Accreditation Standards for Hospitals

in Lebanon

December 2022 Edition

CTAH
Acknowledgement
The Ministry of Public Health would like to thank Dr. Fadi El-Jardali (Lead), Ms.
Clara Abou Samra, Ms. Nour Hemadi and Mr. Nadeem El Halabi for the excellent
work they provided in revising and improving the accreditation standards and
tools.
We would like to thank Dr. Ali Elhaj for his input during the initial phase of the
standards revision.
Special thanks to Dr. Walid Ammar for providing leadership and guidance in
transforming the hospital accreditation system in Lebanon.
We would also wish to thank Mrs. Rita Freiha, Mrs. Perrine Malaud Wakim and
Mrs. Sizar Akoum for their input and facilitation of the process.

International Review Team

Ministry of Public Health and authors wish to thank the Haute Autorité de Santé
(HAS France) and mainly:
• Bruno Lucet / Fabienne Menot, HAS, for their advice and support
• CTAH (Comité Technique d’Accréditation Hospitalière) international
review team that has been composed as suggested by HAS and
established by the Minister of Public Health through a decree; CTAH have
provided thorough feedback and suggestions on the draft standards
before national expert consultations. CTAH composed of:
Dr. Yvonnick Morice Dr. Olivier Debay
Dr. Martial Favre Dr. Charles Bruneau
Pr. Patrice Beutter Dr. Jean Marty
Dr. Faraj Abdelnour Dr. Dominique Maigne

National Hospital Accreditation Committee

We wish to express our sincere gratitude for the National Hospital Accreditation
Committee for providing us with their feedback
Dr. Walid Ammar Mr. Sleiman Haroun
Mrs. Roula Zahar Dr. Michel Jamal
Dr. Fadi El-Jardali Dr. Ali Elhaj
Gen. Phar. Khaled Succar Dr. Leila Haber
Prof. Boutros Yared Dr. Petra Khoury
Dr. Mohamad Houri Dr. Dania Nehme Chelala
Prof. Raymond Sayegh Dr. Imad El Hajj

1
 Dr. Jihad Makkouk Mrs. Sizar Akoum
Dr. Joseph Helou

Stakeholder Organizations
The Ministry of Public Health would also wish to thank the following stakeholder
institutions, organizations and committee: Ecole Supérieure des Affaires,
Comité Technique d’Accréditation Hospitalière, Syndicate of Hospitals, Order of
Physicians, Order of Nurses, Order of Pharmacists, Lebanese National
Committee of Blood Transfusion, Order of Midwives and other stakeholders.

National Experts
The Ministry of Public Health and authors would like to extend special thanks to
the national experts for providing valuable feedback and suggestions on the
standards. We are grateful for their time and contribution.
The following is a list of national experts in alphabetical order:
Mrs. Abir Kurdi Alame Ms. Nadia Hamade Hajj
Ms. Alein Bou Saba Mrs. Nayla Shukri
Dr. Angelique Barakat Saad Ms. Nayla Daou
Mrs. Avdokia Kazan Noujaim Dr. Nazih Youssef
Dr. Bassam Ghazi Dr. Nibal Rachid Chamoun
Dr. Beatrice Chami Dr. Nisrine Bazarbachi
Ms. Christiane Abi Elias Hallit Dr. Omar Ayache
Dr. Daniel Mahfoud Dr. Pierre Béchara Ghorra
Dr. Elie Khoury Dr. Rabab Rassi El-Khoury
Mr. Elie Rizkallah Ms. Rana Husseini
Mr. Fouad Taha Mr. Riad Farah
Ms. Ghada El Keraawi Dr. Rola Hammoud
Dr. Hanady Samaha Dr. Rony Zeenny
Dr. Hanane Barakat Dr. Roukia Tamima Jisr
Mrs. Ibtissam Bou Chakra Ms. Roula Zahar
Mr. Imad El Haddad Dr. Sally Al-Rabbaa
Mrs. Joelle Khysho Mrs. Sana’a Zoghby Hajj Boutros
Dr. Katia Iskandar Ms. Shatha Abi Ghanem
Ms. Katia Saliba Ms. Suzan Azzam
Mr. Khalil Rizk Ms. Victoria Taleb
Mrs. Marie El Khoury Madi Ms. Wafaa Abou Aleiwe El Hajj
Dr. Marwan Haddad Mrs. Yolla Zaitoun Masri
Ms. Marysa Mehanna Dr. Zaki Ghorayeb
Ms. May Saydeh Dr. Christian Haddad
Mr. Mazen Al- Lahham Ms. Ghazwa Barakat Tizani
Dr. Mazen El Sayed Ms. Hera Teshjian

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Dr. Mohammad Ibrahim Ms. Lina Aoun
Dr. Mohammad Nasereddine Dr. Lina Younan Sabbagh
Mrs. Mouhsena El Romeh Ms. Rabiha Sakhat Saidy
Mr. Muhammad-Ali Hamandi Ms. Rana Abdel Malak
Dr. Rita Feghali
Dr. Nabil Diab Mr. Walid Abou Salh

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Table of Contents
Preamble .................................................................................................................................... 5
Standards ................................................................................................................................. 12
Hospital Management ............................................................................................................ 12
Governance and Leadership (GL).................................................................................... 13
Human Capital (HC) ......................................................................................................... 26
Information Management (IM) ....................................................................................... 42
Facility Management and Safety (FMS) ........................................................................... 49
Quality and Risk Management……………………………………………………………………………..…..………. 45
Medication Management and Safety (MM) .................................................................... 66
Infection Prevention and Control (IPC) ............................................................................ 84
Quality Management and Patient Safety (QMPS) ......................................................... 100
Patient Centered Care ……………………………………………………………………………………………………….73
Access and Continuity of Care (ACC) ............................................................................. 115
Patient and Family Rights and Education (PFR) ............................................................. 126
Patient Services: Anesthesia and Surgical Care (ASC) ................................................... 137
Patient Services: Oncology Services (ONCO) ................................................................. 147
Patient Services: Medical Imaging (MI) ......................................................................... 156
Patient Services: Emergency Services (ES) .................................................................... 164
Patient Services: Obstetrics and Child Health (OS) ....................................................... 172
Patient Services: Critical Care (CC) ................................................................................ 178
Patient Services: Laboratory Services (LAB) .................................................................. 191
Patient Services: Blood Bank and Transfusion Services (BB) ......................................... 202
Patient Services: Other Services (OTHER)...................................................................... 216
Appendix ................................................................................................................................ 217
Glossary .................................................................................................................................. 217
References of Glossary .......................................................................................................... 217

4
SECTION I

Preamble

5
 Accreditation, quality and continuous improvement have become an
intrinsic part of the discourse and activities of health services (Greenfield &
Braithwaite, 2008). Accreditation is deemed to be very helpful in maintaining
the improvement in quality in terms of patient care by establishing an optimal
achievement of goals in meeting standards for health care organizations and
reducing health care costs by focusing on increased efficiency and effectiveness
of services (Shaw, 2004). Additionally, accreditation maintains safety of patients
and staff enhances the developing of information systems and assists
management bodies in the planning and the provision of services creates an
accountable and transparent organization, assists the organization in having
evidence based decision and attends to the need of the population that is served
through the health care organizations (El-Jardali, 2007). Besides, it establishes a
comparative database of health care organizations which can meet selected
structure, process, and outcome standards or criteria, provides education and
consultation to health professionals, managers and health care organizations on
quality improvement strategies and “best practices” in health care and
strengthens the public’s confidence in the quality of health care provided(Shaw,
2004). In an era of continuous improvement in the health care delivery process,
a strong foundation for the continuous improvement of accreditation is needed
(Smits et al, 2014).

