patient’s health

In case of absence of a MDT note, how do you

record indicating the multidisciplinary care

prove that MDT rounds did take place?

provided to the patient.



By mentioning the names/designation of participants in regular progress notes.

What is MDT Note Work flow?



By

demonstrating

other

providers’

specific plan and document the same through

consultation notes and by documenting

a standard template having a provision for

verbal or telephone conversations. 

by

way

care

The multidisciplinary team members agree on

update.

contribution

health

of

By being able to navigate and view other health care providers’ documentation in

Do we have multidisciplinary team rounds in

“All Documents”.

the hospital? Yes

Who are the High-risk patients? High risk patients include, but are not limited

When the MDT documentation is initiated in

to:

the critical care areas?



Within 24 hours of patient admission.

New-born infants and children (less than 12 years old), Emergency patients, Patients with

communicable

diseases,

Elderly 26

patients

(>

65

yrs.

old),

Immuno-

-

Medical/surgical

compromised patients, Ventilated patients

(disruption

and

medically

unconscious

patients,

Comatose

needs

of

lines/tubes; based

patients, mentally challenged patients,

confusion/agitation that impacts

Dialysis patients.

safety or care)

They are categorized as high risk because they

-

Presents a threat to self or others.

include patients who:

-

Interference

with

medical



Cannot speak for themselves



Do not understand care process



Cannot participate in decisions

that include a justification or



Are at increased risk for falls

reason for the restraint and the



Are at increased risk for nosocomial / or

duration/time/date.

treatments. -

other infections 

Obtain a valid physician’s order

2. Assessment/monitoring of restrained

Are mentally challenged

patients: - Monitor every two (2) hours (or

How do you restrain patients from interfering

sooner

with their treatment or procedure?

need).

On the general care units, we use soft immobilization

devices.

Please

depending

on

patient

- When removed from restraints,

Refer to

document the restraint has been

Restraints Policy.

discontinued.

Who should order restraint for the inpatient

What are the High-risk services provided in

and how often it shall be updated?

SKMC?

Treating physician should place the ‘Restraint

Intensive care, Neonatology care services

order’ in the system and the order is valid for

Patient with acute medical, cardiac or surgical

only 24 hours and needs to be renewed as

and traumatic life-threatening conditions will

needed.

admitted into these care areas for further management, interventions and continuity of

When do we restrain a patient? When

less

restrictive

alternatives

care for their conditions. are

Emergency Services

ineffective in protecting the safety of the

Patient with acute medical or traumatic life-

patient

threatening conditions will be treated at

or others.

Restraints should be

discontinued at the earliest possible time.

Emergency

Department

(ED)

thereby

Clinical justification and other requirements

requiring immediate and competent treatment.

must be documented. What is necessary when placing a patient in restraints? 1. Determine the reason for restraints (which may include):

Does the High-risk policy identify additional risk?

27

Yes. Additional risks identification e.g.: Deep

Do we have policy for each of the high-risk

vein thrombosis, Decubitus ulcer, Ventilator

patient groups?

associated infections,

Yes, we have.

Blood exposure

in

dialysis patients, Neurological and circulatory injury in restrained patients, Central line infection, Falls. High Risk Patients

Policy Guiding Care

Emergency patients

•

Emergency Department Referral, Transfer and Admission (D-MD-ED-01-001)

Comatose patients

•

Care of Unconscious Patient - Inpatient (C-NURCLI-11-006)

Patients on life support

•

Care of the Patients on Life Support (C-MD-GEN01-019)

•

Transmission based precautions (C-QM-IC-05-002)

Care of patients receiving dialysis

•

SEHA dialysis policies

Care of patients in restraints

•

Assessment and Care of Patients Requiring

Care of patients with communicable diseases

Restraints (C-MD-GEN-01-047) Care of vulnerable patient

•

Assessment and Care of Patients who are

populations, including frail; elderly,

Vulnerable and-or at High Risk (C-MD-GEN-01-

dependent children and patients at

036)

risk for abuse and/or neglect Define pain?

Yes. We have a pain management program. All

Pain is unpleasant sensory and emotional

patients are assessed for pain at all patient

experience associated with actual or potential

contacts.

tissue damage or described in terms of such

characteristics are assessed, intensity, quality,

damage”.

frequency, location and duration. A Pain

The patient’s right to receive appropriate pain

Assessment Chart and re-assessment record is

assessment and effective management will be

available for all age groups: neonates, children

respected and supported throughout the

and adults (Refer to Pain Management Policy).

continuum of care.

All patients have a right to the appropriate

When

pain

is

identified

5

assessment and management of pain and discomfort. The key to successful pain Does SKMC have a pain management policy?

management is to have an active team approach. 28

When pain is identified what 5

condition changes and there is a need for a different tool.

characteristics are assessed? Intensity, quality, frequency, location and

What are the important points staff should

duration.

know when transfusing Platelet concentrate? Platelets should always be run through new

How do you assess pain after procedure/

blood administration set.

surgery? Pain assessment needs to be done within 15

Within how many minutes is the blood

minutes of arrival to the unit for all post-

product transfusion started after receiving in

operative patients and carried out every 30 min

the area?

for 2 hours then hourly for 2 hours (see pain

Within 30 Minutes

management policy and care of post op patient).

Within how many hours the blood products should be infused from issuing time?

Does Pain Management policy include age

Within 4 hrs.

specific (population served) pain assessment?

How to make sure your patient and family

Yes, we use the several evidenced based pain

understand the Health Education?

scales depending on the patient population.

Asking them to verbalize their understanding. Making them perform a return

When are patients assessed/ reassessed for

demonstration.

pain? Upon admission At Least once every shift. After pharmacological and nonpharmacological interventions as follow: •

Oral medication: within 60 min.

•

IM medication including opioids: within 60 min.

•

•

IV medication including opioids: within

What are the basic activities for the care of the

30min of administration. (but vital signs

patients?

will be done immediately after the

Planning and delivering care, monitoring,

administration and again every 15 min till

modifying care, completing care and follow

one hour is over except for Tramal).

up.

Non-pharmacological: within 60 min. Who should be informed about the outcomes

Can more than one pain assessment tool be

of

care

and

treatment

used?

anticipated outcomes?

One assessment tool will be used all time

Patients and their families.

including

the

when assessing the patient, unless the patient 29

Who receive nutritional therapy?

What happens if family insisted to bring food

On ‘initial assessment’ patients are screened by

from outside in some exceptional scenario?

the nurse to identify those at Nutritional risk.

If family insisted to bring food from outside,

When identified she will inform the treating

dietitian consultation will be placed to provide

physician who will request dietitian consult

education.

and these patients will receive nutritional therapy accordingly.

Do we have any policy in this regard? Yes , we have the attachment in D-NUR-CD-

Who does the Nutritional assessment and

09-017 (Visitor Entrance to Food Production

when?

Area Policy) for guidance to patients and

Nutritional assessment

is performed

by

visitors on bringing food into hospital.

dietitian upon receiving consult from the physicians.

Who

is

responsible

for

ordering

and

cancelling patient diet? Patient diet will be requested by Physician. What are the barriers of Health Education? 

Language and education level



Values and benefit



Physical and intellectual level



Willingness to learn age

Does the hospital offer patients choice of

What end of life care does the organization

food preferences?

provide?

Yes, patients have a variety of food preferences

Managing

consistent with their condition and care.

treatment, respecting the values & religion,

pain,

providing

symptomatic

and responding to psychological and cultural When the relatives or family bring in food

preferences, involving patient and family in all

from outside for patients, who is responsible

aspects of care including the decision-making

for food safety & storage?

process for end of life issues.

When patient have food, brought to the hospital by visitor’s/family member, SKMC

How clinical staff responded to any changes

staff will explain visitor/family member that in

in a patient condition?

the best interest of the patient, SKMC has a

All clinical staff are mandated to be BLS

strict policy of serving the hospital prepared

providers.

food only. Homemade or commercial foods are

Repaid response team will respond to any

neither appropriate for the patient nor SKMC

deterioration in patient condition.

has any storage or reheating facilities for such

All nursing staff are trained during nursing

food.

orientation on early warning signs.

30

We have Early Warning Scoring System and

During code staffs provide Basic Life Support

Rapid Response Team or Responder policy (C-

immediately and Advanced Life Support in

NUR-CLI-02-011).

less than 5 minutes. The hospital has standardized the crash carts

Tell us about the Resuscitation services in

in all areas by using same type of defibrillator

SKMC?

machines and making available the same

Resuscitation services are available 24 hours, 7

medications on all crash carts.

days per week.

31

ANESTHESIA AND SURGICAL CARE (ASC) and Surgical Care. The ASC standards are applicable settings where anesthesia and/or procedural sedation are used, and surgical and other

invasive

procedures

that

require

informed consent are performed.

The use of surgical anesthesia, procedural sedation,

and

surgical

interventions

is

common, and is a complex process at SKMC. They require complete and comprehensive

Organization and Management

patient assessment, integrated care planning,

Anesthesia and sedation administration and

continued patient monitoring, and criteria-

use at SKMC is conducted in a uniform manner

determined transfer for continuing care,

and is available 24/7. The service is overseen by

rehabilitation, and eventual transfer and

the chair of Anesthesia Department, who

discharge.

reports to the Medical Division Office. All

Surgery carries a high level of risk, therefore, it

activities

must be carefully planned and carried out.

including procedural sedation privileges for

Information about the surgical procedure and

non-anesthetists, are channeled through the

care after surgery is planned, based on the

Sedation Subcommittee, which reports to the

patient’s assessment, and documented. Special

hospital’s

consideration is given to surgery that includes

(MEC).

implanting

a

medical

device,

related

Medical

to

sedation

Executive

practices,

Committee

including

reporting of devices that malfunction as well as

Sedation Care

a process for follow-up with patients in the

JCI has defined procedural sedation as “. . . the

event of a recall.

technique

Informed

consents

sedatives or

dissociative agents with or without analgesics

and

to induce an altered state of consciousness that

analgesia/sedation, must be taken prior to the

allows the patient to tolerate painful or

procedures. They should be discussed with the

unpleasant

patients and families by a qualified physician,

cardiorespiratory function.” Regardless of the

and is educated on the risks, benefits, potential

medication, dose, or route of administration,

complications, and alternatives of each.

when a medication is used for the purposes of

There are four areas of focus for the ASC

altering the patient’s cognitive state in order to

chapter.

and

facilitate a specific procedure, it is considered

Management, Sedation Care, Anesthesia Care

procedural sedation. For specific details and

These

both

administering

the

surgery/invasive

for

of

procedure,

are:

Organization

procedures

while

preserving

32



requirements for sedation, refer to the SKMC Procedural Sedation Policy (C-MD-ANE-01-

benzodiazepine antagonists •

009).

use and dosage of the opiate and

Have skills in basic airway management and manual ventilation using the bag-mask

Which areas at SKMC is procedural sedation performed?

valve •

Have current BLS certification and ACLS

•

Emergency Department

•

Intensive Care Units - Adult and Pediatric

•

Endoscopy

patients) Additional requirements

•

Cath Lab

monitoring patients under sedation:

•

Radiology

•

•

Dental Clinic

competencies to monitor patients under

•

Neurodiagnostic Department

sedation

•

Wards performing procedures requiring

(adult

•

sedation

patients)

Sedation

or

PALS

(pediatric

for

clinicians

privileges

or

sedation

Present throughout the procedure to monitor the patient, administer drugs as directed by the lead physician and to assess the effects of the sedation on the patient

•

May not be involved in any other tasks while the patient is sedated, until the patient has recovered from the sedation or handed over to the next care provider

Documentation Requirements for Sedation: Requirements for non-anesthetist physicians

•

Pre-Sedation Assessment

to be privileged to perform / order sedation:



History and Physical Examination

•

Current and valid ACLS (adult patients) or



ASA Level Classification

PALS (pediatric patients)



Airway

•



Plan of Sedation (type and level)

Conduct a minimum of 5 sedations

according to the patient requirements

annually

and procedure to be performed •

Monitoring During the Sedation and

Requirements for clinicians administering

Procedure

sedation and monitoring patients under

 

Trained with the: 

basic

pharmacokinetics

used including time of onset, duration of action and dosing

Should

include

physiological

parameters as defined by hospital

and

policy

pharmacodynamics of the drugs being



Must be done at a minimum of 5minute intervals

sedation: •

(Mallampati

Score)

Completion of the mandatory sedation training module in Oracle

•

Assessment

•

Monitoring After the Procedure 

Must be done at a minimum of 15-

potential for synergism when sedatives

minute intervals until discharge from

and analgesics are used together

sedation 33



physiological



No score of “0” in any category of MAS

parameters as defined by hospital



A minimum of 30 minutes stay from

Should

include

policy •

the last Narcotic and/or Sedative drug

Discharge 



administration (e.g. OR, PACU) 

Patients are discharged if they meet the

A pain score of mild pain (numerical

score required by the Modified Aldrete

scale score ≤ 3) or patient’s verbalized

Criteria

tolerable level of pain 

Discharge disposition of the patient

A

discharge

order

written

from

anesthesia provider Anesthesia Care Physician

•

assessment

requirements

Variations from discharge criteria 

for

If and when Modified Aldrete’s Score

patients undergoing anesthesia:

(e.g. less than 14), patient will need

•

Pre-Anesthesia Assessment

anesthesia review unless the score is

•

Pre Induction Assessment

consistent



Done

to

re-evaluate

patients

with

the

patient’s

preoperative status 

immediately before the induction of anesthesia

Under extenuating circumstances, the responsible anesthesiologist may waive

These two assessments must be documented in

the MAS score requirements according

the patient`s record.

to the physician’s clinical judgement on the patient’s condition. A detailed

Monitoring during anesthesia: •

Physiological monitored

status

every

5

is

description of the circumstances shall continuously

minutes

be documented in the EMR.

during

anesthesia administration and documented

Surgical Care

into the patient’s chart

•

The surgical care planned is documented in the patient record including the pre-

Monitoring after the procedure:

operative diagnosis by the responsible

•

Recovery area arrival and discharge times

physician

are recorded

performed.

•

Nurse will provide ongoing assessments (document,

•

procedure

is

A post-operative surgical report or a brief operative note in the patient record before

PACU

the patient leaves the recovery room /

Admission, Assessment and Discharge

transferred to the next level of care must

Policy (C-NUR-PACU-02-001)

include at least the following:

Vital signs will be taken every 5 minutes if



Post-operative diagnosis

patient is unconscious and every 10



Name of surgeon and assistants

minutes if patient is conscious



Name of procedure performed and

the

patient

appropriate)

the

and

manage

when

•

before

as

per

findings Discharge from recovery area:



Surgical specimen, if for examination

•



Complications or its absence during

The criteria for discharge are: 

A Modified Aldrete’s Score (MAS) of

procedure

14/16 or return to pre procedure state 34

  •

Blood loss and transfused blood, or

•

Surgical

procedures

involving

implantation

none

permanent

Date, time and signature of physician

devices have special considerations as in the

of

the

Implantable

medical

The continuing postsurgical plan(s) is

outlined

Devices

documented in the patient’s medical record

Procedure attached in the SKMC Safe

within 24 hours by the responsible surgeon

Surgery Policy (C-MD-GEN-01-009).

or verified by him, if written by a delegate.

35

MEDICATION MANAGEMENT AND USE (MMU)

Medication management & use is the responsibility of all healthcare practitioners under control & supervision of pharmacy department. Medication management encompasses the system and processes that SKMC use to provide safe pharmacotherapy to its patients. This is interpreted in a multidisciplinary coordinated effort of SKMC staff, applying the principles of effective process design, implementation, and improvement to the: a) Planning b) Selection and procurement c) Storage d) Ordering e) Preparing and dispensing f) Administration g) Monitoring h) Evaluation & Up-to-date references. There is also built-in drug information linked to each medication in Cerner. Pharmacy provides drug information anytime.

What laws & regulations applies to the MMU process in SKMC: SEHA, MOH, DOH & Federal Laws Do you have drug information sources here? Yes, we have Lexicomp and the SEHA e-

Do you have a list of medications in SKMC hospital? Yes,

we

have

SKMC

Drug

Formulary,

maintained by SKMC/SEHA Pharmacy & Therapeutic Committee (PTC), all additions or deletions have to be approved first by PTC.

Library which gives us access to Micromedex 36

What do you need to do if patient clinical



Then we have to waste it/flush the drug

conditions needs a medication that is not in

solution in the Pharmaceutical waste

your Drug Formulary list?

(Yellow bag)

We have a policy and process to follow for



Non-Formulary drugs

For contaminated (suspected as infected) medication, we discard in (Red bag) following the same process as mentioned

How do you manage ward stock medications in your unit?

above. 

We have a policy for managing Ward stock. A request to add or delete ward stock to the

The empty syringe & needle are discarded in the sharp bin.



This must be witnessed by another staff

nursing unit should come in collaboration

& the witness co-signs on that in our

between nurse unit manager and IP pharmacy

narcotic log book.

supervisor How do you discard used Fentanyl patches? Explain to me how you maintain secure drug



Used fentanyl patches still contain active

storage here?

drug, and shall be folded as soon as it is



Pharmacy is locked with limited access

removed so that the adhesive side of the



Only authorized staff have access to

patch sticks firmly to itself, the used patch

medication rooms in the wards

shall



Medication rooms are locked.

container. The disposal shall be witnessed



Pharmacy department is monitored by

by another healthcare professional.

be

disposed

into

the

sharps

CCTV camera.  

Narcotics are kept in double locked

Can you explain to me how you administer

cabinets.

Fentanyl patches?

Unit dose cassettes are always locked

Make sure you removed the old patch, fold it

during delivery.

and discard it as mentioned above. Do not stick the used patch on the bed side, sheets or

Where do you store your stock of narcotic

table. Type the date & time of administration

drugs?

on the new patch.

In compliance with Federal Law: 

In a double locked cabinet inside the

Who is responsible of maintaining the

medication room or secure area.

medication rooms? It is a collaboration



Register book are stored in a locked place.

between pharmacy and nursing team. Nurses



Charge nurse has the key.

maintain it daily and pharmacy will check



Physical count is being done every shift

monthly.

during endorsement between out-going &



in-coming authorized personnel.

Pharmacy department has oversight over medication storage all over the hospital



Pharmacists do monthly inspection of

Can you explain to me how do you discard the

medication

remaining of a narcotic ampoule or vial?

inspection are shared with unit managers



for action

We aspirate the remaining in a syringe

rooms,

Findings

of

the

37

How many times you record temperature &

All bulk containers/bottles must be labelled

what is the acceptable range of temperature &

once opened.

humidity?

Examples:

There is a policy for this:

•

Nitroglycerin–(tablet) 8

weeks after



Recording is every shift



Room temperature range is: 18 to 25 °C

•

Topical–1 months after opening.



Fridge Temperature range is: 2 to 8 °C

•

Insulin pens & vials –28 days after



Freezer temperature range is: -30 to -20 °C



Humidity should be: ≤ 60%

opening date.

opening in room temperature. How frequently the pharmacy replaces the

What do you do in case the temp is outside

medications in the crash carts/emergency

the range?

Kits?

For any fluctuations in the medication room

There is a policy for crash cart management

and fridge temperature:

and for emergency drugs

 Follow the instructions on the recording



form

Whenever the crash cart/emergency boxes is opened for use for a code.

 Call Biomed Engineer



 Call pharmacy for advise on drug storage

The pharmacy checks the content of the medication drawers in crash cart either on a monthly basis to check for

When do you remove the expired medications

completeness and expiration dates

from your ward stock? Near expired medications are removed at the

How often are crash carts checked?

beginning of the month in which they are

As per corporate

expiring.

Usually pharmacy removes them

management, the Integrity of the lock on the

during the monthly inspection. . If there is no

cart is checked daily and monthly by charge

replacement, it is flagged with the near expiry

nurses.

date. However, it is the responsibility of the

monthly.

nurse

to

check

expiry

dates

prior

policy of crash cart

And additionally pharmacy checks

to Do you have pediatric supplies in the crash

administration to patients

cart? Do you get informed about recalled drugs?

Standardized

Yes, through a recall email group. Pharmacy

throughout the facility have the necessary

will inspect for recalled drugs from the patient

equipment, medications, and supplies for the

care areas and the pharmacy.

management of any cardiac or respiratory

The recalled

crash

carts

deployed

drugs are returned to the pharmacy stores.

arrest victim regardless of his/her age. Broselow pediatric emergency tape, is a color-

How do you make sure that an Opened

coded tape measure that is used throughout

Container of medication is not outdated?

the world for pediatric emergencies. The

Refer

Open

Broselow Tape relates a child’s height as

Containers in Patient Care Areas” Chart,

measured by the tape to his/her weight to

which is provided in all patient care areas

provide

to

“Expiration

Dating

of

medical

instructions

including 38

medication dosages, it is needed to calculate

Yes. There is a policy for Medication

therapies for each child individually.

Verification. Exception is made for critical situations in: 

Do you have a list of Antidotes?

Emergencies where patient clinical status

Yes, Available in the I-share. The list includes

would be significantly compromised by the

guidelines for dosing antidotes.

delay that would result from a pharmacist review (such as operating room and

How do you know if the physician is

emergency department)

authorized to prescribe medications here? We have a policy “Prescriptive Authority” for



Where a physician performs or directly

who may prescribe.

oversees

prescribing,

Only authorized prescribers have an access in

dispensing

and

the HIS system to prescribe medications.

monitoring of the drug such as (but not limited

Do

you

allow

use

of

patient

OWN

to)

preparation,

administration endoscopies,

and

cardiac

catheterization, interventional radiology or

medications here?

diagnostic imaging, surgery or during

We have a policy and we discourage the use

cardio-respiratory

of Patient’s own medications, but may be

emergency situations.

arrest

or

other

allowed in these situations: a)

That are not part of the SKMC formulary (Non-Formulary drugs)

b) Temporarily out of stock c) That are available in limited stock quantity (examples: due to rare use of medication, procurement

issues,

world-wide

shortages)

How the medication orders are processed in

d) Patients returning with medications from

your hospital?

abroad treatment (after reconciliation with

All

the pharmacy)

computer Physician Order Entry (CPOE) are

medication

orders

entered

through

verified by pharmacist prior to administration. Do the hospital permit the use of sample

All in-patient medication orders that are

drugs?

available as a floor stock must be placed in

No, we have a policy for sample drugs.

computer Physician Order Entry (Cerner) and a pharmacist has to verify and review such

Does

the hospital permit

the use of

investigational drugs?

orders before medication is administered to

Yes, we have a policy for guiding the use,

patients. In emergency

storage, dispensing for investigational drugs.

medications may be given to patient based on

situations,

some

STAT

a licensed physician’s order from the floor Are all inpatient medication orders reviewed

stock before being reviewed by the pharmacist.

and verified by a pharmacist? 39

The nurse has to document the administration

Inpatient Medication labels shall include at a

of the medication to patients in the Medication

minimum:

Administration Record (MAR) in Cerner.



Nurses shall monitor patients as per nursing

Name of medical record number and location of the patient

policies. What do you do if the medication order is



Generic drug name



Dose, dosage from, strength and frequency

unclear or ambiguous?



Route of administration

Nurses don`t administer unclear orders.



Dispense quantity



Expiry date (if not available in the unit dose

Pharmacists

contact

the

prescriber

for

clarification. Order will be clarified/corrected accordingly.

package) 

Dispensing date



Auxiliary label and special information as

From where do you get the medications here?

required (e.g. high alert, protect from light,

From Pharmacy, which is opened 24/7, there is

refrigerate)

always a pharmacist to review the orders and



Medication barcoded information

dispense it. How do you assure medications are safely How do you handle STAT orders?

administered?



STAT and NOW orders should be

All nurses who administer medications are

dispensed within 30 minutes from order

DOH licensed and they have been deemed

entry time.

competent and follow the hospital policies for

Routine orders will be dispensed within 2

administering medications.



hours. How

do

you

identify

patient

before

Who prepares medications here?

medications are verified, dispensed, and

Pharmacy department

administered?



Nurses prepare orders from floor stock.

We use at least 2 approved identifiers: Patient’s



Nurses will mix the IV preparations in the

full name & Medical record number. We never

assigned IV preparation area in the

use patient`s room number.

medication room following pharmacy IV guidelines

What are the elements for verification before administration?

Do you have to label all IV medications here?

8 Rights for medication administration as per

Yes, all medication & IV solutions must be

Nurse Administration Policy. Adhere to the

labelled if not immediately administered

eight rights of medication administration

Pharmacy dispenses all IV preparations

every time medication is administered.

labelled with all details needed for safe

1- Right Patient

administration.

a) Verify the order against the patient b) Identify the patient with two identifiers

Patient medication label content:

2- Right Drug a) Check the medication label 40

Do you have Antimicrobial Stewardship

b) Check the medication order

Program here?

3- Right Route a) Verify appropriateness for patient and for the dosage form.

Yes, The Hospital has a program for antibiotic stewardship with a committee that oversees

4- Right Time

the program.

a) Check the frequency of the ordered medication

ASP team is multi-disciplinary and includes an ID physician, an Infection Control nurse and

b) Verify that is it is the correct time for the dose

Clinical Pharmacists. Guidelines for use of Antibiotics and ASP are

c) Confirm when the previous dose of the

available in the Policy Management System.

medication was administer What are the strategies implemented here to

5- Right Dose a) Confirm that the dose is appropriate for

ensure proper Antibiotics use?

patient age, weight, condition (i.e. renal



Antimicrobial Stewardship rounds

or hepatic function, medication serum



Antibiotic restrictions are applied.

levels),



Monitoring Antibiotics use through

or

other

parameters

as

applicable ( e.g. BSA)

KPIs 

6- Right Documentation

Antibiogram is reported annually

a) Document AFTER administration of Can you explain to me how the medication

ordered medications

reconciliation process is performed?

7- Right Reason a) Confirm the rational of this medication for specific to this patient and patient

Yes 



condition b) Consider the

Admissions

need for continued

It is the responsibility of the physician to document a complete

administration

and accurate medication history

8- Right Response

for each patient at the point of

a) Reassess patient to confirm medication

access to care to the best of

administration resulted in desired

available information from the

effect (i.e. met its purpose)

patient and the medical record of SKMC. The physician shall also

How do you know the medication is due for

reconcile the medications prior to

administration?

ordering.

We

have

standard

administration

time

schedule implemented in Cerner, and we



Transfers 

It is the responsibility of the

follow the MAR.

transferring physician to review

Do you have to perform double checking

and discontinue medications no

with another nurse for all medications?

longer required for the patient.

No, Only for High Alert Medications and Narcotic & Controlled medications.



It is the responsibility of the receiving physician to completely review

and

perform

transfer 41

medication

reconciliation

(maintain, discontinue and order)

to appendix of policy C-MD-PHA-03-307: High Alert Medications).

of the transferred patient.  

Discharges 

Order

sentences

of

high

alert

medications in physician’s view in

It is the responsibility of the physician to review (maintain, discontinue

and

CPOE are in red font. 

High-Alert

Medications

independently

order)

must

be

double-checked

by

medications of the discharged

two nurses to visually and verbally

patient.

verify the accuracy of the dose and

It is the responsibility of the pharmacist to

route

reconcile by comparing the medications the

administration.

patient was taking at the time of admission



with that prescribed on discharge.

of

administration

prior

to

Both nurses must co-sign the (MAR) in Cerner.



Upon storage High alert medications

Medication Reconciliation is the process of

shall

comparing a patient's medication orders to all of the medications that the patient has been

medications, and shall be stored in RED black bins. Storage locations of high

taking. To avoid medication errors such as

alert medications shall be labelled with

omissions, duplications, dosing errors, or drug

a clear red ‘High Alert’ sticker.

interactions. It should be done at every



transition of care in which new medications are

be

segregated

from

other

ALL Concentrated electrolytes are

ordered or existing orders are rewritten.

removed from all nursing units /patient care areas; with the exception of the

Transitions in care include changes in setting,

Perfusionist

service, practitioner or level of care

concentrated electrolyte injections for

OR

trays,

containing

cardiac surgery, and administration Who performs medication reconciliation

will be under the guidance of the

here?

physician.

Physicians. How

has

SKMC

responded

to

the

What medications are categorized as High-

International Patient Safety Goal dealing

Alert Medications at SKMC?

with communication of medication orders?

SKMC

identified

a

list

of

high

alert

medications (Refer to appendix of policy C-

SKMC has adopted the Computer Physician Order Entry (CPOE) to reduce/prevent

MD-PHA-03-307: High Alert Medications).

transcription errors. At the same time, we have implemented a

list

of

“Do Not Use”

Do you take extra precautions with “High-

abbreviations that should not be used in

Alert Medications?” Yes. We maintain strategies to reduce risk

Cerner documentation. These abbreviations are not to be used anywhere in the electronic

associated with high alert medications (Refer

or manual medical record documentations.

42

Do you accept verbal or telephone orders? Yes, there is a corporate policy.

Medications that look alike or sound alike have been segregated in medication storage areas to

Verbal and telephone orders for medication orders in SKMC are accepted only in

reduce the risk of errors. A list of Look Alike Sound Alike medication

emergency situations like codes or during the

has been developed and distributed throughout the hospital, and the list is updated

procedure. We follow procedure of verbal order which is (Physician identifies the

based on reported incidents.

patient correctly, spells out medication order

The use of Tallman is applied in the labeling

with full details, staff writes down the on the

and HIS.

approved Verbal/Telephone order form as it is being communicated then reads it back, then physician confirms the order). 

Ordering through TEXT messages is not allowed. Do you have any look-alike, sound-alike

When

do

physicians

sign

the

drugs in your area?

Verbal/Telephone orders or enter it in

The pharmacy publishes an updated list which

Cerner?

is available on every patient care area. Sound

Within 24 hours.

Alike - Look Alike Medications. Examples: ALPRAZolam LORazepam

How do you monitor Medication effects?

aMILoride

amLODIPine

Nurses: 

Monitoring of medication effect and side

Are patients allowed to self-administer any

effect as per pharmacy drug index and

medications?

reassessment of pain medication as per

There is a policy.

Pain Assessment policy.

Patient self-administration of medications within SKMC is allowed for:

How does SKMC deal with “IV concentrated



Comfort medications (for example, topical

potassium?”

creams) with minimal risk may be

It is included the policy “Concentrated

considered

Electrolytes”

medications by patients.

Concentrated

potassium

chloride

and



for

self-administration

of

Selected patients for medication use and

potassium phosphate are considered as High alert medications and may not be stored in

Selected patients shall have adequate manual

patient

dexterity and cognitive function and the ability

care

units

and

they

are

stored/prepared in the pharmacy only.

compliance for educational purposes.

to demonstrate sufficient knowledge of their medications and its administration.

What are the safety measures for dealing with

Self-administration of narcotics and controlled

“look alike/sound alike” medications?

drugs is prohibited except when given through Patient Controlled Analgesia (PCA)

43

Physician will prescribe it in HIS, pharmacy

Nurses inform

physician

on

duty

and

dispenses it, nurse will educate the patient and

supervisor to decide if patient needs treatment.

assess his ability to administer the medication

Then the allergy has to be documented in

and nurse should monitor the patient while

patient profile in Cerner.

self- administering the medications and dose How do you handle Hazardous Drugs here?

will be charted in MAR.

 What happens to medications after they are

We have a list of the hazardous drugs available in the system.



discontinued? Discontinued medication (including IV) shall be returned to pharmacy if they are Unused

Hazardous drugs are categorized as Cytotoxic, chemicals.



and intact in the original container. Partially

non-Cytotoxic

and

Pharmacy publishes a Hazardous Drugs PPE guidelines for Nurses to

used bulk medications such as inhaler, ointments, etc. should be discarded in

follow

pharmaceutical waste (Yellow bag) What has been done to reduce the risk of Do you report medication errors? How?

medication errors in your area?

Yes, all staff members are expected to report

All

medication errors. Reporting is anonymous

pharmacy before administration to patient.

and non-punitive just culture encourages

All medications are being independently

reporting of medication errors.

double checked by licensed pharmacist before

All medication errors reports are reviewed and

being dispensed to patients or nursing units.

trended by medication safety officer with

Limited concentrations of medications are

coordination of location manager where the

available as per our formulary.

error has occurred.

Developing the strategy to reduce harm and

Medications errors are reported by completing

the precautions for High-Alert Medications.

the Safety Intelligence (SI) report in the system.

Established a process of independent double

medications

are

being

verified

by

checking during preparation, dispensing and Do you report Near miss incidents?

administration.

Yes, through Safety Intelligence as well, it is a

Identifying patients using 2 unique identifiers

good opportunity to learn and improve our

before drug administration – Full Name and

processes.