For this reason, and as a part of its normative and regulatory role in
supporting, financing and supervising the whole process (Ammar et al, 2007),
the Lebanese Ministry of Public Health (MoPH) introduced the accreditation
system using a phased approach to ensure a smooth transition for hospitals in
2000 (Haj-Ali et al, 2014). The development and the implementation of the
accreditation policy in Lebanon was made possible because of the legislation
that was passed in June 22nd 1962 and amended by the legislate decree #139
of September 16, 1983 (El-Jardali, 2007). Furthermore, Lebanon became one of
the first countries in the Eastern Mediterranean Region (EMR) to have a policy
on accreditation (Shaw, 2015) and to implement a comprehensive accreditation
system (Haj-Ali et al, 2014). The Lebanese hospital accreditation system has
undergone seven phases in the implementation of accreditation.

6
 For the purpose of improving and updating the current hospital practices,
the Ministry of Public Health has initiated the revision of the Hospital
Accreditation System in Lebanon aiming to revise and develop new Lebanese
hospital accreditation standards according to latest evidence and international
best practices and also to comply with International Society for Quality in
Healthcare (ISQua) requirements.

This was established through a signed agreement with the French

National Authority for Health HAS (Haute Autorité de Santé) and in collaboration
with the Ecole Supérieure des Affaires (ESA) Business School in Beirut.
In the framework of this collaboration, Dr. Fadi El-Jardali and Dr. Ali Elhaj
have been appointed by MOPH through ESA as coordinators for the revision of
the Lebanese standards of accreditation. To fulfill this task, they collaborated
with national experts to review the standards prepared jointly by them and the
CTAH (HAS).
The fundamental intent of the new system is to determine the level of
compliance with the new standards by all aspects of the healthcare system, and
assure the functional documented existence of structure (organizational
parameters), and process (methods of practices), in order to achieve optimum
clinical measurable outcomes (consequences and results) for the patient.
Mapping out the patient experience and the functionality of the hospital
system (pre, during, and post) accreditation, will ensure the level of consistency
and continuity in meeting the standards, thereby guaranteeing continuous
systematic improvement, continuous efficacy in delivering patient care and
continuous readiness for future accreditation.
Abiding by a standard-based systems approach for quality evaluation, the
accreditation standards cover the structure, process and outcome of the system.
Moreover, the standards will be piloted and finalized based on a standardized
process.

Standard Development Methodology

Building on the gap analysis of the international and regional
accreditation systems and the ISQua priority themes, the new hospital
accreditation standards were developed.

7
 Targeting each
Conduct a thorough Decide on expert
chapter and
gap analysis groups
identifying standards

Preparing a protocol/
Presenting the priority Expert recruitment
procedure manual that
themes to expert based on selection
will be customized to
groups/ teams criteria
each expert group

Revision, validation
and alignment of the Finalization of the Pilot testing in
standards according to draft standards hospitals
ISQua standards

Evaluation of the
Capacity building of
standards and
surveyors/reviewers
finalization

Flow Chart 1 Standard Development Process

Expert Consultation Process

The standards were revised through three rounds of expert and
stakeholder consultation processes using evidence-based standard evaluation
tools. 62 national experts were allocated to different chapters for the revision
of the standards, based on their professional knowledge, training and
experience. The standard evaluation phases included the application of an
evidence-based tool 1 and tool 2 with defined criteria including clarity,
importance, specificity and inclusiveness in phase one, and feasibility,
surveyability and risk assessment in phase two. Both standard evaluation tools
have been piloted and revised accordingly.

After the dissemination of each tool, the received data was analyzed,
standards were revised, validated and aligned according to ISQua standards and
the revisions were shared with the experts. The two phases of consensus were
followed by 16 face-to-face expert subgroup meetings during the month of

8
January 2017. The purpose of those meetings was to update the experts on the
process and to discuss the revisions of their assigned chapters. Additional
comments and feedback were provided during the face to face consultation
meetings. All additional comments were integrated into the accreditation
standards included in this document.

Values
The hospital accreditation system has adopted seven core values in the
approach taken to develop the standards. The values are:
1. Patient safety and protection from harm
2. Continuous quality improvement
3. Efficiency enhancement
4. Teamwork
5. Dignity and respect
6. Customer focus
7. Transparency

Chapters
 Hospital management
▪ Governance and Leadership (GL)
▪ Human Capital (HC)
▪ Information Management (IM)
▪ Facility management and safety (FMS)
 Quality and Risk Management
▪ Medication management and safety (MM)
▪ Infection prevention and control (IPC)
▪ Quality management and Patient safety (QMPS)
 Patient Centered Care
▪ Access and continuity of care (ACC)
▪ Patient and family rights and education (PFR)
▪ Patient services
• Anesthetics and surgical care (ASC)
• Oncology services (ONCO)
• Medical imaging (MI)

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 • Emergency services (ES)
• Obstetric and Child Health (OS)
• Critical care (CC)
• Laboratory services (LAB)
• Blood bank and Transfusion (BB)
• Other Services (OTHER):
• Burn care
• Dietary services
• Social care services
• Physiotherapy services
• Mental health services

Chapter Composition
Each chapter is composed of an introductory chapter followed by the set of
standards and its risk score. Each standard has been supported by a
corresponding set of guiding measures that clarify further the standard. The
guiding measures aim to facilitate the implementation of the standards and to
guide the hospitals in fulfilling the objective of the standard.

COR (Critical Organization Requirements) standards

The COR standards the minimum required standards that a hospital should meet
to be accredited, the “make it or break it” standards. Those standards are
essential to ensure patient safety and include the international patient safety
goals. The COR standards are incorporated from different themes and were
selected based on a risk assessment that involves identifying a numerical risk
score based on the likelihood that the identified risk will actually happen or
materialize and the consequences on the organization if the risk does
materialize or happen.

10
Intents

In the composition of the chapters of Lebanese accreditation standards, after

the introduction of each chapter, there is a need to develop Intents for further
explaining the rationale of the guiding measures in order to:

1- Better clarify their aim and purpose,

2- Remove any grey zone in their understanding, harmonize their correct
perception by professionals
3- Highlight their reasons for being and relevance for the continuous
improvement of quality and safety of care
4- Stress on the importance of the chapters and the guiding measures
(COR, Hospital Management, Quality and risk management, Patient
centered care, Critical care, Governing Body etc.)
5- Sometimes, suggest adding international standardized tools for
benchmarking

In summary, the intents aim at highlighting the spirit of the guiding measures
which, in redundancy focus on the core values of the chapters (Patient safety
and protection from harm, Continuous quality improvement, Efficiency
enhancement, Teamwork, Dignity and respect, Customer focus, Transparency).