Medical Record number. High Alert Medication, Narcotics, before they

Can you tell me the difference between

administered the drugs to patients are

medication

independently double checked.

errors

and

adverse

drug

reactions?

If patient has a known allergy documented in

Adverse drug reactions are Non-preventable.

patient profile, it will give an alert if ordered again, also it shows on patient information

And how about adverse drug reactions, how

banner in patient profile, and it shows on any

do you report them?

medication label for this patient.

Report the ADR in Safety Intelligence. 44

Refer to the different pharmacy policies in the

Is it allowed here to share INSULIN pen

SKMC Policy Management System.

devices between patients if we change the needles?

What are the PPEs you need to handle High

No, it is not allowed to share insulin pens to

Risk Hazardous Drugs?

avoid infections and medication errors with insulin pens, each patient has his insulin pen labelled from pharmacy. Pharmacy attaches the patient label on the pen barrel not the cap to avoid mix up of insulin pens in nursing unit. Nurse administers insulin as per dose and protocol. Insulin is a high alert medication and 2 nurses have to double check prior to administration and co-sign in e-MAR. The expiry date of INSULIN pens is 28 days after opening and to be stored in patient cassette drawer. How

do

you

monitor

the

effects

of

medications on patients? There is a multidisciplinary approach in SKMC to monitor the effect of medication in patients; The Multidisciplinary Approach as: 

Pharmacy: Drug-drug interactions, Drugfood interactions, adverse drug reactions reporting in SI System and patient



electronic file. Laboratory results: sub therapeutic or toxic levels/labs.



Each health care provider is eligible to

How do you store multi-dose vials after

evaluate patient for a suspected adverse

opening?

drug reaction in SI System and patient

Pharmacy publishes “Expiration Chart for

electronic file. Nursing documentation

Open Containers” for all the patient care areas.



in

Cerner,

All Multi-dose vials are labelled & dated upon

reports Side effects, Adverse drug reaction

first use, Check rubber integrity before use.

reporting. Nursing and Physician monitor the therapy outcomes.

45

PATIENT AND FAMILY EDUCATION (PFE) SKMC provides education that supports patient and family participation in care decisions and care process. All education activity at SKMC is overseen and coordinated through PFE taskforce. Patient and family education helps patients to participate in their care and to make informed care decisions. All staff that interact with the patient, families/significant others and participate in their care are responsible to provide comprehensive multidisciplinary patient education. Effective education thus begins with assessment of patient and family learning needs. Education needs to be a coordinated effort among the health care staff so that education is individualized and focuses on what the patients / families need to learn. The purpose of patient education is to improve healthcare outcomes by educating patients and their families in the promotion of healthy behaviours which aid recovery and encourage them to adopt a healthier lifestyle through a multidisciplinary personalized educational approach. The main goals are: 

Reduce patient/ family anxiety related to disease or hospitalization.



Enhance patient’s and family’s ability to participate in healthcare decisions



Ensure the educational needs of each patient are assessed and recorded to maximize the health promotion encounter.



Provide patients/ families with current and accurate information in order to maintain a healthy lifestyle and/ or cope with their illnesses.



Reduce unnecessary utilization of healthcare services. (E.g. Unnecessary OSC/ ED Visit, readmission)



Enhance patient and families’ ability to understand health status/ prognosis/ outcome.

 Learning needs SHOULD BE ASSESSED /REASSESSED: o

UPON patient admission

o

On daily base and when patient’s condition or needs change.

When are your patient’s education needs

o

Before discharge.

o

Each outpatient visit

assessed/ reassessed? 46



Documentation evidence needs to be available in patient Medical record (DOCUMENTED IN

The plan of care, treatment and services, disease process and diagnosis.



I VIEW

Safe and effective use of medication and medical equipment



What is the patient education process? Education process consists of the following



ASSESS (Assess patient learning needs& Assess



educational

barriers,

education history) Plan the education 

Whom to be taught?

-

Individualize the educational plan

interaction

Warning signs and when to get immediate medical care

health

-

Potential

between medication and other /food

steps: 

Medication,



Anesthesia and surgical consent



Pain Management

 Community resources Affective : Rehabilitation

technique,

attitude, Beliefs and values

based on learning needs assessment,

-



patient condition and patients’ goals

What are the learning barriers you may face

and objectives.

during patient and family education?

Select the appropriate

method of

The learning barriers include: -

education (demonstration, explanation,



Language and education level,

printed material, audio-visual materials



Values and beliefs,

…etc.) Implement the education: choose the



Physical and intellectual level



Readiness to learn,

appropriate education moments, create a



Age and culture

proper learning environment, You should



Sensory impairment

have



Pain and acuity of illness

the

knowledge,

time

and

communication skills Evaluate the effectiveness of education

In case of language barrier or low literacy level

(return demonstration, verbalization, needs



Bring translator



You can draw and explain.



reinforcement …etc.) Document in SALAMTAK



Provide information in simple words and



Reassess /refer (consultations)



ask

patient

to

verbalize

his/her

understanding by using his/her own words. What are the recommended educational topics to be provided to the patients and their



If patient is a child and cannot understand, educate parents and use pics

families? The patient is educated about the following and

Who is responsible for patient and family

other as per learning needs assessment:

education at Sheikh Khalifa Hospital?



Psychomotor: Physical skills such as

Patient education is integrated process and it’s the responsibility of all health care providers



injection usage, machines usage…etc. Cognitive: Knowledge and understanding of facts such as

respiratory

(physicians, nurses, dietitians, physiotherapist, therapists.

etc.)

To

provide

47

comprehensive

multidisciplinary

patient

Documentation by

multidisciplinary team

education.

occurs on SALAMTAK PATIENT RECORD

How do you select the Educational Methods?



Doctors: power Note





Ancillary & Nurses: power chart- AdHoc

resources should be selected according to



Learning needs assessment in I /View



Disease and Patient Condition,



To view the previous education done by



Learning needs, Age-specific and Patient

other health care providers check document

learning preferences

viewing.

Educational

methods

and

learning

How will you manage in case of language

What resources are available to assist you with

educational barrier?

patient education?



Utilize the multinational staffs available in



SKMC patient and family education policy

your unit /clinic if the language you need is



Printed educational material in Arabic and

not available.  

English.

Check the language assistant directory in

SEHA portal/ Tathqeefi , SEHA eLibrary-

SKMC iShare.

Lippincot Advisor, Lexicomp Handouts,

If the language you need still not available

Drugs handouts 

in the directory. 



Trained health care providers for specific

There is an Interpreter Services under

diseases (Diabetes, RT, PT, dietitians and

Nursing Division available on SKMC

lactation consultant)

Portal. How

do

you

document

Patient/Family

education?

48

QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS)

The goal is to support SKMC with comprehensive approach ensuring Medical Staff, Nursing Staff, Allied Health Staff and Administration staff will work in collaboration to quality improvement and patient safety that influences all aspects of facility’s operation. Sheikh Khalifa Medical City’s (SKMC) Quality Improvement and Patient Safety (QIPS) program provides a framework to monitor, assess and improve the quality and safety of care delivered to patients, leading to a timely, effective, efficient, and patient centered healthcare system. This approach includes: 

Department-level input and participation into the quality improvement and patient safety program;



Use of objective, validated data to measure how well processes work;



Effectively using data and benchmarks to focus the program; and



Implementing and sustaining changes that result in improvement.

In addition, to ensure both quality improvement and patient safety, SKMC QIPS programs are: 

Leadership driven;



Seek to change the culture of an organization;



Proactively identify and reduce variation;



Use data to focus on priority issues; and



Seek to demonstrate sustainable improvements.

The SKMC QIPS program is aligned with 

SEHA’s vision, mission and values, and its strategic themes and initiatives



SEHA’s Quality Department Objectives



Emirate of Abu Dhabi’s Department of Health (DOH) requirements.



Joint Commission International (JCI) standards

In coordination with SEHA Strategies, SKMC Senior Management and Quality and Safety Division sets organizational Performance Improvement priorities. Directors and Head of Departments set departmental goals to assist in addressing these priorities. All staff work together to improve performance and meet these wide goals. 49

link between Quality Department and their department staff and assist in identifying, prioritizing,

evaluating,

monitoring,

improving, sustaining, and validating their quality activities outcomes through using quality tools and methods. What

is

our

Approach

(method)

performance improvement?

to

How are the

What is your responsibility for improving

staff and physicians involved in performance

care and services?

and continuous improvement?

It is everyone’s responsibility to look for

The overall program for quality and patient

opportunities to improve care and services.

safety in a hospital is approved by the

When you see opportunities, discuss them

governing entity SEHA, with the hospital’s

with your Department Head and participate in

leadership

making

defining

the

structure

and

improvements.

Also,

incorporate

allocating resources required to implement the

performance improvement principles and

program.

values into your everyday work processes.

Leadership identifies the hospital’s overall priorities for measurement and improvement,

How has your department improved care or

with

services in the last 12 months?

the

department/service

leaders

identifying the priorities for measurement and

Surveyors often ask staff to explain staff role in

improvement within their department/service.

improving care. Plan ahead and speak with

a) All performance improvement activities in

confidence about something you or your

the hospital are guided by the annual

department did to improve care or services for

Quality Improvement and Patient Safety

patients/ families. Your department manager

(QIPS) plan (C-ORP-PIA-01-001).

can help you prepare for this question. When

b) All staff and physicians are responsible for

possible, the answer should be expressed in

and involved in performance improvement

measurable outcome statements, e.g., we

activities through KPIs and PI Projects

reduced fall rate from X to Y) or we increased

either through ongoing data collection,

patient satisfaction rate from A to B).

analysis of results, development of action plans, and/or measurements of success or

What is a function or process that you have

team

personally improved in your area?

participation

in

Performance

Be confident to explain the continuous

Improvement projects. c) The SKMC Quality Council monitors the

improvement activity/project you are involved

performance and continuous improvement

in. Or give example of any Best practices you

activities reported by every Department

were involved in and have sustained.

and

provides

required

support

and

guidance. d) In addition, all departments have Quality

How is Performance Improvement (PI) or continuous improvement projects chosen?

Ambassadors/Champions who serves as a 50

Priority is given to high-volume, high-risk,

The quality program staff are constantly

high-cost or high problem prone Processes and

involved in training and communicating

any

quality and patient safety issues throughout

regulatory

body/accreditation

body

requirements and performance measures.

the hospital. SKMC Hospital Quality Dept.

In addition, the Key Performance Indicators

Staff are assigned as quality link and advisory

(KPIs) are selected based on strategic priorities

member to every Clinical and Non-Clinical

set by SEHA.

Institutes/Departments. In the SKMC portal, there is also Quality

Do

you

know

the

results

and

Department site where all the information,

recommendations for the QI projects done on

quality

your Unit/Department?

performance reports, Clinical Quality and

If asked, be prepared to show the surveyor the

patient safety measures, Regulatory KPIs,

Performance Improvement Project reports for

Quality

your unit / Department Quality activity data

published and communicated. Quality Dept.

shown

Staff are integral part of Quality Council and

in

your

Quality

Board.

E.g.

Department/Institute KPI tracking, the QI

resources/materials,

improvement

Quality

projects,

etc.

and

are

Quality Staff attend Quarterly meetings.

Projects submitted during Quality Week celebrations. The projects uploaded in SKMC

What

are

Performance

Measures/Key

Quality Management iShare site under Quality

Performance Indicators (KPIs)?

Improvement Project Database.

Performance Measures/KPIs are a set of

What Performance Improvement model is

quantifiable measures that the organization

used at SKMC?

uses to measure the performance over time. It

SKMC uses PDCA Cycle/Deming Cycle.

is also called Key Performance Indicators (KPIs). Why are Performance Measures important? Measurement is a critical part of testing and implementing changes; measures tell a team whether the changes they are making actually lead to improvement.

With Performance

Measures in place we can set appropriate goals, develop strategies to reach them and evaluate our progress. An

important

use

of

performance

How does Quality Department communicate

measurement is to provide feedback to clinical

quality information to hospital wide staff

practitioners on their actions.

with regard to quality improvement and

measurement systems should be monitored

patient

quality

frequently to ensure alignment with other

improvement resource, quality measures

health system mechanisms and to identify

outcome, issues and areas of improvements?

areas for improvement.

safety

strategies,

Performance

51

In SKMC, what are the different Performance

Department leads are communicated to Senior

Measures/ KPIs, being monitored?

Management Committee and action plans are

SKMC monitors Performance Measures from

addressed accordingly.

SEHA

and

DOH,

in

addition

to In SKMC, what system is used to report

Service/Department specific KPIs.

incidents,

near

misses,

risks

What are some of your departmental KPIs

events/occurrence variance?

and how are you performing on them?

Safety Intelligence (SI) system is our reporting

Be prepared to answer this question in

system for incidents, near misses, sentinel

consultation with your Department Head or

events and risks/unsafe conditions related

Manager. You can find the results for SKMC

patient, staff, facility, and visitor issues. (Learn

KPIs on Quality Management iShare site which

how to locate and access and use Safety

is updated on a regular basis.

Intelligence (SI) system).

What is Data validation and what is the

How are Incidents Scored?

process



adopted

in

SKMC

for

Data

validation? Data validation is an important tool for

Harm Score 1 – 2 

understanding the quality of the data and for establishing the level of confidence decision

Unsafe conditions / near-misses are scored Incidents that reached patients are scored 3 -5



makers can have in the data. Data validation

Incidents whereby harm caused to patients are scored 6 - 9

becomes one of the steps in the process of setting priorities for measurement, selecting

What is a Sentinel Event?

what is to be measured, extracting or collecting

A

the data, analysing the data, and using the

occurrence of patient safety event that reached

findings for improvement.

a patient and resulted in death, permanent

Refer to SKMC Policy C-QM-PIA-01-007 Jawda

harm or severe temporary harm, not related to

Performance Management Policy.

the natural course of the patient’s illness or

Sentinel

underlying

Event

is

condition.

an

unanticipated

Definition

of

How are the Departmental and Institute

Occurrences that Must Be Reported under the

Level Quality improvement tasks, process

Sentinel Event Policy at SKMC are:

and outcomes - Key Performance measures

1. Suicide

and also challenges communicated to SKMC

2. Unanticipated death of a full-term

Leadership and Quality Dept.?

infant 3. Discharge of an infant to the wrong

SKMC have structured Quality Council Team

family

chaired by CEO and CQO. Quarterly Forum

4. Abduction of any patient

meeting scheduled with Institute/Department.

5. Elopement

Every Institute and Department leads presents

6. Hemolytic transfusion reaction

Quarterly the Quality improvement and

7. Rape, assault

patient safety reports. The challenges raised by 52

8. Surgery on the wrong patient, wrong site or wrong procedure

communicate the lessons learned to the concerned department. Refer to C-QM-PIA-

9. Unintended retention of a foreign

01-005: Sentinel Event Reporting Policy.

object in a patient after an invasive How does the organization identify and

procedure/surgery. 10. Severe neonatal hyperbilirubinemia

reduce adverse events and safety risks?

11. Prolonged fluoroscopy

It is through Risk Assessment and Failure

12. Fire, flame, or unanticipated smoke/

Mode and Effects Analysis (FMEA). An FMEA

heat/flashes occurring during patient

is a team-based, systematic, and proactive

care.

approach for analyzing a high-risk process and

13. Any maternal death or severe maternal

identifying ways the process can fail, why it

morbidity (related to the birth process).

might fail, and how it can be made safer. Its

Please refer to SKMC Incident Reporting and

purpose is to prevent problems before they

Management

occur.

Policy

(C-QM-PIA-01-003),

Sentinel Event Reporting Policy (C-QM-PIA01-005) for details of types of Sentinel event to

As per JCI, what are the 5 categories of risks

be reported as required by SEHA as well

that would impact a hospital?

Regulatory body (DOH)

There are several categories of risks that can have an impact on hospitals. These categories

What will you do if you identify or are

of risks include

involved in a Sentinel Event or Potential



Sentinel Event? 

Remove any immediate threat or danger to Notify

your

Department



Report

the

associated

with

Quality



Financial (safeguarding assets);

C-QM-PIA-01-005:



Compliance (adherence to laws and

Manager (follow incident

Operational (plans developed to achieve organizational goals);

and

Sentinel Event Reporting) 

(those

organizational goals);

the patient or facility 

Strategic

regulations); and through

Safety

Intelligence System



Reputational (the image perceived by the public).

How are Sentinel Events managed at SKMC?