Finally, it is important to note that only guiding measures are applicable whereas
the intents objective is to bring more information to the professionals

11
SECTION II

Standards

12
 Hospital Management

Governance and Leadership (GL)

Introduction
The Governance and Leadership chapter is designed to achieve excellence in
governance and leadership practices at the following levels:

Level 1 Governing body

Level 2 Chief executive

Level 3 Executive management

Level 4 Department/unit/service leaders

Other themes Ethics, safety, education,

research, community needs assessment

Level 1 Governing Body: represents the shareholders or the board members

having the highest authority.

Level 2 Chief Executive: The chief executive (e.g. chief executive officer [CEO] or
hospital director) is responsible to manage the organization on a daily basis.

Level 3 Executive Management: represents the senior officers of different

disciplines, such as the senior nursing officer, chief medical officer, senior
administrator etc.
Hospital committees consist of professional staff committees formed; this could
be committees from the same discipline or multidisciplinary committees.

13
Level 4 Department/Unit/Service Leaders: represents the managers of
departments, units or services.

Other Themes: Ethics, safety, education, research, community needs

assessment.

The Governance and Leadership chapter targets the following sections:

 Governing body roles and responsibilities

 Chief executive roles and authority
 Executive management structure, role, responsibility and authority
 Department/Unit/Services Leaders
 Hospital scope of service
 Dissemination of information to Ministry of Public Health
 Resource allocation
 Human based research
 Clinical and non-clinical contracts
 Department/unit/service roles and responsibilities
 Hospital-wide ethical framework
 Community needs assessment

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

14
Standards
Risk
Standard and Guiding measures
Score

GL 1. Organizational structure, roles, responsibilities and authorities are

delineated, documented and implemented.
The governing body represents the shareholders or the board members
who hold the highest authority. The by-laws in the hospital should set
the structure and power of the governing body including the number
4 and names of members, the election process, responsibilities, authority
and frequency of meetings. The list of members should be displayed
The governing body practices its responsibilities and is evaluated based
on pre-defined criteria at least every two years. This evaluation should
be documented with clear evidence of improvements based on the
results.
Guiding measures:
1.1. Governing body members are identified by names and
responsibilities.
1.2. Responsibilities and authorities are described and documented in by-
laws.
1.3. By-laws are implemented.
1.4. Evaluation methods and criteria to monitor and improve the
governing function are specific and documented
1.5. Governing body performance is reviewed and documented at least
every two years.
GL 2. The governing body oversees and approves the vision and mission
statements, values, strategic and operational plans, policies and
procedures and capital and operation budgets.
The strategic plan is a long-term plan that builds on the needs, mission
and vision to guide the hospital in achieving high priority objectives.
It should be developed on the needs of the hospitals. The needs can be
identified through SWOT analysis and/or PEST analysis and/or
6
corporate social responsibility. The objectives of the strategic plan
should be clearly linked to the needs-assessment and the hospital’s
mission and vision.
Based on the strategic plan, a capital and operation budget are
developed, and resources are allocated which are similarly approved by
the governing body. The capital and operational budgets are yearly
plans for expenditure.

15
 The hospital should develop clear processes to carry on audits. The
processes should include the person(s) responsible for the audit, time
period of audit, tools used during the audit, process for reporting the
results to the governing body and department heads and plans for next
steps after the audit.
The governing body should oversee and support the development of
the mission and vision, strategic plan and operational budgets as well as
the auditing processes.
Guiding Measures:
2.1 The governing body oversees and supports the development of the
vision and mission statement, values and the overall strategic plan.
2.2 The governing body approves the hospital’s strategic plan and it is
related strategic actions/operational plans.
2.3 The strategic plan identifies goals, objectives and key performance
indicators that are consistent with the hospital’s vision and mission.
2.4 The strategic plan takes into consideration the SWOT (strengths,
weaknesses, opportunities and threats) analysis, PEST (political,
COR
economic, social, and technological) analysis and/or corporate
social responsibility.
2.5 The governing body approves the hospital’s capital and operational
budgets.
2.6 The governing body oversees and evaluates the resource allocated
to the strategic plan.
2.7 Evidence of internal audit process that is reviewed by the governing
body with a clear scope.

GL 3. The governing body oversees and approves the development of quality

and patient safety programs and/or plans.
The involvement of the governing body in the oversight and approval of
quality and patient safety programs and/or plans and continuous
discussion on quality and patient safety should be a top priority to
improve the quality of care in the hospital by safeguarding top-level
dedication to quality and patient safety.
6 The governing body have a critical role in raising a culture of quality and
patient safety in the hospital, therefore, the need for the approval of
the governing body on the hospital’s quality and patient safety program
and/or plans.
As per the hospital’s policies, at least twice yearly (the hospital may
choose to report more frequently), the results of the quality and patient
safety programs/plans should be reported to the governing body for
decision making. The reports may include but not limited to the

16
 following: the objectives achieved, the challenges, areas pending, and
critical adverse events.

Guiding measures:
3.1. The governing body oversees and approves the hospital’s quality
and patient safety program and/or plans.
3.2. The governing body receives, at least twice per year, reports on the
COR quality of care and patient safety including critical adverse events.
3.3. Decisions taken on patient safety and quality including
improvements made are documented.
3.4. Quality of care and patient safety are regularly present on the
meeting agenda of the governing body.
GL 4. The chief executive’s role and authority are delineated and
documented.
- The chief executive is appointed by the government body and should
have a clear job description, in line with the strategy of the hospital.
He ensures that the hospital is performing efficiently and should lead
strategic development initiatives but at times but also deal with day-
to-day operations.
4 - Some of his responsibilities include overseeing the development of the
strategic and operational plan, responding to external inspecting
agencies, promoting quality in the hospital, and ensuring patient
safety.
- The process of evaluating the chief executive is a collaborative process
between the chief executive and governing body that is based on pre-
identified criteria and secures continuous improvement at the
hospital.
Guiding measures:
4.1. The chief executive is appointed by the governing body with defined
objectives and job description coherent with the strategies defined
by the board.
4.2. The chief executive has the appropriate education, experience and
training as defined in the job description.
4.3. The chief executive oversees the development of both the strategic
and operational plans and ensures the hospital's compliance with
laws and regulations
4.4. The chief executive responds to external inspecting agencies’ (i.e.
external auditor, Ministry of Public Health, National social security
fund) reports.
4.5. Annual review of the chief executive’s performance conducted by
the governing body based on a delineated process.
GL 5. The executive management’s structure, role, responsibility and
authority are delineated and documented.
4
The hospital’s executive management has a critical role in the
operational aspect of the hospital and in ensuring that the hospital

17
 provides high-quality patient care. All hospital executive management
members should have clear roles and responsibilities that are agreed
upon prior to the assignment of the members. The list of members
should be displayed
The executive management team should develop operational plans on a
yearly basis and follow up on its implementation with clear reviewing
documentation of achieved objectives.
As well, all hospital-wide policies and procedures should be developed
by the executive management, the members can get support from
frontline healthcare workers or specialists for the development of the
policies. The policies should be approved, signed, accessible to staff and
implemented.
Guiding measures:
5.1. The hospital’s executive management members are defined by
name and function.
5.2. Members of the executive management have the appropriate
education, experience and training.
5.3. Evidence of a multidisciplinary (be at least 4 executives; the chief
executive officer or a board of director representative, medical,
nursing, quality and finance officers) professional background of the
hospital executive management members.
5.4. Annual review of the performance of the hospital executive
management based on a defined set of responsibilities and
accountabilities.
5.5. The executive management implements through documented
operational plans the hospital’s vision, mission and strategic plan.
5.6. The implementation and progress of the operational plans are
regularly monitored
5.7. The executive management develop hospital-wide programs,
policies and procedures
5.8. There is a process to ensure that policies and procedures are
documented, disseminated, up to date, implemented and available
for use by all hospital staff.
5.9. The executive management develops, ensures implementation and
evaluates the patient flow plan (admission, transfer, & discharge) in
the hospital.
5.10. Executive management develops and implements operational and
capital budgets.
5.11. The executive management evaluates the performance of the
hospital on annual basis based on achievement reports and
indicators in accordance to the strategic plan.
GL 6. The hospital’s scope of services required to meet the needs of the
3
patients is clearly identified and documented.

18
 Availability of a clear scope of services helps direct the patient to the
hospital that provides the services that the patient needs at the right
time.
The scope of services should include the list of services provided by the
hospital; for example, adult critical care services, intervention
radiology, pain management, and pediatric medical/surgical.
Depending on the patients, the community needs and the strategic
plan, the scope of services at the hospital should be
identified/modified/revised. For example, if the hospital’s population
served has a high rate of smoking, the hospital may decide to develop a
smoking cessation program.
Client feedback survey (such as satisfaction survey or complaint reports)
can reflect a need to integrate additional services at the hospital.
Based on recurrent feedback on the same services, the hospital may
decide to develop direct and systematic referral processes to hospitals
providing neonatal care.
The scope of services needs to be readily available to the community
and patients, this can be through the website, and/or brochures, and/or
banners in the hospital.
Guiding measures:
6.1. The executive management in collaboration with the
department/service heads ensures that the strategic goals are
aligned with the scope of services.
6.2. The scope of services is described and documented reflecting the
needs of the community.
6.3. There is a collaborative process to ensure effective sharing of
operational information among departments/units/services.
6.4. The executive management receives and acts upon input/feedback
from the clients, families and community regarding the services
provided.
6.5. Information on the scope of hospital services is available to the
community.
GL 7. There is a communication plan to disseminate information to Ministry
of Public Health and stakeholders.
The communication plan should play an important role in ensuring that
patient, staff, and stakeholders understand the mission, vision, and
3
objectives of the hospital and act effectively to achieve them.
It should aim to deliver the right messages to the right audiences at the
right time and ensures that information is shared with recipients in a
timely manner.
Guiding measures:

19
 7.1. The executive management communicates the vision mission and
values to the public.
7.2. The internal and external communication plan is established and
evaluated by the hospital executive management, for effectiveness
and timely dissemination of information.
GL 8. Executive management develops hospital-wide quality management
and patient safety programs and/or plans.
Involvement of executive management in quality improvement and
patient safety is a high priority when it comes to institutionalized and
sustainable quality improvement and patient safety initiatives.
The quality and patient safety program/plans should ensure that the
4 safety of the patient is secured and there is continuous quality
improvement at the hospital. The executive management develops the
quality improvement and patient safety plan/ programs that integrate
areas of high priority and/or high risk.
To ensure a proper evaluation the management should accompany the
plans and/or programs with key performance indicators that are
reported to the governing body and key stakeholders.
Guiding measures:
8.1. Executive management develops and implements a uniform process
to monitor and evaluate at least once a year, the quality
improvement and patient safety plans.
8.2. Executive management approves and monitors the implementation
of a systematic process of identifying and analyzing actual or
potential risks and safety issues.
8.3. The hospital has a dashboard that identifies and prioritizes the key
performance areas and indicators to be measured.
8.4. The executive management reports twice a year to the governing
body on the results of the patient safety and quality improvement
programs including approved key performance indicators.
8.5. Hospital executive management members are trained on
continuous quality improvement programs.
8.6. The executive management, after the approval of the governing
board, communicates to stakeholders the essential key
performance indicators related to quality management and patient
safety, when required.
GL 9. Resource allocation and purchasing decisions support quality of care
and safety in the hospital and are aligned with the strategic plan.
Inefficient allocation and purchasing of resources pertain significant
5 unnecessary cost on the hospital, especially where resources are
scarce. Therefore, an allocation and purchase of resources based on
need should support the hospital in providing high-quality care. This
can be achieved by aligning each objective in the strategic plan with

20
 specific resource needs. Resources include human resources, capital
resources, and financial resources.
The purchase of new technology needs to undergo a process that
secures the quality and safety of the technology, such as a pilot testing
phase and calibration.
It is critical that all suppliers are evaluated to ensure that the supplies
that are purchased abide by the quality and safety needs.
Guiding measures:
9.1. The resource allocation and infrastructure needed to achieve the
goals and objectives of the strategic plan are included in the
operational plan.
9.2. Executive management establishes a process to monitor and
evaluate purchases including new technologies taking into
consideration quality and safety requirements.
9.3. Executive management identifies critical resources and prepares
plans to monitor their availability and safe use.
9.4. There is a process of evaluating suppliers based on hospital policies.
GL 10. The hospital has medical committees that are chaired by the medical
staff director. [HC-22]
The committees provide a platform for members to indulge in group
problem solving and decision making for better quality of care. The
medical committees should have a crucial role in decision-making and
reviewing and supervising the processes in the hospital.
The members of the committees should be selected to ensure a
5
balanced and multidisciplinary team.
The terms of reference includes but not limited to the purpose of the
committee, the functions, the structure and working methods
including reporting structure, meeting frequency, chair and committee
members names, roles and responsibilities of the members, policies
that may apply, obligations, date of assignment, date of committee
members’ reassignment and process review, etc..
Guiding measures:
10.1. The hospital has the following, but not limited to, medical
committees including the head of departments:
10.1.1. Mortality and morbidity committee
10.1.2. Medical review committee
10.1.3. Medical Record Committee
10.1.4. Credentialing Committee
10.1.5. Occupational health and safety committee
10.2. Terms of reference of the medical committees are delineated and
documented.