What are the essential components of SKMC

Once a Sentinel Event is identified, Quality

Clinical Risk Management Program?

Department will notify DOH and SEHA,

SKMC

submit a Preliminary Assessment Report,

Management Program (C-ORP-PIA-01-002)

coordinate with involved department/s for A

which

Root Cause Analysis (RCA), submit RCA and

components

action plan to DOH and SEHA within 45 days

1. Risk identification: Sources of information

from the date of the event or when made aware

include proactive risk assessments, adverse

of the event.

event

Quality Department will ensure action plan is

licensing surveys, medical records audits,

has

developed

includes

reports,

the

a

Clinical

following

past

Risk

essential

accreditation

or

implemented following an RCA and will 53

quality improvement and patient safety



committee reports, etc.

Reporting all unanticipated events in accordance with the incident reporting and

2. Risk analysis through different methods as

sentinel event policies.

Root-cause analysis, Failure mode and What is Root Cause Analysis/RCA?

effects analysis and process reviews. 3. Risk prioritization according to the risk’s inherent severity , Probability

A Root Cause Analysis (RCA) is a systematic

and

approach to understanding the causes of an

detection as well as in the context of the

adverse event and identifying system flaws

hospital’s strategic priorities and resources

that can be corrected to prevent the error from

4. Risk control by lowering the probability of an adverse event (i.e., loss prevention) and eliminating,

or

minimizing

individuals

harm

and/or

financial/reputational/

happening again. 

to the

an error that occurred. 

Strategic/

Operational/ Compliance severity of losses monitoring

by

evaluating

RCA is not appropriate in cases of negligence or willful harm.



when they occur (i.e., loss reduction) 5. Risk

RCAs are retrospective: they look back at

Laying events out in chronological order is one way to understand the past, but when

the

we start to group events into categories, we

effectiveness of actions taken to control risks and evaluating the Clinical Risk

begin to see them in a different way. 

Management Program

Focusing on system causes, rather than blame, is the central feature of root cause analysis.



An RCA team consists of four to six people from a mix of different professionals.



It’s

important

for

clinical

and

administrative leaders to support RCAs.

How do you as a staff are committed to Quality Improvement, Patient Safety and Risk Management? Answer as relevant and keep some examples ready. 

By

participating

in

performance

measurement (KPIs) or improvement (PI project) activities, as assigned. 

By submitting ideas for improvement to your manager



Reporting any safety risks or concerns.

54

If a sentinel event occurs, Root Cause Analysis

Safety Intelligence (SI) web based system is

(RCA) is performed to determine the “root

used. SI is Web-based reporting tool used in

cause” of the event, and make necessary

capturing information about safety-related

changes to structure/processes to prevent it

incidents, near misses, unsafe conditions

from happening again. The RCA must be completed within 45days of

reviewing; analyzing and identifying trends to

event occurrence/identification. Each RCA is

and environment.

assist improve healthcare services, processes

followed up with action plans. One useful tool for identifying factors and

What is SKMC Risk Management program?

grouping them is a fishbone diagram (also known as an “Ishikawa” or “cause and effect”

The SKMC Clinical Risk Management program

diagram), a graphic tool used to explore and

improve the quality and safety of patient care

display the possible causes of a certain effect.

delivered,

provides a framework to monitor, assess and leading to

a

safe

integrated

healthcare system serving the people of the What system does SKMC Hospital staff use

Emirates of Abu Dhabi.

to report sentinel events, incidents, near misses,

unsafe

conditions,

risks

events/occurrence variance?

55

PREVENTION AND CONTROL OF INFECTIONS (PCI): The goal of the organization’s Prevention & Control of infection program is to identify Healthcare Associated Infection (HCAI) and to reduce the risks of acquiring and transmitting infections among patients, staff, doctors, contract workers, volunteers, students and visitors within SKMC Hospital by envisage the strategy to minimize the risk of acquiring HCAI by developing appropriate policies and procedures, providing staffs, patients and visitors education in infection control, and ensuring that policies and practices in infection control have been implemented throughout SKMC Hospital. SKMC establishes and maintains a comprehensive Infection Prevention and Control Program within the standards of regulatory agencies of UAE, JCI, and the recommendations of CDC and guidelines of DOH. The prevention and control of infection manager, infection Preventionist team are assigned to carry out the daily functions of the Infection Prevention Program as outlined by the Prevention & Control of Infection Control Committee (PCI). Unit managers and each health care providers are responsible for ensuring the compliance with every infection prevention control policies of SKMC Everyone in the hospital. What are the information resources available for PCI program?

Which are the two major goals of PCI program?



PCI SKMC policy manager.



SEHA ,DOH & EHSMS Guidelines



Centre for Disease Control (CDC, USA), WHO, APIC& NHSN guidelines.

Goal 1: Protect the patient, from acquiring a healthcare associated infection from the

How does PCI committee concerns/updates

hospital

are communicated to the frontlines?

Goal 2: Protect the healthcare worker, visitors

PCI consists of multidisciplinary team. Each

and others from acquiring a healthcare

team takes back the info to their relevant team.

associated infection while working in the

Updates are communicated thru weekly

hospital.

Nursing Leadership meetings also thru unit meeting huddles.

Who is responsible for implementation of PCI program? 56

Have you received education on PCI? How

4. Sharps safety (engineering and work

often are you required to attend in-service education on PCI? There

are

two

practice controls). 5. Safe

separate

PCI

education

programs exist in the hospital. The PCI

injection

practices

(i.e.,

aseptic

technique for parenteral medications). 6. Sterile instruments and devices.

orientation education is given to all employees at the time of joining the employment in

What are transmissions based precautions?

SKMC. The second PCI mandatory online

Transmission-Based

education and quiz is compulsory for all staff

second tier of basic infection control and are to

to complete once in a year. Unit Nurse

be used in addition to Standard Precautions for

Educators, educate front liners on relevant

patients who may be infected or colonized with

infection prevention competencies.

certain infectious agents for which additional

Infection Preventionists educate the frontline

precautions are needed to prevent infection

team on respiratory protection program,

transmission

Prevention Bundles, PPE donning/doffing

Contact Precautions

training etc...



Precautions

are

the

Use Contact Precautions for patients with known

or suspected infections that

How do you prevent the spread of infections

represent an increased risk for contact

among patients, visitors, employees & in

transmission. Example –any patient with

hospital environment?

Multi

By

complying

with

IPC

policies

Drug

Resistant

organism

and

colonisation/Infection (as decided by PCI

procedures which is not limited to Improve

Committee during the annual RA or as

compliance with Standard Precautions, Hand

directed by SEHA/DOH.), patients with

Hygiene, Transmission Based precautions,

viral haemorrhagic fever, patients with

Respiratory protection program etc…

diarrhoea etc. Ensure appropriate patient placement in a

 What are Standard Precautions? Standard

Precautions are

the

single patient space or room if available in minimum

acute care hospitals

infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These practices are designed to both protect DHCP and prevent DHCP from spreading infections among patients. Standard Precautions include Hand hygiene:



Use personal protective equipment (PPE)

1. Hand hygiene.

appropriately, including gloves and gown.

2. Use of personal protective equipment (e.g.,

Wear a gown and gloves for all interactions

gloves, masks, eyewear). 3. Respiratory hygiene / cough etiquette.

that may involve contact with the patient or the patient’s environment. Donning PPE upon room entry and properly discarding 57

before exiting the patient room is done to



appropriately. Don mask upon entry into

contain pathogens. 

Limit

transport

Use personal protective equipment (PPE)

and

movement

of

the patient room or patient space

patients outside of the room to medicallynecessary purposes. When transport or movement is necessary, cover or contain the infected or colonized areas of the patient’s body. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on 

Contact Precautions. Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If





Limit

transport

and

movement

of

common use of equipment for multiple

patients outside of the room to medically-

patients is unavoidable, clean and disinfect

necessary

purposes.

such equipment before use on another

movement

outside

patient. Prioritize cleaning and disinfection of the

necessary, instruct patient to wear a mask

rooms of patients on contact precautions

Etiquette.

If of

transport the

room

or is

and follow Respiratory Hygiene/Cough

ensuring rooms are frequently cleaned and disinfected (e.g., at least daily or prior to

Airborne Precautions

use by another patient if outpatient setting)

Use Airborne Precautions for patients known

focusing on frequently-touched surfaces

or suspected to be infected with pathogens

and equipment in the immediate vicinity of

transmitted by the airborne route (e.g.,

the patient.

tuberculosis,

measles,

chickenpox,

disseminated herpes zoster). Droplet Precautions 

Use Droplet Precautions for patients



Source control: put a mask on the patient.



Ensure appropriate patient placement in

known or suspected to be infected with

an airborne infection isolation room

pathogens transmitted by respiratory

(AIIR) If AIIR is not available masking the

droplets that are generated by a patient

patient and placing the patient in a private

who is coughing, sneezing, or talking.

room with the door closed will reduce the

Examples

likelihood of airborne transmission until

are

Bacterial

Meningitis,

Pertussis, and Mumps.

the patient is either transferred to a facility



Source control: put a mask on the patient.

with an AIIR or returned home.( Ensure a



Ensure appropriate patient placement in a

portable air purifier is place in the room in

single room if possible. In acute care

such scenarios) Restrict susceptible healthcare personnel

hospitals, if single rooms are not available,



utilize the recommendations for alternative

from entering the room of patients known

patient placement considerations in the

or suspected to have measles, chickenpox,

Guideline for Isolation Precautions.

disseminated zoster, or smallpox if other

58

immune

healthcare

personnel

are

Pressure, Paper strip will be blown

available. 

inward. 

Use personal protective equipment (PPE) appropriately,

including

a

fit-tested

the air pressure countersigned by the

NIOSH-approved N95 or higher level 

respirator for healthcare personnel. Limit transport and movement

charge nurse. 

of

purposes.

If

transport

If the reading is changed to POSITIVE (+)

patients outside of the room to medicallynecessary

Engineering will do daily checking of

Permanently,

Call

Facilities

department immediately.

or

movement outside an AIIR is necessary,

Do you have a Triage or screening tool for

instruct patients to wear a surgical mask, if

communicable disease?

possible,

Yes – It is part of ED triage assessment tool

and

Hygiene/Cough

observe

Respiratory

Etiquette.

Healthcare

personnel transporting patients who are on

This tool can be used in ED, OSC and in inpatient.

Airborne Precautions do not need to wear a



mask or respirator during transport if the

What are the 3 elements in the Communicable

patient is wearing a mask and infectious

disease screening tool? Three I’s

skin lesions are covered. Immunize susceptible persons as soon as



possible

unprotected



Isolate and use PPE

contact with vaccine-preventable infections



Inform –supervisor, Infection control and

following

(e.g., measles, varicella or smallpox).

Identify signs and symptoms and exposure history (Travel, sick/Animal contact)

DOH

What is AGP?

What is the process of isolating a patient?

AGP- Aerosol Generating Procedures such as

Nurse can initiate the isolation physically by

nebulization,

placing the patient in the room with isolation

suctioning,

intubation/extubation, bronchoscopy etc.

poster then entry in Cerner with date and time started

What is TNPI?

Nurse documents in the admission screening

TNPI- Temporary Negative Pressure Isolation.

isolation entry or the 1st isolation entry put

An alternative for AIIR where you place

date and time started and sends to physician

airborne infectious patient in a private room

for Verification and signature.

with HEPA filter.

SKMC IPC policy manual has reference for specific

isolation

guidance.

Infection

How is Negative Pressure Room (AIIR)

Preventionists and IC oncall can be another

checked?

resource when needed





A digital monitoring device is located in front of isolation room that shows

What is cough/Respiratory etiquettes?

the air pressure reading.

It is part of standard precaution practices

Tissue paper check – can also be used to

where it prevents the spread of infection by

determine if the room is Negative 59

covering the mouth with tissue or placing

Doffing:

mask while coughing.

gown, surgical mask, hand hygiene.

What are blood borne pathogens?

Do you use sharps containers for all sharps?

Blood borne pathogens organisms found in

How are the containers disposed of? Who is

blood and certain other body fluids that, if

responsible for disposing of them?

transmitted, are capable of causing disease in a

In SKMC sharps containers (robust puncture

contacted person e.g. Hepatitis C (HCV),

proof) are located in all areas where sharps are

Hepatitis B (HBV), and HIV (the virus that

used. When the sharps container is 2/3 filled,

causes AIDS) are the main blood borne

the nurse seals them and HK staff place the container in red bag. HK will place it in big

pathogens.

Gloves, goggles (or face shield),

waste container in dirty utility room to be Where do you disposed of infectious waste?

collected by HK staff. It will be stored in locked

Red waste bag

medical waste room until it will be collected by contracted waste company for processing.

Where do you disposed of domestic waste? Black waste bag

What is the proper method of needle disposal?

What is PPE? Give examples.

Avoid recapping. Dispose in the sharp box at

Personal Protective Equipment (gown, mask,

the point of use.

goggles, gloves, head cover when necessary) What do you do when you sustained Needle When to use and discard Personal Protective

stick Injury or Sharp injury?

Equipment?







Business Hours (0800

-1600,

Personal Protective Equipment is used

Sunday-Thursday):

when we anticipate a blood or body fluid

OH Clinic and goes to the OH clinic to have

exposure or any kind of contamination.

initial assessment as a ‘walk in’- register at

PPE is removed after that procedure before

Central Registration

coming out of the room. 

During



Employee contacts

Outside of Business Hours:

Employee

PPE should not be worn in the hallways in

reports to Emergency Department (ED),

appropriately

Surgical Pavilion if the incident occurs

Surveyor will look for the appropriate use of

during the period of 1600 to 0800 hours, on

each PPE. Know the rationale of use if asked.

weekends or holidays. 

Do you know the location of PPE In your unit? If not, find out from your Unit Manager

Employee informs immediate supervisor / person in charge in their department.



Employee completes an occurrence report using Safety Intelligence (SI) online.

Donning/Doffing sequence of PPE.

How would you handle blood or body fluids

Donning: Hand Hygiene, gown, surgical mask,

spill in a unit?

goggles or face shield (if required), gloves 60





Ensure isolation of spill area by placing wet

We follow WHO 5 moments of hand hygiene,

floor board or alerting nearby staff about

and they are

the spill

 Before touching a patient,

Call the housekeeping

 Before clean/aseptic procedures,  After body fluid exposure/risk,

How do you care for a patient with TB?

 After touching a patient, and.

Follow Air borne isolation precautions.

 After touching patient surroundings

Patients with TB or suspected of having TB

Wash

preferably be kept in isolation room with

functions such as using the restroom and

negative pressure. Healthcare worker or any

before and after eating.

hands

after

completing

personal

person entering in the room or examining the patient with TB must wear N95 mask. Any staff

How do you wash your hands?

who provides care to the TB patient has passed

Wash all surfaces of hands with soap and

in the N95 fit test.

water, make lather with rubbing hands together, being careful to clean under and

How often N95 fit testing is done for

around fingernails and ends of fingers

healthcare workers with direct contact with

following the WHO 6 techniques for hand

patients?

hygiene for 15 -20 seconds.

Yearly and whenever staff had a major weight gain or loss or had any major facial

Do you know the six steps/techniques of

reconstructive surgery.

hand hygiene and can you correctly perform it?

Do you know your Hepatitis B antibody titer?



Rub hands palm to palm

If No please have it tested or check with



Right palm over left dorsum with

Occupational health clinic for record.

interlaced fingers and vice versa 

Palm to palm with fingers interlaced



Back of fingers to opposing palms with

What is the normal Hepatitis B protective antibody titer?

fingers interlocked 

>10miu/ml.

Rotational rubbing of left thumb clasped in right palm and vice versa



Rotational

rubbing,

backwards

and

Did you receive the seasonal influenza

forwards with clasped fingers of right

vaccine?

hand in left palm and vice versa

It is highly recommended for healthcare workers to receive seasonal influenza vaccine

When should you decontaminate hands

every year to protect themselves and their

using the alcohol-based hand rub?

patients from the serious consequences of

When hands are not visibly soiled or

influenza which include H1N1 strain.

contaminated

with

blood/body

fluids

following the WHO 6 techniques for hand When should you wash your hands?

hygiene for 20 -30 seconds or until dry.

61

Do you know the WHO five moments of

Do you know emerging and re-emerging

hand hygiene?

infections of recent times which affected

1.

Before patient contact

SKMC?

2.

Before any aseptic procedure

Covid

3.