21
 GL 11. Hospital executive management approves and ensures the monitoring
of human-based research in the hospital, when applicable.
Any research proposal that will include human subjects at the hospital
should be reviewed by a research review board prior to
implementation at the center.
4 Securing patient confidentiality, privacy, safety, and well-being are
critical aspects that the hospital needs to respect when it comes to
human-based research.
Review boards aim to protect the rights and privacy of human subjects
recruited for a research study by ensuring that ethical principles are
followed.
Guiding measures:
11.1. Hospital executive management identifies responsible entities (i.e.
Institutional Review Board) that review and monitor the compliance
of human-based research with bylaws, policies and procedures.
11.2. There is a delineated process to identify unfavorable incidents from
trial and research.
11.3. Hospital executive management ensures the protection of patients
from adverse events resulting from approved research.
11.4. Evidence of continuous patient safety and care after adverse
events from research or trials.
11.5. Outcomes from clinical trials and research are continuously
evaluated and proper measures are implemented.
GL 12. Hospital executive management manages clinical and non-clinical
contracts.
Clinical and non-clinical contracts entail all services at the hospital that
include but not limited to medical services, administrative services,
sterilization, outpatient care, laundry, housekeeping, pest control, and
waste management.
Hospital executive management should list all clinical and non-clinical
services needing contracts and identify the scope of service
accordingly.
4
Documented policies and procedure should support the hospital
executive management and department/unit/service heads/managers
in reviewing, selecting and monitoring the contracts. Monitoring of
contracts can be assigned to department/unit/service heads/managers
with clear reporting and communication pathway with the hospital
executive management.
The hospital needs to ensure that if any contract is revised or
renegotiated, the safety of the patient is not affected, and the same
quality of care is maintained.
Guiding measures:
12.1. Hospital executive management, in collaboration with
department/unit/service heads/managers, follows specific policies
and procedures in reviewing, selecting and monitoring clinical and
non-clinical contracts.

22
 12.2. Patient safety is maintained when contracts are renegotiated or
changed.
12.3. Hospital executive management has a process in place to evaluate
clinical and nonclinical contracts (including renting of outpatient
clinics).
GL 13. Departments/units/services are managed by qualified heads/managers
with delineated roles and responsibilities.
Departments/units/services managers/heads have a vital role in
leading their development and enhancement to provide high-quality
tailor services.
Qualified heads and managers should guide the
5
department/unit/service to serve their purpose to the best possible
extent.
The hospital should identify the education qualifications, skills and
training of heads and managers to be able to fulfill their roles and
responsibilities. And also evaluate them based on a pre-identified
criterion.
Guiding measures:
13.1. The department/unit/service heads are identified by name and
department/unit/service.
13.2. Qualification, training, education and experience of the
department/unit/service head match the position description.

13.3. The roles and responsibilities of department/unit/service

heads/managers are specific and documented in a job description.
13.4. Department/unit/service heads’ performance is evaluated every
two years.
GL 14. Department/unit/service leaders participate in quality and patient
safety programs and/or plans.
The commitment of leaders to quality improvement and patient safety
is critical when it comes to the implementation of initiatives and
activities.
4 There is a need to prioritize quality and patient safety activities within
each area and raise those priorities to the executive management.
Those should be then be integrated within the hospital-wide quality
and patient safety plans and programs which should be monitored and
evaluated based on a pre-identified criterion at the departmental level
and reported to the executive management.
Guiding measures:
14.1. Improvement needs are assessed, prioritized and properly
coordinated based on a participatory approach.

14.2. Department/unit/service leaders implement, monitor and evaluate

the implementation of patient safety programs and/or plans at the
departmental/unit/service level.

23
 GL 15. Governing body approves and monitors the overarching ethical
framework.
As the hospital is a high-risk area with a possibility that hospital staff,
4 providers, patients, and families might face ethical issues, the
Governing body should constitute and monitor an ethical framework
that supports a culture of ethical practice and provides overall
guidance for staff and providers in case of any arising conflict/concern.
Guiding measures:
15.1 The hospital has a multidisciplinary committee with a delineated
term of references that address clinical ethical conflicts and
concerns.
15.2 The ethics framework implemented, monitored, evaluated and
documented.
15.3 The committee supports departments/units/services in the
implementation of ethics and ethical conduct activities.
GL 16. The hospital has an ethics framework that defines processes to address
clinical ethical conflicts and concerns.
The ethical framework is a critical component to ensure a culture of
3 ethical in the hospital. The processes that guide the implementation of
the framework should include the management of ethical concerns,
conflict of interest, disclosure of ownership and scope of services and
billing and finances of hospital services.
Guiding measures:
16.1. The ethics framework provides guidance in identifying and
managing ethical concerns.
16.2. The ethics framework requires the disclosure of the hospital’s
conflict of interest and ownership and the scope of services.
16.3. The ethics framework includes a process by which staff can report
on ethical concerns without compromising their career.
16.4. Hospital billing services are properly controlled and audited against
services provided.
16.5. Evidence on timely responsiveness of ethical concerns.
GL 17. Community healthcare needs assessment is used in developing
corresponding services.
The hospital should assess the Community healthcare needs in order to
be able to reflect them in the strategic plan and develop it scope of
4
services.
This allows provide guidance and tackle high priority needs in the
community and also identify partners and stakeholders to properly
deliver healthcare services.
Guiding measures:

24
17.1. Community healthcare needs assessment is done in collaboration
with the community leaders and stakeholders and documented.
17.2. The community needs assessment report is used to plan the scope
of services and strategic plan of the organization.
17.3. Community needs assessment is shared with the governing body
and relevant internal and external stakeholders.
17.4. Hospital executive management members identify partnerships
with community leaders, organizations and primary healthcare
centers, when applicable, to adequately deliver and coordinate
healthcare services.

25
Human Capital (HC)
Introduction
The Human Capital chapter focuses on developing the capacity of human
resources (clinical and non-clinical staff), including the knowledge, skills and
motivation of the individuals responsible for delivering health services in order
to provide safe and high-quality services. The standards are aimed at providing
safe and effective patient care taking into consideration the hospital’s strategic
human resources plan. The chapter addresses all care issues including patient
access and receiving care, transfers and discharge from the facility. This chapter
ensures that the care is provided in a coordinated and multidisciplinary
approach.
The Human Capital chapter targets the following sections:
 Hospital strategic human resources plan
 Staff satisfaction and retention
 Occupational health and safety program
 Work-life balance
 Staff education, skills and knowledge

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

26
Standards

Risk score Standard and Guiding measures

HC 1. The hospital has a human resources plan.

A human resources plan supports the identification of the current
human resource (HR) situation in a hospital and future should be based
on projected expansions (bed capacity, departments, services…).
Human resources planning have to follow the administration’s future
strategies for expansion by identifying HR needs, recruitment,
development, allocation, and utilization of human resources in an
5
organization. All aspects of employment from start to finish have to be
clear, standardized and fair to ensure a safe, productive and attractive
working environment while ensuring that the right type of personnel
for the right job at the right time.
The human resources plan should be revised on an annual basis or
upon any major planned or unplanned circumstances (mass exodus,
national economic crisis…)
Guiding measures:
1.1 A human resources plan is developed and documented.
1.2 The human resources plan includes the overall number and type of
human capital needed to meet the needs of the patients.
1.3 The human resources plan includes but not limited to:
1.3.1 A uniform process for recruitment of employees
1.3.2 A uniform process for evaluating employees.
1.3.3 A uniform process for reappointing employees
1.3.4 Strategy for staff retention
1.3.5 Employee orientation
1.3.6 Pre-employment medical examination procedure
1.3.7 Grievance procedures
1.3.8 Termination procedures
1.3.9 Remuneration scales
1.3.10 Policy for confidentiality (commercial, patient and staff
specific)
1.3.11 A policy for department acuity
1.3.12 A policy for unexpected staff events
1.3.13 Staff negligence and malpractice
1.4 Evidence of annual evaluation and revision of the human resources
plan
HC 2. Department/service/unit leaders develop and document a staffing
plan.
3
Similar to how the hospital has an institution-wide staffing plan; each
unit/department/service must develop a plan to asses and identify its

27
 current and future staff needs in a systematic way, which is regularly
revised according to needs and demands.
As such a staffing plan answers the following questions, what are the
services provided? How many people are needed to provide the services?
What are the skills and qualifications needed to provide the services
effectively?
The aim of having such plans, being developed and regularly updated is
ensuring all services are providing efficient, effective, high quality care
focused on patient safety and satisfaction.
Guiding measures:
2.1 Each department/services/unit has a documented staffing plan.
2.2 The staffing plan contains:
2.2.1 Number of staff needed
2.2.2 Type of staff needed
2.2.3 Qualification of staff
2.3 Evidence of annual evaluation and revision of the staffing plan.
HC 3. Hospital department /service/unit leaders delineate and document
staff qualifications.
All staff members’ qualifications (education, knowledge and skills...)
should at first align with the documented requirements in the
4 respective job description for each position and second, be kept in the
unit/department/ service records.
The number of staff in each unit must follow the predefined staffing
plan and their required qualifications should follow the hospital’s
overall mission, bed capacity and each service’s patient volume
Guiding measures:
3.1 Staff qualifications (i.e. education, knowledge and skills) are defined
and documented.
3.2 Staff qualifications and number align with the hospital’s mission
and patient volume.
HC 4. All staff members (clinical and non-clinical including medical staff
members) have a delineated job description and contracts.
Job descriptions provide staff, managers and leaders with a clear
understanding of the scope of work and responsibilities that each staff
member (clinical and non-clinical including medical staff members)
should undertake. Job descriptions also have a critical role to
standardize staff evaluations based on the pre-designated job
description allowing more accurate performance assessment whether
5
for improvements or career advancement.
All staff members including (part-time, full time, temporary and/or
voluntary) have an up-to-date job description that includes the job brief,
responsibilities/duties and required skills and qualifications. All job
descriptions are signed and revised every 3 years.
The hospital delineates the privileges of all independent healthcare
providers based on their qualifications and job descriptions. All
employees of medical and non-medical fields must sign on their job

28
 description accepting responsibilities for their expected roles, services,
limitations and responsibilities.
Guiding measures:
4.1 All staff members including (part-time, full time, temporary and/or
voluntary) have job descriptions
4.2 Staff required education level, experience, language/literacy, lines
of reporting, roles and responsibilities are delineated in the job
description.
4.3 Individual healthcare providers who can practice independently
have delineated privileges.
4.4 The job description is signed and documented in the staff members’
personnel file.
4.5 Evidence of job description revision at least every 3 years.
HC 5. The hospital has a standardized process to ensure the competency of
clinical staff (those who provide direct patient care i.e. nursing,
paramedical staff), excluding independent healthcare providers that
can practice without supervision, and nonclinical staff (support staff
who provide indirect patient care i.e. administrators, food services).
It is critical to ensure that the staff qualifications and competences
align with the position, job requirements and responsibilities. A
standardized process is utilized by the senior staff leaders starting from
5
pre-employment and throughout the 3 months’ probation period
allows the staff to implement their skills while being evaluated and
supervised by the hospital. Yearly staff evaluations are important in 2
folds. First, is to assess any deficiencies in training and competences
and subsequently directed to the required training courses. Second, is
identifying high performing staff members who would be ideal for
hierarchy progression. These yearly evaluations are kept in the workers
employee file.
Guiding measures:
5.1 The hospital has a uniform process to align clinical and nonclinical
staff qualifications with the position.
5.2 Evidence of initial clinical and nonclinical staff qualification
evaluation performed by department/service/unit leaders during
the 3 month probation period.
5.3 Evidence of at least yearly clinical and nonclinical staff evaluation of
each staff member.
5.4 Evaluations of clinical and nonclinical staff are kept in the personnel
file.
5.5 Defined operational mechanism and management structure is in
place to provide medical education in the hospital.
HC 6. Each staff member has personnel file.
Personnel files provide the hospital with a structured and systematic
5 approach to standardize and store staff related information (CV,
qualifications, job description…). Such organized, easy to access data
allows the administration to quickly allocate personnel in case of need,

29
 manage staff assessments, development and competences to maintain
and improve a high-quality care.
Guiding measures:
6.1 The personnel file is uniform amongst all staff.
6.2 The personnel file contains the following, but not limited to:
6.2.1 Staff qualification
6.2.2 Full curriculum vitae
6.2.3 Signed Job description
6.2.4 Working history
6.2.5 Performance appraisal
6.2.6 Orientation, continuing education, and training records.
6.2.7 Disciplinary actions
6.2.8 Attendance documentation
6.2.9 Confirmation of recruitment/appointment
6.2.10 Contractual agreement
6.2.11 Confidentiality agreement
HC 7. All new employees (clinical and nonclinical) and healthcare
professionals undergo an orientation phase.
The staff orientation phase is essential for any new employee in all
fields of work in a hospital. It helps a smooth and safe initiation into
the workplace helping achieve more retention of new graduates while
increasing clinical leadership skills in more senior staff members and
overall staff satisfaction.
The orientation phase ensures that the staff are aware of the general
4 policies and procedures, especially emergency procedures (that may
occur at any point in time) for all workers (including infection control,
emergency preparedness, fire drill etc.), ethical framework, and their
roles and responsibilities. Clinical and non-clinical workers should
undergo unit/department/service specific orientations related to each
worker’s definite job description.
The hospital needs to indicate within its policies the specific orientation
period that each clinical, nonclinical and contract workers will undergo
and has to be part of the employee file.
Guiding measure:
7.1 The orientation phase for clinical, nonclinical and contract workers,
covers the general hospital, the department/services/unit and their
roles and responsibilities
7.2 The orientation phase for volunteers, students and trainees, covers
the general hospital and roles and responsibilities.
7.3 The orientation is signed and documented in the clinical and
nonclinical new employee’s personnel file.
HC 8. Staff satisfaction surveys are conducted
There is a link between staff satisfaction and patient satisfaction,
4
retention of staff, better quality of care and higher staff productivity.
Therefore, conducting staff satisfaction surveys is critical to ensure that