After contact with blood and boy fluids

Haemorrhagic fever, PTB. Etc.

4.

After Patient contact

5.

After contact with patient’s environment

19

Pandemic

Crimean

Congo

What are the Cleaning and disinfecting solution used for equipment?

How do you notify Infectious diseases and

Cavi wipes - Use 2 wipes (First wipe to pre-

occurrence of infections in your ward/unit?

clean the surface. Second wipe to disinfect the

Through notifying infection control team and

surface). Wait for 2-3 minutes to use the surface

through

again. Wet contact time: 2- 3mins

electronic

Infectious

disease

notification (IDN) to DOH.

Biotek & Cryoside - Clean the surface with biotek, then wipe cryoside wait for 10 minutes

What type of PCI Key performance indicator

then wipe it off.

is run on monthly basis in every clinical unit?

Bleach- used for spore forming microorganism

Hospital acquired,

(C.difficile) and Ebola viral disease (EVD)/



VAP/VAE -

Ventilator

Associated

Pneumonia/ Ventilator Associated events 

Crimean Congo Hemorrhagic fever (CCHF). Contact time is 10 minutes.

CLABSI - Central Line Blood Stream Infection

Do you use point of use cleaning before



SSI - Surgical Site Infection

sending the used instruments to CSSD?



CAUTI - Catheter associated Urinary Tract

Yes-We used enzymatic form solution to keep

Infection

the instruments wet and prevent drying of



MDRO-Multidrug resistant organisms

debris immediately after procedure.



Hand Hygiene

The instruments are then stores in a leak proof



Central line bundle compliance

container and CSSD collects it.

Where you can look for PCI data, and audit or

How do you ensure the sterility or expiry of

stats reports?

Sterilized instrument?

In the unit based Quality Board.

It is event related (No expiry date) - Items are considered sterile unless the integrity of the

Do you know if anyone monitoring Hand

packaging

Hygiene in your unit? What is the compliance

damaged)

is

compromised

(wet,

Open,

rate? Infection Control Links is monitoring the HH

Do you have an antibiotic stewardship

in each month. Compliance rate is uploaded in

program (ASP)? Do you have a policy?

Nursing I SHARE SITE.

Yes.

SKMC

have

an

stewardship

Committee

department

chair

and

active

Antibiotic

chaired liaison

by

ID

with,

Microbiology, clinical pharmacy, and Infection 62

control team, to provide guidance to front line

emergency response system and or

clinicians on judicious and proper use of

organization resources.

antibiotics,

review

and

update

annual

antibiogram in view of local epidemiology

Responsibilities:

guided by antimicrobial annual report

1. Emergency Department: Notification:

What is Code DELTA?

Nursing

This plan is designed to outline the basic

Prevention and Control Infection Manager

infrastructure

E-notification to DOH

and

operating

procedures

supervisor/Bed

Manager/

utilized to mitigate, prepare for, respond to

Patient Placement:

and recover from infectious disease mass

Liaise with Bed manager to admit the

causality situations that impact the routine

patient directly to the assigned unit as per

operating capabilities of SKMC facilities.

Code Delta patient placement options if it

To provide for an effective response to a real or

is a highly infectious disease (HID) case,

risk of influx of infectious patients

getting referred/ transferred to SKMC with

To establish a plan for management of

pre referral.

potential & actual mass causality caused by

If the patient is already at the door, then

Infectious Disease. Entity that may present at

triage the patient in EDA Room 15 and

any point of entry into the SKMC Healthcare

admit the patient as per Code Delta patient

system

placement options after consultation with

To ensure that SKMC is better prepared to

Infection Control

effectively recognize and respond to an

If it is cluster of other infectious disease

infectious disease mass causality event Purpose of Code Delta Activation:

cases,

Alert/activate designated staff to respond and prepare for receipt of surge of Infectious

EOP. Patient Transfer: Ensure patient is safely

patients

the

transferred to assigned room/unit/hospital

organization or Highly Infectious disease that

as per Code Delta procedure and disease

overwhelms the emergency response system.

specific guidelines.

beyond

the

capacity

of

Code Delta Alert versus Code Delta  Code Delta Alert: Applies when there is

follow

ED

infectious

disease

management as per P-A-6 Appendix of

2. Unit Manager or the Most Senior Staff in the department:

a suspected highly infectious diseases or

Most senior staff or Manager takes charge

cluster of communicable disease patients

of the situation – giving instructions to

which may result in overwhelming the

other staff members and monitoring

emergency response system and or

departmental response

organization resources.

2.1 Determine whether curtailment of

 Code Delta: Applies when there is a confirmed highly infectious diseases or

normal activities is required. 2.2 If Code Delta Alert/Code Delta is

cluster of communicable disease patients

activated:

which may result in overwhelming the

a. Assign competent staff and a trained observer to support for 63

PPE DONNING and DOFFING HID b.

3.1

PPE requirement based on IC policy

computer, open Outlook, monitor

and procedure

for

communications

3.2

provision of patient care to the absolute

and

necessary

pass

on

the

broadcast 3.3

Healthcare

patient room

e.g.

for

3.4

managing

Refer to disease specific guideline / policy for patient care management

3.5

Notify

Communicable

department

to your unit.

notification

Ensure a record is maintained to

https://bpmweb.DOH.ae/UserManage ment 3.6

214) Document (internal

system

Follow DOH directive for managing and ensure color coding is followed as per Care of the deceased patient C-

daily census and identify who can be another

NUR-CLI-16-001

home

(in

3.7 3.8

Refrain from using the telephone (both land lines and mobiles) except for code

case

response

additional actions of this nature need to be taken).

Notify Mortuary 02 819 6666 /6644 before transferring a HID body

unit,

transferred to another facility or to

online

external

Nursing units review the patient

discharged

via

dead bodies based on their diagnosis

/

to

DOH

communication

communication) (HICS 213)

transferred

at

disease

have been transferred / admitted

document times/actions (HICS

3.9

Calls to the Emergency Department

Information is entered into ‘electronic

must be limited to urgent hospital

whiteboard’ and updated every 30

matters

minutes on the half hour. 2.5

for

Contact Command Center if

additional patients who may

2.4

record

workers and any other visitor entering

required

2.3

Maintain

the area. more staff or other resources are

e.

Minimize number of staff involved in

coming from Command Center messages to Person In Charge of

d.

Comply with Isolation precaution and

Assign individual to log onto email

c.

3. Staff Members ( Physicians and Nurses):

3.10 Calls from family / friends of casualty

The downtime procedure / form is

patients may be directed to Family Pool

used when the electronic system is

– do not forward call to Emergency

not functioning and is delivered to

Department

Command Center.

3.11 Elevators are to be used only for transporting patients or equipment; they are not to be used for any other purpose. Staff, visitors etc. should use the stairs.

64

GOVERNANCE, LEADERSHIP AND DIRECTION (GLD) Providing excellent

patient

care

is leadership

responsibility. Leaders must work together well to fulfil hospital mission, coordinate and integrate all the organization’s activities, including those designed to improve patient care and clinical services.

How is SKMC Hospital strategic plan developed?

There are several ways in which resources are

Information is gathered from many sources:

allocated:

SEHA, the Senior Team, management staff and



Each department director and nurse

members of the medical staff participate in

manager develops a budget based on

planning future direction and programming for

their plans for services, the number of

the organization.

patients and the needs of the services provided. 

How are resources such as staff, finances and equipment allocated?

Department directors, administration, nursing and allied health set staffing guidelines that are based on



The scope of care provided by each

priorities are set for the items to be

department or service. Medical and

purchased.

nursing use the zero based budget plan for 

 

each

unit

/service

that

is

How

are

these

discussions/decisions

standardized across the SEHA BE’s

communicated?

Input from the medical staff leadership



Department Chairs Meetings

and from the departments is actively



Staff meetings

solicited and included in the process.



Town Hall Meeting

Each department requests the capital



Hospital Standing Committee Meetings

equipment it needs on an annual basis.



Senior Management Committee Meetings

This information is reviewed and studied

by

several

different

interdisciplinary groups of directors. Physician

input

is

included

Do you know where to find the SKMC Mission Statement?

and 65 | P a g e

Yes. They are posted on SEHA Portal and

can access the Scope of Services on SKMC

SKMC CEO ishare site.

Portal.

Do you have a chain of command? Can you tell

Do you know what the hospital Quality Plan

me how you would handle an issue (patient or

is?

personal)

The hospital has a written quality program

if you

were not getting an

appropriate response?

revised and updated annually which focuses on

Yes. We have a chain of command. With patient

quality management and improvement issues

issues, we would notify our senior according to

in all areas of patient centered care. The Quality

the reporting hierarchy. Personal issues, can be

department supports quality projects across the

discussed with Unit Manager. If this does not

services.

solve the problem, appointment request with

Refer to Quality Improvement and Safety

the Senior Team member can be made

Program on Policy Management System.

according to my chain of command (e.g. if I am a nurse, first my CN, Nurse Manager, ADON

What is your understanding of the SKMC

and if unresolved then the Chief Nursing

safety program?

Officer.

The hospital has a written safety program which focusses on a range of areas including,

How do you receive communication about

safety and security, hazardous material, fire

changes in the organization?

and safety, medical equipment and utility

We have regular monthly staff meetings where

system management.

we discuss issues and our Unit Manager gives us feedback on questions that we raise and

What is your understanding of a Culture of

information from the Management meeting,

Safety?

minutes are available for staff unable to attend.

•

The Hospital establishes and enforces a

Email communication is used often from Unit

Quality Improvement & Patient Safety

Manager to convey information.

Program that promotes accountability and transparency.

How do you know what type of current

•

services that are offered throughout SKMC

SEHA Standards of Conduct. •

Hospital?

The Hospital follows and enforces the All employees receive education and

As a staff member you can refer to the scope of

information on the Hospital’s culture of

service for the service or department. The scope

safety program through various on-going

of service includes the types of patients

events.

managed by specific teams/units. It includes the

•

The Hospital uses a SEHA-wide, real-time,

admission and discharge criteria, the functional

online

relationship

monitor

between

departments,

the

quality safety

monitoring and

system

to

effectiveness

by

mechanism to coordinate patients care and

reporting incidents and near-miss events as

staffing positions as well as future planned

detailed in the Incident Management Policy.

services and these are located on the portal. You

Any staff can report issues related to safety culture without fear of retribution. As much 66

•

as possible, system issues are identified

needs,

for

example

security

services,

through the incident investigations.

housekeeping

services,

catering,

laundry,

The culture of safety is measured using

transport, medical equipment maintenance,

regular surveys and monitored by various

SEHA dialysis service, waste management etc.

means, with the results used to implement

The

improvements in identified areas.

contract

responsibilities of maintaining valid are

under

Support

Services

Department. What do you do as an organization to improve

Do we do Human Subject research in SKMC?

culture of safety at SKMC?

Yes. What will you do if you have an ethical dilemma regarding the medical care of your patient? You can share your concern with your Unit Manager and if unresolved, they will escalate it to the Medical Ethics Committee. Do you have a Code of Conduct? Yes, HR Department has a Code of Conduct policy (as part of the HR Manual) which is available on their department’s iShare site. Link of HR

Do you have any contracted services in SKMC? Yes, there are a number of contracted services

policy: http://portal.seha.ae/SKMC/departme nts/HR/HR%20Policies/Forms/DocumentsVie w.aspx

at SKMC to meet patient and management

67

FACILITY MANAGEMENT AND SAFETY (FMS) Health care organizations work to provide a safe, functional, and supportive facility for patients, families, staff and visitors. This requires effective management that strives to reduce and control hazards and risks, prevent accidents and injuries, and maintain safe conditions. Within this chapter there are six elements/components: 1) Safety and Security 2) Hazardous materials 3) Emergencies 4) Fire safety 5) Medical Technology 6) Utility systems (PMS)’ under ‘Environment Health & Safety’ location Facility Inspection: 

property,

medical

technology,

and

equipment,

and systems do not pose a physical risk to patients, families, staff, and visitors (FMS4.2). Written Policy, Procedure, Program or other Written Document: In compliance with JCI requirement FMS.4 ‘Safety Management Program’ has been developed which is available in ‘Policy Management System (PMS)’ under ‘Environment Health & Safety’ location for staff access and awareness. Link: Click Here 

of utility systems throughout the

Safety refers to ensuring that the information



Construction

schedule of inspection & maintenance

Definition: building,

and

Management (FCM) follows a planned

SAFETY: 

Facilities

Other policies mentioned below are available in ‘Policy Management System

facilities. 

Environment Health & Safety (EH&S) conducts

Occupational

Safety

&

Health (OSH) internal inspections & audits to ensure non-conformance are identified and approved corrective action plans are implemented as per SKMC Standard OSHMS Audit and Inspection (C-QM-EHS-11-008). OSH inspection plan (schedule) is developed year in advance and unplanned random OSH inspections are also carried out as needed. Inspection reports are sent to departments

and

uploaded

on

InsideSKMC portal (Link: Click Here Inspection

2020

and

Click

Here

Inspection 2019 )

68 | P a g e

  



EH&S Links / Department Managers

EH&S

ensure action items are completed.

departments to ensure action items are

Completed and follow-ups are properly

where contractors do not have access to

documented.

SI system.

Other

preventive

programs

are

Incident

follow-up

Investigation:

with

Incidents /

established to proactively identify risk

Accidents are investigated as per SKMC

and plan for and follow-up on corrective

policy

action. Preventive programs includes,

Exposures/Injuries/Illness

but are not limited to:

Employee

audits &

inspections,

practice

drills

on

emergency

response,

hazardous

materials

management

program,

education,

awareness,

‘Work

Related and

Accident/Incident

Investigation (C-OP-EHS-00-005). 

Root cause(s) are analysed and action plan

is

developed

to

prevent

a

&

recurrence. RCA & action plan are

competency of staff, risk assessment,

documented in SI system, Abu Dhabi

etc. Environment Health & Safety (EHS)

Occupational Safety & Health Center

Committee: Oversees and directs the

Report’ etc.

training

planning, coordination, development,





department

(OSHAD) Form e.g. G2 or ‘After Action 

EH&S Links / Department Managers

implementation and monitoring of

maintain

the

copy

of

incident

implementation of OSHMS programs.

investigation report and ensure action

(Link: Click Here - EHS Committee)

items are completed.

EHS Links post minutes of meeting and key messages on the notice board / communicate in departments for staff

Hazard Identification & Risk Assessment: 

awareness and compliance.

Definition ‘Risk’: Risk is the product of the likelihood of occurrence of an undesired event and the potential

Accident / Incident and Investigation: 

adverse consequences which this event

Incident Reporting - All workplace

may have upon (Risk = Likelihood

incidents involving employees, patients

(Frequency) x Consequences).

and other persons shall be reported



immediately following the incidents, as per



the

SKMC

policy

‘Incident

‘Hazard’:

Hazard

is

anything with potential to cause harm. 

Definition

‘Consequences’:

The

Reporting and Management (C-QM-

outcome of an incident. A single

PIA-01-003).

incident

Incidents / Accidents are reported using the Safety Intelligence (SI) system

consequences,

(Link: Click Here) 

Definition

can

generate and

the

multiple initial

consequence of an incident can escalate. 

Definition ‘Risk Assessment’: The

SKMC contracted staff (contractors &

process of determination of risk, usually

sub-contractors) are to report any

in a quantitative or semi quantitative

incident / accident to their SKMC

manner.

managers for reporting in SI system 69



EHS Links and Department Managers conduct ‘departmental risk

Management of Change – CQM-EHS-10-004) o

assessment’ and develop an action plan with input from key stake holders using

new Contractors, new task, new

SKMC approved departmental risk

equipment etc.) o

assessment template. 

Completed

department

assessments

are

InsideSKMC

(under

Department

associated with a specific work

on

activity (e.g. confined space,

uploaded

Environment

Managers;

hotwork); etc. o

Link:

Such risk assessment documents are maintained by end-user

http://portal.seha.ae/SKMC/sites/qmd/

departments,

OHS/Generic%20Departmental%20risk

Construction Management, etc. o

%20assessment%20reports/Forms/AllIt

Departments

Facilities obtains

& MOC

ems.aspx

approval from Chief(s) on MOC

Environment Health & Safety (EH&S)

approval form. o

Department conducts an annual review of ‘SKMC Risk Register’ with input

Link on InsideSKMC: Click Here

from key stakeholders and maintains

Safety during Demolition, Construction, or

the records in compliance with OSHAD

Renovation:

and Department of Health (DoH)



Presence of a high level of risk

risk

Health & Safety Section) by EHS Links /



Before work activities begin (e.g.