30
 processes at the hospital are modified to ensure staff are satisfied and
thus retained. These surveys should follow a preset time interval
(yearly or shorter in high stress units) and may include sections on the
work itself, job reward, hospital management, work condition,
practicing environment. Their data aid in highlighting areas for
improvement and help the administration implement the required
changes.
Documented evidence of improvement based on staff satisfaction is
needed.
Guiding measures:
8.1 Evidence of yearly staff satisfaction survey conduction.
8.2 Results of staff satisfaction surveys are analyzed and improvements
are documented and implemented accordingly.
HC 9. Designated staff requiring training on resuscitation is delineated in
hospital policies and procedures.
High-quality resuscitation is vital for the survival of the patient.
Adequate training on resuscitation practices critically affects the
quality of resuscitation practices and the outcome on the patient. The
hospital determines which certifications must be attained by all clinical
staff to satisfy the risks and needs of the patient population and unit
6
(i.e. all healthcare professionals should be able to recognize cardiac
arrest and be certified in BLS).The staff that are designated to be
trained on resuscitation, are identified in the hospital policies and if
required, trained in more advanced resuscitative certifications based
on their specific area of work (pediatric vs. adult, ATLS or ACLS …).
These certifications must be, renewed to ensure staff competency and
knowledge is up to date and be in staff member’s employee files.
Guiding measures:
9.1 There is a policy identifying the staff that should attain resuscitative
certifications and/or training and level of certification/training (i.e.
Basic cardiac life support, advanced cardiac life support in adult,
COR
pediatric, neonatal).
9.2 The resuscitative certifications and/or training are valid and
renewed accordingly.
9.3 Certifications and/or training are placed in personnel files.
HC 10. Occupational health and safety program is developed and
implemented.
If patient safety is a pillar of healthcare, occupational safety for
healthcare workers should not be any less important. The hospital
needs to develop occupational health and safety policies and
6 procedures, educate and train all staff achieving not only a higher
quality of clinical care but also improving staff experience, safety and
productivity. These policies are developed by a multidisciplinary
committee, based on local laws/regulations and international
guidelines (for e.g. OSHA, CDC, ILO etc.), encompassing members from
all aspects of healthcare (medical, nursing, safety, infection control,

31
 quality…), the hospital’s administration (senior management, human
resources…), and engineering (biomedical, infrastructure…).
Occupational health starts upon employment, by a full assessment by a
member of the medical team (i.e. hospital employee’s physician) to
assess the medical needs of the new employee and getting all
immunizations up to date, this data is kept in the employee’s file, with
set calendar dates for checkups and future immunization tests and
boosters as per evidence based guidelines. The hospital staff are
exposed to various and sometimes life-threatening hazards (physical,
chemical, biological, psychosocial, ergonomic, and infrastructural…)
during their presence in the work environment or while performing a
certain task, depending on the service provided and the unit they are
members of. The committee ensures that all potentially harmful
situations or actions that could endanger the staff’s physical and
mental health are managed by policies and procedures (from a simple
needle capping procedure training to equipment malfunction and
nuclear/radiation exposure…).
These policies, procedures should be evaluated regularly or when an
issue arises by a set of indicators, identified by the committee to
monitor the efficacy of the program in general or a specific
action/environment targeting a high level of health and safety of staff.
These indicators are checked at least on yearly basis and used to
update or amend any part of the occupational health and safety
program.
Guiding measures:
10.1 The hospital has an occupational health and safety program that is
managed by an occupational health and safety officer/coordinator
and coordinated with quality management and patient safety
program, risk management program, infection control program,
medical administration and human resources.
10.2 The hospital has a multidisciplinary occupational health and safety
committee.
10.3 The occupational health and safety program includes but is not
limited to:
COR 10.3.1 Pre-employment medical examination
10.3.2 Immunization program with evidence of results recorded
10.4 Policies and procedures exist for at least the following:
10.4.1 Manual handling
10.4.2 No recapping of needles
10.4.3 Documented process for completing accidents and incident
forms
10.4.4 Precautions during pregnancy
10.4.5 Guidelines on risk management in the event of e.g.:
equipment failure, unsafe electrical appliances.

32
 10.4.6 Appropriate indications for barrier equipment (e.g. gowns,
gloves, masks, eye protection)
10.4.7 Blood exposure
10.4.8 Spills management (e.g. chemicals, blood)
10.4.9 Employee illness
10.4.10 Radiation safety
10.5 Evidence of continuous monitoring of occupational health-related
indicators.
10.6 Evidence of yearly evaluation and revision of the occupational
health and safety program based on the indicators.
HC 11. There is evidence of accident and incident reporting and a resolution
procedure that includes:
Reporting on accidents and incidents is a vital step to ensure that the
same accident or incident is not repeated, if done properly. The hospital
needs to have a just and systematic accident and incident reporting
system (As part of the hospital’s risk management/quality improvement
program) that aims to objectively assess the reports and implement
corrective procedures at the individual and system level in order to
5
provide the best possible care.
The first step, after establishing the accident and incident reporting and
resolution procedure, is to raise the awareness of the staff to the
availability of the procedure and train the staff to utilize the reporting
system. The hospital needs to develop a decision tree/procedure that
supports the hospital in taking systematic and objective decisions once
an incident or accident is reported.
Documented evidence for improvements is required.
Guiding measures:
11.1 Type of accident/incident
11.2 Action provided for accident/incident
11.3 Evidence of Occupational Health & Safety data which includes:
11.3.1 Type of accident/incident
11.3.2 Cause of accident/incident
11.3.3 Time of day of accident/incident
11.3.4 Department where accident/incident occurred
11.3.5 Length of employment at the hospital ( if applicable)
11.3.6 Analysis of all of the above using an evident appropriate
tool.
11.4 Evidence of planned intervention to prevent reoccurrence
HC 12. The hospital ensures that all staff is safe from the radiation hazards.
[FMS-8]
Radiation can create potentially hazardous situations for both staff and
6
patients if not handled properly. The hospital needs to develop a
radiation safety policy that is approved, diffused, used as basis for
education and training before being implemented and later on audited.

33
 Several aspects of radiation safety should be well delineated within the
policy. Most important, is the occupational exposure limits to radiation
and maximum permissible occupational doses, ensuring protective
shielding (aprons, glass radiation shields…) and dosimeters for all
employees exposed to radiation. By policy, the dosimeters should be
tested on regular basis, and according to results decisions to maintain
safety of employees.
Another important aspect of the radiation policy is safeguarding
radioactive and nuclear materials, labeling and handling requirements,
area and room positioning, and radioactive packaging. The policy
should note the staff that is allowed to handle nuclear and radioactive,
and are well trained and educated on safe practices.
Guiding measures:
12.1 A radiation safety policy is developed and implemented.
12.2 Radio-active materials are properly labeled, and safely and securely
stored and discarded.
12.3 Nuclear materials are handled safely by qualified staff as per
hospital’s policies and procedures.
COR
12.4 The availability of lead aprons and gonad/thyroid shields to cover
patients and staff needs is ensured at all times.
12.5 Testing of the personal radiation dosimeters is conducted every 3
months, results are evaluated and actions are taken when test
results exceed permissible levels.
12.6 Training on radiation hazards is documented
HC 13. Patients and staff are protected from unnecessary laser beams
exposure, when applicable. [FMS-9]
Laser beams can be used for many medical purposes such as kidney
stone removal, removal of tumors, eye surgery etc. However, if the
laser is not properly maintained, monitored, and operated, it can lead
5
to serious injury at the level of the patient and the provider. Therefore,
the need for the availability of safety equipment, warning signs and
safe environmental measures for laser utilization. It is important to
train the staff in contact with laser beams on the safety measures for
the utilization of laser
Guiding measures:
13.1 Staff is provided with protective eye goggles.
13.2 Warning signs are available in areas where laser is used.
13.3 Rooms, where the laser procedures are performed, is free from
refractive surfaces as per hospital’s policies and procedures and/or
manufacturers’ recommendations.
HC 14. Staff (clinical and non-clinical) is educated, trained and evaluated for
their role in attaining a safe and effective patient care facility. [FMS-25]
Staff education on safe and effective patient care facility is critical when
5
it comes to ensuring that the facility services are maintained and
supportive of patient safety. On an annual basis all staff are trained on
hospital-wide general facility procedures, or specific, department-based