Risks

associated

with

construction

requirements. ‘SKMC Risk Register’ is

activities are assessed, control measures

available

(under

are implemented in accordance with the

Environment Health & Safety Section) –

hierarchy of controls as per SKMC

Link:

policy C-QM-EHS-11-005 (OSHMS Risk

http://portal.seha.ae/SKMC/sites/qmd/

Management) and EHSMS-SOP-FCM-

OHS/SKMC%20Risk%20Register/Form

10-001

s/AllItems.aspx Management of

Construction

on

InsideSKMC

Management Work

and

during control

(MOC)

measures are taken to prevent injury,

Process: The risk assessment is an

illness and disease to persons who

ongoing

might be exposed to risks arising from

process

Change

-OSH

and

may

be

undertaken at various times including below as per SKMC policy C-QM-EHS11-005 (OSHMS Risk Management): o

o

construction activities. 

Permit to work (PTW) procedure is followed with demolition, construction

When planning or making a

& renovation projects by Facilities &

change to a work procedure,

Construction

activity and/or practices;

which includes:

When introducing new plant, equipment,

materials

o

Management

(FCM)

Pre-construction risk assessment

or

(PTW risk assessment template

substances into the workplace;

has been customized for this

(as per SKMC policy on OSHMS 70

o

purpose to include required areas as per JCI & OSHAD) o



risk

o

Work Stress Management

assessment (ICRA template is

o

Compliance & Ethics

followed)

o

Covid 19 Back to Work

Required areas of the pre-construction

o

OSHMS

risk assessment include:

o

Fire Safety

o

Customer Services

Infection

Control

air quality;

o

infection control;

o

utilities;

carried out by EHS Links within the

o

noise;

o

vibration;

departments as identified necessary based on departmental ‘Training Plan’

o

hazardous materials;

and

o

emergency services, such as

Record’.





Other safety related trainings are

‘EHS

Competency

Summary

EHS Links / Department Managers

other hazards that affect care,

ensure training and competency of their

treatment, and services.

staff and contractors are carried out

Notice and warning signs are posted at

within the year. Training attendance

the

or

records and competency evaluation

and

records are maintained within the

demolition,

renovation

sites

construction, for

safety

awareness.



and

o

o



Prevention

Control Education

response to codes; and



Infection

departments.

Related documents e.g. PTW, PTW risk



Links to ‘EHS Training Plan’, ‘EHS

assessment, ICRA etc. are maintained

Competency Summary Record’ and

by

‘Hazard

Facilities

and

Construction

Specific are

Competency

Management Department.

Templates’

available

Contractor compliance is monitored,

InsideSKMC (Under EH&S) -

enforced, and documented EHSMS-

Click Here

on Link:

SOP-FCM-10-001 -OSH Management during Construction Work.

HAZARDOUS MATERIALS: Safety Training and Competency Program: 

Definition:

mandatory

 Hazardous Materials: Solids, liquid or

refresher trainings is the responsibility

gaseous materials having properties that are

of each employee. Annual mandatory

harmful to human health or severity

refresher trainings include:

affecting the environment, such as materials

Completion

o

of

annual

Emergency Preparedness and

that are toxic, explosive, flammable or

Business

emitting

Continuity

ionizing

radiation

(Refer

Management 2020

introduction section of Abu Dhabi OSHAD

o

Facilities Management Program

SF - COP – ‘Hazardous Materials’ for

o

Manual Handling & Ergonomics

details).

71

 World

Health

Organization

(WHO)



End-users request hazmat via Product

identifies hazardous materials and waste by

Evaluation

the following categories:

Department. 

Committee/Purchasing

o

Infectious

o

Pathological and anatomical

condition of sale for the vendor to supply

o

Pharmaceutical

the product’s safety data sheet.

o

Chemical

o

Heavy metals

Services (for any hazmat they bring on

o

Pressurized containers

site).

o

Sharps Safety (F

o

Genotoxic/cytotoxic

o

Radioactive





Purchasing

Department

makes

it

a

Contractors obtain approval from SKMC

Safe Use – Handling, Segregation & Storage:  End-user departments are responsible for

SKMC follows United Nations Globally

safe storage of hazardous materials and

Harmonized System (GHS) for hazmat

wastes.

classification and symbols. Written Policy, Procedure, Program or other

HazMat Registry (Inventory) / Safety Data

Written Document:

Sheets (SDS)/Material Safety Data Sheet



In compliance with JCI requirement FMS.5 ‘Hazardous Materials Management Program - C-QM-EHS-02-001’ has been developed to address issues related to inventory, handling, storage, and use of hazardous materials which is available in ‘Policy Management System (PMS)’ under ‘Environment Health & Safety’ location for staff access and awareness. Link: Click Here



SKMC

General

Services

policies

on

‘Contracted Waste Management Services’

(MSDS): 

Other

policies mentioned

below

are

available in ‘Policy Management System



SKMC

‘InsideSKMC’

QM-EHS-02-001) Ordering – Identification, Selection & Approval:

are

available Portal

on (under

Environment Health & Safety) Link:

Hazardous

Materials Management Program Policy (C-

registry

Soft-copies of departmental hazmat inventory

Safety’ location. Components:

with

in each end-user department.

(PMS)’ under ‘Environment Health & Key

binder

(inventory) & MSDS/SDS are available

deal with hazardous wastes. 

Hazmat

Click Here 

Hazmat registry (inventory) include: o

Name of the hazardous materials;

o

Manufacturer of the hazardous materials (where necessary);

o

Hazardous class;

o

United Nation (UN) Code; 72

o

SDS/MSDS;

o

Location

International Best Practices for hazmat of

the

hazardous

materials;Quantity

of

the

classification and symbols. 

hazardous materials onsite

Placards are available in SKMC with different types of symbols (including GHS) for staff awareness.



Sample of SDS / MSDS

Workplace Labels: 

End-users use SKMC workplace label template when decanting (pouring) into another container.

PPE (Personal Protective Equipment) / Bottles with Workplace Labels

Decanting and Spill Procedure:

Workplace Labels



End-user Departments ensure hazmat is stored/handled/decanted



placard,

hazmat



End-user Departments provide PPE to



staff. Spill kits are accessible to be used in

segregation table etc. and others : Click Here

suitably

ventilated area.

Link to workplace labels, hazard classification

in

spillage / Staff are aware in spill Hazard Classification / Symbols: 

SKMC follows United Nation’s Globally Harmonized

System

(GHS)

and



procedure. Spills are reported in SI system and via Emergency Operations Plan (e.g. ‘2222’) as needed. 73

Compressed Gases and Air: Link - Click Here 

Policy on Compressed Gases and Air Cylinders and System (C-QM-EHS-03006) is available in PMS portal under Environment Health & Safety.

 Chemical Spill Kit

Medical gas panel signage (procedure to turn off gas) should be present next to

Chemotherapy Drug spill Kit

medical gas panel. 

Distribution gas map indicates which areas are controlled by the valves in that medical gas panel and should be available next to medical gas panel.

 Body Spillage

Medical gas (panel) isolation valves should be unobstructed.

Staff Training, Competency & Awareness



Medical gas cylinders are labeled in a

/ Roles and Responsibilities: 

Training / Competency for staff & contractors



legible manner (as to contents of cylinder).

handling

hazmats



Medical gas cylinders are stored indoors

are

in secured area. Medical gas cylinders

completed in the departments during

have appropriate signage. Link: Click

orientation & annually as refresher.

Here

General awareness for all other SKMC



Medical gas cylinders are segregated and

staff in hospital orientation & through

stored by contents of the cylinders using

on-line mandatory training ‘Facilities

‘full’ and ‘empty’ posters. Link: Click Here 

Management Program’.

Large gas cylinders are stored upright and

Safe Disposal / Legal, Regulatory and

secured by chain.

other requirements e.g. JCI:

Chemotherapy: Pharmacy, Housekeeping &



Process for hazardous materials waste

Nursing are responsible to establish policies

removal from end-user departments –

and procedures for safe handling, storage, use

Link: Click Here

and disposal of chemotherapy products, to

 

SKMC

Support

Services

manages

monitor compliance and to take corrective

disposal of hazmat and wastes.

action

Disposal are carried out via approved

Housekeeping

contractor

available on ‘Policy Management System

in

compliance

with

Departmental of Health (DoH) & Center

when

required. and

(See

Pharmacy,

Nursing

standards

(PMS).

of Waste Management Abu Dhabi requirements. 



Radioactive

Materials

and

Waste:

‘Legal Registry’ is maintained where

Radiology is responsible to establish

legal requirements are documented –

policies

Link: Click Here

handling, storage, use and disposal of

and

procedures

for

safe

74



radioactive materials and waste, to

Management

monitor

‘Environment Health & Safety’ location for staff

compliance

and

to

take

System

(PMS)’

under

corrective action when required. (See

access and awareness. Link: Click Here

Radiation Safety standards available on

Other policies mentioned below are available in

‘Policy Management System (PMS).

‘Policy Management System (PMS)’ under

Medical and Infectious Waste: General

‘Environment Health & Safety’ location

Services-Housekeeping and Infection Control are responsible to establish

Fire Risk Assessment:

policies



and

procedures

for

safe

An ongoing assessment of compliance with

handling, storage, use and disposal of

the fire safety code and hazards are carried

medical and infectious waste materials

out.

and waste, to monitor compliance and

SKMCwide Fire Risk Assessment (EHS-

to take corrective action when required.

RA-43 60 61) Click Here. The assessment of

Waste

risks includes but not limited to the

management

compliance

with

shall

UAE

be

in

regulations

following: 

(Refer to Infection Control Manual and General Services Policies). 

The assessment is documented in

Pressure relationships in operating rooms

License, Permits, Approvals and Other



Fire separations

Necessary

The



Smoke separations

department responsible to purchase or



Hazardous areas (and spaces above the

dispose

Documentation:

of hazardous materials is

ceilings in those areas) such as soiled

responsible to obtain a license, permit,

linen rooms, trash collection rooms, and

approval

oxygen storage rooms

and

other

necessary

documentation required for any specific



Fire exits

hazardous material and waste



Kitchen

as

required by the relevant federal and 

copies for of these documents. ‘Legal license

etc.

Emergency

power

systems

and

equipment 

Registry’ is maintained where legal e.g.

cooking

devices

Abu Dhabi authorities and to retain

requirements

grease-producing

are

Medical

gas

and

vacuum

system

components 

documented – Link: Click Here

Other fire related hazards

FIRE SAFETY :

Fire

Prevention,

Detection

&

Written Policy, Procedure, Program or other

Equipment & Systems:

Written Document:

Fire Detection and Alarm Systems:

In compliance with JCI requirement FMS.7 ‘Fire



Fighting

Fire Alarm System – Fire break glass and

Safety Management Program - C-QM-EHS-03-

fire alarm are installed throughout the

001’ has been developed for the prevention,

facility and are connected to an alarm

early detection, suppression, abatement, and

panel.

safe exit from the facility in response to fires and non-fire emergencies. It is available in ‘Policy



Departments that have a known hearing impaired employee must identify this 75



information in their response procedure

Storage of Flammables:

(Refer to EOP Appendix J-A-04: Evacuation

 Types of Cabinets - Flammable products

Plans for Patients, Employees and other

should be stored in a closed metal cabinet

Persons with Special Needs) Click Here

or flammable cabinet.

Smoke/Heat Detectors – are installed in

 Locations of Storage - Flammables should

SKMC and are designed to be activated

be stored in secure areas that are well

automatically by smoke or heat. Activated

ventilated and away from sources of heat

detectors will identify the location of the

and electrical equipment. Warning Signage - should be mounted on

detector on a main alarm panel/stand-alone 



panels in the building. Installing and Uninstalling caps on fire detection

system

Contractor

/

storage cabinets that indicate ‘Flammable’ 

materials are stored inside. Hand Sanitizer Dispensers – Alcohol

Subcontractor personnel working under

based hand sanitizer dispensers e.g. Purell

Facilities and Construction Department is

etc. should be installed and/or stored away

responsible

from

for

the

installing

and

electrical sources e.g. electrical

electrical

uninstalling caps on fire detection system

sockets,

switches,

WoWs

where needed. No other individuals are

(computer on wheels) etc. and away from

authorized to install and uninstall the caps

heat sources e.g. electro-cautery machines,

on the fire detection system

photocopiers, heating appliances etc.

Fire Extinguishing System:

Smoke Extraction System:



Fire Hoses – Available at places.

Smoke extraction is the responsibility of



Fire Extinguishers - Fire extinguishers are

Facility

available every 20 meters. Two types of fire

Department.

extinguisher are present in majority of

extraction system is present in SKMC -

SKMC sites: carbon di-oxide (black color /

Entrance of each ward in Surgical Pavilion.

red color) and dry chemical / dry powder

Portable smoke extractors are available

(red color). A non-magnetic type of fire

with FCM to be used as needed in any area.

extinguisher is only present in MRI section

Portable smoke extractor is moved to area

of Radiology.

as required.

Automatic fire extinguishing systems –

Emergency Lighting:

such as sprinkler System, FM200 systems





&

Construction Locations

Management where

smoke

Is installed to provide lighting in the

are installed by Facilities and Construction

event of power failure. Emergency

Management in areas as required by UAE

Lighting is installed by Facilities and

regulations, or as deemed appropriate by

Construction Management in areas as

SKMC. Locations where sprinkler system

required by UAE regulations and as

is present in SKMC: Example: Executive

deemed appropriate by SKMC.

Building (all floors), Ward D0, D1, D2

Combustibles and Housekeeping:

(Medical Pavilion), Central Stores (Surgical



All departments are responsible to

Pavilion), Mussaffah Warehouse, New

minimize volume of combustibles such

Emergency Department & Peds Emergency

as paper, rubbish, debris, etc in

Department

workplace to prevent fire. 76



Items must be stored in a manner that

resistance of each compartment as required by

permits paths of walkway / egress and

UAE legislation and SKMC requirements.

must not be stored within 50 cm of Fire Doors:

ceiling.



Automatic Closure of Fire Doors - Fire

Electrical Equipment Safety (see SKMC policy

doors are connected to the alarm system so

on Electrical Equipment Safety – C-OP-GEN-

that the magnet will de-energize when the

01-030 for details on electrical equipment safety requirements - Click Here):

fire alarm is activated, providing automatic



overall

pavilion. As renovations are planned for

electrical

other buildings, then this feature will be

Department

Managers

responsibility equipment

to in

have

ensure

the

areas

of

closure of fire doors in the surgical

their

added where possible in the building and

responsibility is tested and tagged as safe

alarm system design.

for use.  Facilities and Construction Management



Fire Door Requirements - Facilities and

Department have overall responsibility to

Construction

test non-medical electrical equipment and

responsible to install 2-hour fire rated

extension cords, including Information

doors in all fire exit corridors. Fire Doors with Access Control Locks -

Technology

(I.T.)

and

Photocopier



equipment.

are

Fire doors that have access control locks

 All Hospital owned electrical appliances for heating food will be

Management

should be connected to the alarm system

in rooms

so that the magnetized lock will de-

designated as kitchens, staff rooms, staff

energized

lounges or pantries only

activated, providing free access to fire

 See SKMC policy on Electrical Equipment

when the

fire

alarm

Safety – C-OP-GEN-01-030 for prohibited

doors. Fire / Emergency Exit Doors / Doors:

electrical items and exceptions.



 Use of burning materials e.g. incense, are strictly prohibited at SKMC.

Fire / Emergency exit doors, stairwells, and

bukhoor, candles and any source of flame

is

hallways

should

be

kept

unobstructed. 

Fire / Emergency exit doors including

 All staff shall be aware of the emergency

stairwells should be kept closed. Doors

escape plan and firefighting systems in

should not be propped, wedged, taped,

their area.

or tied open.

Passive Fire Protection Measures:

Managing Risk during Construction/

Fire Compartments:

Renovation:

Are designed to effectively prevent the spread



Safe Exits – If exits are compromised

of fires into other compartments and contain

during

construction

/

renovation,

the heat and smoke within the compartment of

alternate exits will be identified prior to

origin. FCM determines the size and fire

commencing work.

77





Signage for altered fire exit routes -

required to maintain safe work area

Signage will be

and to

installed prior to

remove

at

frequency

commencing work if fire exits routes

determined

need to be temporarily altered.

Construction

Management,

as

Work Permit - Contractors notify / obtain

outlined in work contract. Smoking – Contactors

/

approval from end users, Facilities and Construction

Management,



by

a

Facilities

and

Infection

subcontractors are required to comply

Control, Environment Health & Safety

with the UAE law & SKMC ‘No

and

Smoking’ policy.

Security

Department

prior

commencing work. Work Permit is 

posted at construction / renovation site. Hot Work Permit - Hot work permit is

Fire Abatement & Fighting Equipment and

issued by Facilities and Construction

Maintenance:

Systems’

Inspected,

Testing,

and

Management for any operation involving –





open

flames

or

heat

spark

in

Responsibility

for

Inspection

Facilities

a

Management

is

activities. Hot work permit is issued to

inspection

of

fire

ensure required precautions are met,

facilities

such

as

prior to commencing and for the duration

extinguishers, wet risers, sprinklers,

of the work.

suppression

few

maintenance

and

servicing

and

-

construction and renovation areas and in

Construction responsible

for

equipment

and

fire

fire

systems,

hoses, fire

alarm

Orientation of construction workers -

systems, lighting, signage, fire exits

Orientation education on fire and

(regular and with access control), fire

emergency response at SKMC are

doors & automatic closer of fire doors

provided to construction company

and automatic ventilation control or

staff by Facilities and Construction

shut off in all buildings and on grounds

Management Department prior to

of all SKMC facilities. Frequency of Inspection - Facilities and

commencing on-site work. Safety Inspection of Individual Work Sites

–

Construction



Construction Management inspects fire

Company

equipment and maintain records for

Supervisors in charge of each project

each equipment, as per the planned

are required to inspect their work site.

preventive

Facilities

(inspection of fire extinguishers, hoses,

and

Management assigned

Construction

Project

to

each

Managers

construction

wet

risers,

maintenance dry

risers,

schedule sprinklers,

/

suppression systems and fire pump

renovation project are responsible to

systems) and update the inspection

ensure inspections and corrective

labels. Maintenance of Fire Equipment &

actions are completed as per policy, 





and records are maintained.

Record

Removal of debris / garbage –

Construction

Contractors

responsible for equipment maintenance.

/

subcontractors

are

Keeping

-

Facilities

Management

and is

78

Maintenance records are maintained by Facilities

and

Construction

Management. Inspection – EHS related inspection is



carried out by EH&S department as per planned

EHS

Internal

Inspection

your computer Desktop)

Schedule. 

Refer to Emergency Operations Plan (EOP Link on

Department

Responsibility:

Departments are responsible to report

Risk Assessment (Departmental and Hospital-

FCM for any deficiency for correction.

wide) SKMC has completed Risk Assessment (RA) is

Eliminating or Limiting Smoking within

conducted and reviewed annually. The purpose

SKMC:

of the RA is to determining the type, likelihood,



SKMC is a ‘no-smoking’ facility by law.

and consequences of hazards, threats, and



“No-smoking

events:

is

maintained

at

all

locations in buildings and on SKMC grounds. Drill, Training, Disaster Response Process,



Departmental Risk Assessment (available within the department)



Operational Enterprise Risk Management

Disaster Responders & Staff Education: See

or ERM (available on EOP Link on your

‘Disaster Preparedness’ section. Staff & Patient Evacuation: See ‘Disaster

computer

Preparedness’ section.

or HVA)

Disaster Preparedness Program SKMC is developed, maintains, and tests an emergency management program to respond to emergencies and natural or other disasters that have the potential of occurring within the community. Responsibility for the Emergency Management Program is assigned to Environment Health & Safety (EH&S) department. Emergency Management Program is monitored by Emergency Preparedness and Business Continuity Management Committee. Current Emergency Operations Plan (EOP) and other related documents are available in EOP link on each computer desktop and inside SKMC

Desktop)

(also known as Hazard Vulnerability Analysis

EOP Education / Training Orientation, education and targeted training are provided to ensure staff is knowledgeable and competent about the EOP.

SKMC will

ensure:  New

employees

receive

Emergency

Preparedness/Fire Training a part of new employee orientation / employees receive general information

about the hospital’s

EOP as a part of new employee orientation  Employees Preparedness/Fire

receive Training

Emergency refresher

training annually and records available in Human Resource department  Hospital department managers are held accountable for their employees being introduced to and competent in their roles in emergency mitigation, planning, response and recovery. 79

 Hazard specific trainings and competencies

All Hazards Plan

for concerned employees are assured by

The EOP utilizes an ‘all-hazards’ plan format to

department managers (e.g. Department –

provide a basic framework for responding to a

specific training)

wide variety of emergency / disasters (key

 Human Resources and hospital departments are

documenting

and

continuously

monitoring the valid medical and technical

hazards and vulnerabilities) and following this process:  Base Plan addresses similar actions that

certification of staff (e.g. BLS. ACLS, PALS,

commonly

occur

in

a

variety

of

ATLS etc.) as per DOH, SEHA and other

circumstances. These actions provide a ‘base

legislative requirements

plan’ for responding to unexpected events.  Annexes provide guidance for dealing with

Exercises (Drills)

specific events / functions (e.g. Fire / Smoke).

As part of its emergency preparedness, SKMC

Emergencies / disasters that are identified as

will

new risks based on the SKMC annual

 Establish an annual Exercise and Evaluation

hospital Risk Assessment (RA) are added in

Program (SKMCEEP) (schedule of drills)  Drills

the current list of annexes.

objectives

 Appendices provide specific details in

established before an exercise and are

support of an annex (e.g. Forms to be used in

conducted and evaluated from a multi-

support of an annex).

have

measurable

disciplinary perspective, with identification

Refer to Emergency Operations Plan (EOP Link on

of opportunities for improvement.

your computer Desktop)

 Document drill observations, opportunities for improvement and corrective action plans

Departmental Action Cards

for each exercise, and implement actions in a

 Department / units are responsible to

timely manner following each exercise.

develop incident/code response ‘Action

 Reports of drills identify recommendations

Cards’ using SKMC format / template.

for improvement, responsibility for action,

Communications utilizes log sheet for

timelines for completion of task and status

guidance and documentation.

on follow-up. Documentation includes list

 Managers are responsible to ensure their

of participants or departments involved in

employees

each drill.

competent in their roles during EOP

Reports are circulated to

appropriate Managers, Directors and Chiefs in the organization for review and action on recommendations.

are

knowledgeable

and

activation.  Action Cards must be updated annually or frequently if required and submitted to

Note:

Environment Health & Safety (EH&S)

Related Drills/Exercises reports and documentation

Department for inclusion in the on-line EOP

are available in respective department (e.g. Fire and

documents.

Evacuation Drill Report) and Environment Health

Refer to your Departmental Action Cards

& Safety Department Organization

Assignment

of

Roles

and

Responsibility 80

SKMC maintain an Emergency Management Team that consists of SKMC personnel who are

 Staff provides ‘name, department, building and details of the situation’.

assigned to specific emergency roles and

 When the Switchboard Operator is advised

responsibilities. Each position on the SKMC

of an incident or situation the Switchboard

Emergency Management Team identified a

Operator will notify a pre-determined

primary and an alternate person for the

response team and announce over the public

position.

address (PA) system.

Refer to Departmental Action Cards and Emergency

Refer to Departmental Action Cards

Operations Plan related to roles and responsibilities Level of Emergency Code  Code Alert is something where you need

Emergency Hotline Number

technical people to evaluate and correct SKMC Main Campus

2222

this may need to escalate to a code

Behavioural Science Pavilion (BSP) 3888

 Code is required: When the entire hospital

Diabetes & Endocrinology Clinic

1350

needs to be informed and staff take actions

Abu Dhabi Blood Bank (ADBB)

1717

according to their departmental Action Plans

Mussafah Warehouse

Refer to Departmental Action Cards

(for Fire/Smoke Call, '999' then 999 '2222')

Emergency

Codes

(Refer

Annexes

and

Appendices for details) Communication Plan for Incidents Urgent situations may occur that require immediate assessment and corrective action. Usually these situations are resolved by a

Red

Fire / Smoke

Orange

External Disaster / Mass Casualty

Green

Internal Disaster / Evacuation Aggressive

response team without activating an EOP Code.

White

Examples include, but are not limited to loss of

Yellow

power, water leaks, etc. Each response team has

Brown

a Leader@Scene. Initial & Chain of Notification of Urgent or

have observed.  Staff call Switchboard Operator when they

Missing Adult Person Hazardous Material Release Radiological Exposure / Spill

Amber

Missing Child / Child Abduction

Silver

Weapon / Hostage Situation Utility Failure & Essential Services Outage

 Employees inform the Switchboard of an

and providing information on what they

Violent

Suspicious Object / Bomb Threat

Gold

loss of utilities etc.) by calling Switchboard

/

Black

Emergency Situation

emergency situation (e.g. smoke, fire, flood,

Behavior

Person

IT System Planned Outage / Failure Grey

Weather Warning

Delta

Infectious Disease

Pink

Pediatric Cardiac Arrest

Blue

Adult Cardiac Arrest

Refer to Emergency Telephone Poster within the department

observe an urgent situation which requires emergency assessment/response.

Public

Address

(PA)

Announcement

Notification 81

 Code Alert (unconfirmed event): When announcement is a ‘Code + Color + Alert + Location’ - only pre-planned Responders go to the area  CODE

tender

operating

procedures

and

departmental action cards  Annex G: Utilities Failure and Essential Services Outage Annex

When

 Clinical/Support Activities: throughout

announcement is ‘Code + Color + Location’ –

the EOP and in departmental Action

All staff responded as per EOP and

Cards of clinical areas

(confirmed

event):

 Business Continuity Plans (e.g. to manage

Departmental Action Cards. Refer to Departmental Action Cards

manpower, equipment, alternate care sites etc.)

Business Continuity Plan

 Surge Capacity Management Plan

 SKMC Business Continuity Plans (BCP) are

Refer to Emergency Operations Plan (EOP Link

developed to describe how the organization

on your computer Desktop) and Policy Manager

will

respond

to

and

recover

from Fire/Smoke Emergency Response

disruptions.  These disruptions can be localized threats

The acronym ‘RACE’ will be used to remind

(e.g., earthquakes, fires, floods, bombs, etc.)

staff of the steps to follow when responding to

or global threats (e.g., Flu Pandemic)

fire: Rescue, Alarm, Contain and Extinguish.

Refer to assigned Business Continuity Plan

This information shall be posted with fire extinguishers, added to a card in the ID badge

Resources  SKMC

holder and documented in the Fire/Smoke has

access

to

resources

and

capabilities, which, when used effectively in a disaster, will enhance the preservation of

(Code Red Alert / Code Red) Action Cards for all units and departments. In the event of fire, think “RACE”:

life and property.  SKMC identifies organizational capabilities

R – Rescue:

:

Remove all people from

and response in the critical areas to manage

immediate danger to an

resources during events, include alternative

unaffected area of the

sources, clinical activities, alternative care

building

sites etc.

A – Alarm:

:

fire alarm (break glass);

 Annex O: Crisis Communication Annex

Call Emergency Contact

 Annex R: Staff Resource Annex  Annex L: Assets, Stocks, Pharmaceuticals,

Number C – Contain:

:

Consumables Annex  Annex

Q:

Activate nearest manual

Close doors between you and the fire or smoke as

Medical

Equipment

–

you exit the area E – Extinguish

Emergency Management  Safety Management Program

:

Only if safe to do so, do not take unnecessary risks

 Security Management Program  Staff

in

The acronym ‘PASS’ will be used to remind

Emergency Operations Plan, policies,

staff of the steps to follow when using a fire

responsibilities

–

outlined

extinguisher: Pull the pin, Aim at the base of the fire, Squeeze the handle and Sweep side to side. 82

This information shall be posted with fire

Center will determine where patient &

extinguishers, added to a card in the ID badge

staff are to be relocated if entire building

holder and documented in the Fire/Smoke

is evacuated. Patient ‘Order of Evacuation. The

(Code Red Alert / Code Red) Action Cards for all units and departments. P Pull Pin

facilities follow a plan for patient order of evacuation, following these three

A

-

Aim at base of fire

steps to identify and move patients to

S

-

Squeeze Handle

safer areas. The responsible team on a

S

-

Sweep Side to Side

patient area will identify which category

Refer to Departmental Code Red Action Card Evacuation

each patient falls into for evacuation

Managers

establish

ambulatory). Patients are moved from

procedures specific to their own department or

the area by following this order for

unit, documented in the Fire/Smoke and

evacuation:

are

responsible

to

(ambulatory,

Internal Disaster/Evacuation Annexes and

o

wheelchair,

non-

Ambulatory

following the principles of progressive building

Group all ambulatory patients and lead

evacuation and patient order of evacuation.

them together to the next safe area Wheelchair

o 

Progressive

Building

Evacuation.

The

Move these patients to the next safe area

facilities follows a plan for progressive

in wheelchairs if additional wheelchairs

building evacuation, following these four

or personnel are required, notify the

steps to progressively move employees,

Command Center to identify your

patients and other persons to safer areas: o Room Evacuation - moving to an

requirements. Non Ambulatory

o

alternate room on the same ward or

Patients are moved by bed, stretcher or

unit.

on patient rescue sheets.

o

Horizontal Evacuation - moving to a

o

safe area on the same floor. Vertical Evacuation - moving to an

Emergency Dependent Care

alternate floor, preferably one floor

Emergency

down.

established and may be activated to manage

Building / Total Evacuation - moving

emergencies when personal responsibilities of

out of the building and congregating at the assigned assembly points until

staff conflict with the SKMC’s responsibility for

o

Refer to Departmental Code Green Action Card

Dependent

Care

has

been

providing patient care.

informed by Area Fire Warden or Civil Defense of next step– either “all clear”

Employee’s dependent will be cared in Child

to re-enter the building or everyone to

Psychiatry Clinic in BSP while parent is recalled

be moved to an alternate facility.

to workplace during disaster situation. If Child

Instruction to building Command

evacuate the

would Center.

come The

from

entire

Psychiatry Clinic is not available for some

the

reason, dependents will be allocated in Surgical

Command 83

Pavilion, Ground Floor next to Ward A -

-

Find the due date

Paediatrics.

-

If the due date matching current date OR overdue, Biomed to be informed for a

Refer to Emergency Operations Plan (EOP Link on

further action

your computer Desktop) under Annexes – Annex R: Staff Resource Annex

MEDICAL TECHNOLOGY The Medical Technology Program of SKMC is designed to assure selection of appropriate medical equipment to support the medical care

Procedures to be followed when medical

processes and to assure effective preparation of

equipment has an issue

staff responsible for the use of or for the

•

Open work order in CAFM

maintenance and repair of the equipment.

•

Decontaminate the equipment - ’ Portable/ Movable ’

It assures continual availability of safe, effective equipment through a program of planned

•

Send it to Biomed workshop

maintenance, timely repair, ongoing education and training, and evaluation of all events that

Single Patient Use Device

could have an adverse impact on the safety of

Medical devices that may be used for more than

patients or staff.

one episode on one patient only. The device

The Biomedical Engineering department is

may undergo some form of processing between

responsible for performing preventive and

each use but must never be used on more than

corrective maintenance as well as acceptance/

one patient.

installation of new medical equipment's. Single Use Device The medical device is intended to be used on an individual patient during a single procedure and then discarded. The item will carry the marking on its packaging.

Preventive Maintenance Frequency: 

For General/ Generic equipment's - Once a Year



For Life Support/Critical equipment's - As per manufacturer recommendation

Identify dates on equipment in SKMC & their validity Look for the Green and the Yellow labels on the device. Green sticker is Inspection Maintenance Sticker and Yellow sticker is Safety Test Sticker.

Device

Recall

Management/Incident

Investigation Biomedical

Engineering

Department,

in

conjunction with a variety of user departments, including SEHA, maintains a tracking system, identified as ECRI Recall Tracking System, which encompasses all available hazard and recall information with appropriate corrective action and reporting.

UTILITY SYSTEMS 84

SKMC Facilities Management Department,

performing Health Safety Environment

under Operation Division establishes and

(HSE) regulation through-out the process.

implements systematic program to ensure that

•

all Electro-mechanical utility systems operate

Review and design new electro-mechanical systems as per project need.

safely, effectively and efficiently. Critical Equipment under Utility systems are :

•

•

Air Conditioning

•

•

Fire Fighting

activities of all utility systems as per

•

Medical Gas

approved PPM program (HVAC, Water

•

Water supply

system, Elevator etc.)

•

Steam generation

SKMC staff can notify FCM for any failed

•

Drainage

critical utility system by calling 2179/2458 - 24/7

•

Pneumatic Tube Systems Elevators

or through CAFM system.

•

Low Voltage Electrical Power Panels

•

Lighting Systems

When Code Gold Facilities can be activated:

•

Uninterruptible Power Supply “UPS”

(Utility System Failure & Essential Services

•

Fire Alarm System

Outage)

•

Closed-Circuit Television “CCTV” etc..

•

Power Outage (Switch to Generator Power)

Facilities and

•

Power Outage (Generator Failure)

Construction Management are included under Planned Preventive Maintenance Program

•

Flooding / Water Leaking

•

Gas Leak / Smell

“PPM”.

•

Loss of Elevator / Passenger Trap

•

Fire Alarm Activation

Our Engineering team complies with the

•

Loss of Medical Gas

Healthcare standards and meet Local regularity

•

Loss of Medical Vacuum

requirements. (JCIA, DOH, OSHAD, ADCD

•

Loss of Nurse Call System

etc.)

•

Sewer Stoppage / Blockage

As per FCM policy the approved temperature

•

Loss of Water Supply

and relative humidity is maintained between

•

Water Determined to be Non-Potable

All

utility systems under

system are achieved.

21-24 Deg.C and 30-60% respectively. FCM team responsible for but not limited to:

•

•

Perform and monitor PPM and CM

(drinkable) •

•

Ensure the sustainability of all utility

Loss of Heating, Air Conditioning or Ventilation Service

Design, implement, maintain and operate

•

Loss of Public Address System

any electro-mechanical system at SKMC.

•

Loss of Pneumatic system

Participate

and

conducting

evaluate

existing

study

to

electro-mechanical

Utility Systems in Critical Area;

equipment for renovation or expansion

•

Electrical Power

projects.

•

Uninterrupted Power Supply (UPS)

Plan, Monitor and ensure all maintenance

•

Generator Power

activities in SKMC are carried within

•

Medical Gas

planned schedule and ensure quality by

•

Medical Vacuum 85

•

Air Conditioning System

•

Fire Alarm System

patients, and unauthorized person

•

Nurse Call System

especially at identified high risk areas

•

Water supply and Drainage system

o

Responds to alarms

•

Firefighting system

o

Physical security of the facility or

o

Assists with the control of visitors,

building

SECURITY MANAGEMENT PROGRAM

o

Escort people / patients

Important

o

Helipad Area Management

o

Lost and Found Reporting and

Security

Services

Contact

Numbers:

Safekeeping

Security Hotlines: (Emergency Situation) •

SKMC Main Campus

-

o

3999

• BSP 3888 Security Desks: (For inquiry / assistance) •

SKMC Main Campus

Coordinates activities with law enforcement and public safety agencies

o

Conducts security well-being checks for employees and staff members

-

working in a department alone.

2049/3600/ 050-8181372 •

•

BSP

-

4241/4159

•

ADBB

-

1750

but not limited to:

•

Diabetic Center

-

1350

Aggressive Person / Violent Behavior, Fire

•

Mussaffah Warehouse

-

Responds to emergency situations such as

/ Smoke, Missing Person/Child, Weapon /

1149

Hostage Situation, Suspicious Object / Security System/Control Available:

Bomb Threat, etc.

•

Uniformed Security Personnel / Guard

•

Door Access System (Electronics)

SKMC Badges / Identifications:

•

Manual Punch Locks

•

•

Key Cylinder Lock

Human

•

CCTV System

identification badge to all staff members –

Employee Identification Resources

issues

an

official

permanent, locums, outsourced, students Security Services and Resources Offered: •

Responds

to

security

incidents

and volunteers. All are required by hospital and

policy to wear their ID badge whenever

documents follow-up actions

they are on duty in the Hospital Premises.

•

Identifies security risks and vulnerabilities

The identification badge is designed to

•

Responds to requests such as locking or

assist security staff, employees, patients,

unlocking doors, patients assists and visitor

and visitors to identify staff and ensure

services

appropriate access to employee entrances

Investigates hospital incidents:

and security sensitive areas or functions.

•

•

o

Unsafe/unsecured conditions

o

Missing property

Each department is responsible to provide a

o

Suspicious activity

list of personnel coming to the hospital to

o

Vandalism

Security Office and/or advice them to wear

o

Accidents / Traffic Accidents

their company badges with picture while

Contractors / Official Visitor

86

o

official visitors will be used Visitor badge by •

Outpatients

and

the

general

public

Security Services.

(visitors) are not provided identification

Vendor or Medical Representative

badges.

Identification Vendors and other business representatives

Physical Security Tips at Workplace:

are required to register with Purchasing

•

Securing your workstations

Department, where they are oriented to the

•

Be Observant / Vigilant

policies and procedures of the institution

•

Take Care of Your Personal Belongings

and issued a temporary badge and Vendor

•

Report all suspicious activity to the

Visit Form •

security or proper authorities •

Patient Identification o

When unlocking doors, do not allow

Emergency Department patients are issued

unauthorized or unknown individuals to

an identification bracelet when they are

follow behind you.

registered. o

Hospital

inpatients

are

issued

an

identification bracelet by the nursing unit at the time of admission.

87

STAFF QUALIFICATIONS AND EDUCATION (SQE) A health care organization needs an appropriate variety of skilled, qualified people to fulfil its mission and meet patient needs. The organization’s clinical and administrative leader’s work together to identify the number and types of staff needed based on the recommendations from department and service directors. Recruiting, evaluating, and appointing staff are best accomplished through a coordinated, efficient, and uniform process that includes documentation of skills, knowledge, education, and previous work experience. In-service education and other learning opportunities should be offered to staff. 

If we are not assigned to the area of our expertise, we are given additional training and experience so that we can perform the job we are assigned.

Is each staff member oriented to his or her job Where are staff responsibilities defined?

prior to being given the responsibility?

Staff responsibilities are defined in their Job

Yes, in addition to the general orientation there

Descriptions, Medical Privileging for Doctors

is

and in SKMC hospital and nursing policies and

probation period.

departmental

orientation

during

the

procedures. Staff members are responsible for knowing what is in the policies and procedures and for following their job description. Do

your

qualifications

match

the

requirements of the unit / clinic where you are assigned to work? Yes, 

First selection and CVs sourcing is made based on the PQR and the need of the hospital.



During the interview and recruitment process all the documents gathered based

How were you oriented to your job and your responsibilities as an employee? 

description, signed by him/her. 

qualifications.

We

have

to

produce

documents that support our qualifications.

Every new employee is expected to attend the general orientation, and department-

on the PRQ and Job Requirements are reviewed along with our training and

Every employee have a copy of his job

specific orientation. 

For nurses, additionally they will attend nursing orientation.

88

How does the hospital know you are competent to perform your job? For nurses: 

Orientation to the organization/annual and core competencies.



Ongoing

competency

assessment

on

entrance and yearly, each department assesses their staff members on a select number of items that are high-risk, low-

What is the process adopted in SKMC for

volume or problem-prone, point of care

verification

testing, for example on operating the blood

‘Credentials’ (License, education, training,

glucose monitor. You should be able to

competence and experience) of the Medical,

discuss how your department assesses your

Nursing, Allied Health Staff?

competence including age appropriate

Al SKMC Hospital uses the outsourced service

competencies. 

by DOH, which is ‘Dataflow’. The Credential

Continuous Nursing Education (CNE)



verification process is linked with DOH

Nursing competencies



licensing process for New as well as renewal of

Performance Improvement plan



DOH licenses or any change of the professions.

Departments Workshop



Mandatory Trainings



As a medical staff am I allowed to provide

I-Perform—Performance Management

clinical

services

verification For physicians Based

primarily

of

evaluation

in

SKMC

Credentials

of

before and

the

the

granted

privileges?

At the initial appointment: 

and

on

Absolutely No. At the time of joining the information

and

documentation received from outside the

verification of credentials must be completed as well as the privileges will be granted.

hospital. It includes but not limited to:



specialty education programs, letters of

As a Medical Staff, how could I be granted

recommendation and any quality data that

with ‘Clinical Privileges’?

be released to the hospital. These outside

There is objective, evidence based process in

sources identify at least the areas of

place for granting the privileges starts by

presumed competence.

completing the application by the medical staff

Through FPPE during the first three months

and ends by approval of the Privileging

and OPPE for reappointment

Committee. What is the validity of the granted ‘Clinical privileges’ in SKMC? The granted privileges are valid for 2 years.

89

What is the process for ‘Reappointment of

In regards to clinical privilege delineation at

Clinical privileges’ in SKMC?

reappointment: Medical staff members may

The

reappointment and the

renewal of

have

their

privileges continued,

limited,

privileges process is the process of reviewing

reduced or terminated based on:

every 2 years the medical staff's file to verify:



The result of OPPE review process



valid license



Limitations



absence of disciplinary actions



the medial staff member is physically and



The request of the practitioner

mentally able to provide patient care &



The hospital findings from an evaluation of

on

individual's

privileges

treatment 

placed

a sentinel or other events

The file contains sufficient documentation



for seeking new or expanded privileges.

The result of this review process every 2 years

The health of the practitioner

must be documented in the medical staff's file.

90

MANAGEMENT OF INFORMATION (MOI) Providing patient care is a complex endeavor that is highly dependent on the communication of information. The sound and effective management of information can help to improve individual and hospital performance in patient care, governance, management, and support processes. Because we all depend on information to provide patient care and services, our goal is to ensure that information is complete, accurate, timely, and readily accessible when and where it is required. This must be accomplished having the sensitivity and confidentiality of the information safeguarded at all times. 

Locking or signing out the computer accesses of staff after a device use.



Automatic locking of opened computer devices left idle after certain period of time.



Access to the electronic medical record is audited periodically to monitor

Information Management 

SKMC

maintains

the

unauthorized access. confidentiality,

Individuals/entities requesting copies of

security, and integrity of its data and

medical records are referred to Health

information through the following:

Information



Only staff who are authorized, can

where the information is released based on

view a patient’s Medical Record.

the release of information process, and

Access to computers and to Health

required documents and consents.



Information System require secure  





SKMC staff are NOT allowed to access their own medical record, even if they have been

The granted access level and privileges

granted access to the Health Information

reflect the staff role within the facility.

System. Staff needs to follow the same

files

are

protected

from

process as regular patients by making a

unauthorized viewing, loss, and kept secure by:



Department,

passwords.

Patient’s



Management

request to the HIMS department. 

SKMC is not allowed to dispose any

Keeping inpatient files inside the

medical record in compliance with the

nurse’s station, and only authorized

SEHA Circular MD/02-2010. This means

staff members have access.

that the retention period of patients’

Tracking patient files at any time they

medical records is indefinite.

are moved from the HIMS department or patient care areas.



There is a list of approved abbreviations, and they are the ones that can ONLY be 91



used for documentation. SKMC also has a

own

list of Do-Not-Use abbreviations, and

departments, Chair of Services, Unit

clinicians documenting in the patients

Managers, and Committees review their

chart must refrain from using them.

relevant policies on a timely manner and

However, abbreviations are never to be

submit the changes to Quality Department

used on:

for approval. Once approved, Quality



informed consent

Department uploads all polices/procedures



patient rights documents

on the Policy Management system.



discharge instructions



discharge summaries

required to be reviewed every 2 years and



other documents patient or family may

all the programs or plans, Emergency

read or receive on patient’s care.

Preparedness



documents.

SKMC

policies

The

and

Policies

Head

of

procedures

and

the

are

OSHMS

Refer to the following documents for more

documents are reviewed on an annual

information and details:

basis.

 

C-OP-HIMS-01-001 Access to Patient

expected that the changes are reflected in

C-OP-HIMS-01-015

the

Patient Privacy

and



SEHA Information Security Policy



C-IT-IT-01-007 Access Control Policy



C-IT-IT-01-022

Access

Control Access

of

the

Refer to the Policies and Procedures

The patients’ medical record at SKMC is available for every patient assessed or

Control Procedure C-IT-IT-01-012

section

Medical Record 

Network

history

Management Policy - C-QM-PIA-01-001

Procedure C-IT-IT-01-011

revision

documents or the policy system. 

Confidentiality



Whenever documents are revised, it is

Information and Medical Records Information





treated by SKMC.

Application

Access



Control Procedure

Patient medical records must be factual, consistent and accurate. Documentation, Orders/actions must be signed by the

Management

and

Implementation

of

person carrying out the order/action, as

Documents

soon as possible after the episode or



Valid hospital policies are posted in the

encounter has occurred. This should be

SKMC Policy Management System.

within 24 hours of the episode or

All SKMC staff have access to the

encounter.



documents



posted

in

the

policy



All components of the patient’s medical

management system for viewing and

record generated within the hospital shall

reading.

be kept together in a unit record, under one

All

policies,

programs/plans

procedures of

the

hospital

and

medical record number, comprised of

are

managed by the Quality Department, with

original documents. 

There are standards for documentation

the exception of Laboratory documents, as

followed by clinicians at SKMC to ensure

the Laboratory department manages their

that the specific content, format, and 92



location of entries for patient medical records is done in a consistent manner. 

documents into the discharge summary 

The medical records of emergency patients should always include the following: 

Arrival and departure times



Conclusions at the termination of their 







Any follow-up care instructions

from another system 

Compliance monitoring on the practice of copy-and-paste is conducted by HIMS

make entries in the patient’s medical

department, through monthly chart audits

record, and proper access has been

and is reported to the Head of the

provided to them.

Departments and CMO, and summaries to

When documenting on paper, entries must

the Medical Executive Committee, for

be written legibly, in permanent black ink

review and action. 

Compliance with timeliness, legibility and

erased; dated, timed and signed; pencil and

completeness of the medical record is

colored ink must not be used. Grammar,

assessed using the following:

spelling and capitalization rules should be



followed

in

paper

and

electronic

HIMS department is conducting chart audits

on

specific

requirements

Alterations/Corrections to manual records

communicated by the HIMS staff to the

must remain legible by using a single line

concerned staff and their Head of

to score out the information to be corrected.

Departments 

and

documentation

documentation.

Correction must be accurately dated,



Using screenshots of another note or

SKMC has defined who are authorized to

and in such a manner that they cannot be



Copying of all medications regardless of significance

treatment The patient’s condition at discharge

Copying of all diagnostic test results, regardless of significance





Copying entire H&P and/or other

deficiencies

are

The open and closed record review is

timed, and signed. The use of correction

also one of the tools used. The review is

fluid or tape is not allowed under any

conducted

circumstance. An addendum is a late entry

team, and the chart review results are

that

additional

shared by the Manager of Health

information related to a previous entry by

Information Management Department

the

with the concerned staff and their Head

is

used

author

to or

provide attending

physician.

by a

Electronic correction will follow the same

of

guideline.

Committee,

SKMC has a process to address the proper

committee and to the SKMC Quality

use of copy-and-paste function. As per

Council as well.

SKMC policy, the following scenarios are the criteria considered

violation of the

Copy and Paste policy: 



Medical

Medical

Records Executive

Refer to the following documents for more information and details: 

If a note is identical to previous, without notation of previous author

Departments,

multi-disciplinary

C-MD-HIMS-01-002

Authors

of

Medical Record Documentation 

C-MD-HIMS-01-009

Physician

Recording Standards 93

 

C-NUR-ADM-01-063



Nursing

Medical record forms used during

Documentation Policy

Downtime events will be maintained

C-MD-GEN-01-055 Copy and Paste

permanently

Policy

medical record, regardless of whether

in

the

paper-based

the information is entered in Salamtak Information Technology in Health Care 

system or not. 

All relevant workflows and forms related to the Salamtak downtime practice should

Downtime will be maintained as

be accessible for reference and use by all

documented

staff in the department. New employees

Downtime plans. 

should be trained on downtime procedures



Non-medical record forms used during in

Refer to the

section

specific

Appendices of

as part of their department training. The

downtime

downtime policy should be referred to in

specific processes to follow during

the event of planned and unplanned

downtime and recovery. 

downtimes. Points to remember: 

policy

for

the

department-

Refer to the Downtime Plan for Hospital Information System (Salamtak) Policy - C-

Healthcare providers should follow

IT-IT-01-015,

standard

practices

Operations Plan Icon/Link in the desktop -

while documenting in paper medical

Code Gold I.T., for more information and

records.

details.

documentation

and

in

the

Emergency

94