34
 procedures that are required to be known, especially in case of
emergencies; such as fire response, medical gases and hazardous
materials, wastes disposal and medical technology/utility systems
operation. The training needs to be documented in the staff personnel
file and competency testing performed to ensure that the staff have
attained the objectives of the training and are able to respond and act
appropriately
Guiding measures:
14.1 Education is provided annually on comprehensive facility
management and safety programs.
14.2 The staff’s knowledge about their roles in different facility
management and safety programs is tested.
14.2.1 Staff demonstrates/describe their role in response to fire,
actions taken to eliminate or minimize fire and properly
report.
14.2.2 Staff demonstrates/describe their role in disposing medical
gases and hazardous materials and wastes.
14.2.3 Staff is trained to operate medical technology/utility
systems
14.3 Testing, results of the competency testing, and training are properly
documented.
HC 15. Violence prevention plan is implemented, evaluated and integrated into
the occupational health and safety program. [OTHER-17]
The National Institute for Occupational Safety and Health (NIOSH)
defines workplace violence as “violent acts (including physical assaults
and threats of assaults) directed toward persons at work or on duty”. A
comprehensive violence prevention plan includes the following,
management commitment and employee participation [i.e. members
5 involved in the development of the plan, regularity of meetings etc.],
worksite analysis and violence hazard identification, workplace violence
hazard prevention and control, violence safety and training and
recordkeeping and program evaluation.
In case of occurrence of violence, the hospital needs to have policies
and procedures to support the process of reporting and management
including the availability of resources to aid staff that were affected by
the violence.
Guiding measures:
15.1 The hospital develops, implements and documents a violence
prevention plan.
15.2 Evidence of proactive assessment of areas with possible workplace
violence and develops plans accordingly.
15.3 The hospital implements a Zero-tolerance policy for forms of
violence or aggressive behavior whether verbal, physical, or sexual.
15.4 Support resources are available for staff enduring work violence.

35
 HC 16. Staff is regularly educated and trained on techniques to prevent and
respond to violent and/or aggressive patient and family acts. [OTHER-
18]
In addition to the importance of establishing violence prevention plans,
any occurrence of violence towards health care workers by a patient
5 and/or family member can lead to a myriad of minor to serious physical
and psychological effects. All such acts must be reported and
documented. All Health care workers, but especially ones in high risk
units (emergency rooms, psychiatric wards…) must be educated and
trained, not only in prevention, but also in the early identification,
management and resolution of these violent acts.
Guiding measures:
16.1 There is a policy and process to report violent and/or aggressive
patient and family acts.
16.2 Staff is regularly educated and trained on techniques to prevent
and manage violent and/or aggressive patient and family acts.
16.3 Violent and/or aggressive patient and family acts are documented.
HC 17. The hospital ensures a work-life balance of its staff.
Healthcare professionals’ burnout is a serious condition affecting all
levels of medical and non-medical workers and has been shown to
affect the quality and safety of care delivered. A main cause of
burnout is a disturbance in work-life balance affecting healthcare
4
workers at the physical, psychological and behavioral level. The
hospital needs policies and staff education encouraging staff
satisfaction, workload fairness, staff voicing complaints, occupational
health and safety, sources of pressure, coping and interpersonal
support.
Guiding measures:
17.1 The workload is assigned, divided and reviewed in a way to ensure
patient and staff safety.
17.2 A policy is in place to guide staff member to express concerns and
complaints.
17.3 Evidence of staff education and training related to occupational
health and safety and hospital’s policies regarding workplace safety.
HC 18. Staff education, skills and knowledge are defined and supported by the
hospital executive management.
Continuous education should be key when it comes to maintaining and
improving patient services. Commitment from the hospital executive
management is critical to maintain continuous education by supporting
5 it through planning, budgeting and encouragement of staff to indwell in
the training and education.
This comes in line with the hospital’s mission, quality improvement plan
and other measures implemented at the hospital. Education sessions
can be provided in an individual or group format, and can be at
scheduled time intervals or upon any updates/policy changes.

36
 The educational program is revised and updated on a yearly basis and
staff attendance is documented in personnel files.
Guiding measures:
18.1 There is a policy for providing continuous education to staff
18.2 Staff educational planning depends on the hospital’s mission,
services, medical technology and volume and mix of patients.
18.3 The hospital ensures proper education on quality improvement
processes related to quality and patient safety.
18.4 Staff attendance to educational activities is documented in the
personnel file.
18.5 The educational program is revised and updated on a yearly basis.
HC 19. The maintenance/advancement of the staff’s knowledge and skills is
ensured via ongoing in-service education and training.
Based on each department/unit/service’s data from previous or
ongoing quality and safety improvement plans/incidents, targeted
educational and training programs are set up as an essential part for
reaching set goals in high level, quality patient care and safety. These
5 training programs established by each department and revised yearly,
can be done in house or utilizing out of hospital resources or training
centers (i.e. simulation centers…). Staff need to have a structured
yearly training program with a set number of hours needed (e.g. 30 hrs.
for nursing). They must have the necessary time and resources to
attend such courses and their attendance recorded and kept in their
employment files.
Guiding measures:
19.1 The hospital ensures the proper utilization of data and information
resources including the results of quality and safety measures
guides the staff education and training program
19.2 Each department conducts an annual assessment of the continuing
education requirements of staff
19.3 The staff has time and resources to be involved in education and
training opportunities.
19.4 Staff attendance to educational activities is documented in the
personnel file.
19.5 The educational program is revised and updated annually.
19.6 Agreement with external educational institutions with clear
responsibilities of each party is documented.
19.7 Structured nursing education program allocates a minimum of 30
hours annually, per nurse.
HC 20. The organization ensures that the management and the staff receive
proper education related to Information Management and use.
Key personnel in both higher management and leaders of each
5 department/unit receive data from several sources (quality
improvement plans, quality indicators, audits both internal and
external, financial revenue…) concerning the functioning of every
department as a unit or the hospital as a whole. This data and

37
 information are key tools to improve the services provided to the
patients. Staff and management need to be trained on the means to
integrate the data and information in improving the services and basing
their decisions on evidence. Staff needing training and education on
information management utilization is delineated. All education
provided is documented in personnel files.
Guiding measures
20.1 Education sessions and training are provided to the relevant
decision-makers and staff.
20.2 The education is consistent with the roles and responsibilities of the
staff.
20.3 Evidence that education related to process improvements using
indicators, data collection and analysis, decision making based on
data and information, and data privacy and confidentiality is given
to the relevant staff.
HC 21. Organization, function and responsibilities of medical staff are defined
and documented.
Medical staff is an essential element of the hospital body which includes
physicians, dentists and professions licensed to practice independently
without supervision. The medical director provides guidance and
leadership to the medical staff at the hospital, in addition to overseeing
5 and defining the function and responsibilities of the medical staff. The
hospital assigns a medical director that is qualified by education and
training for this position. The medical director works within a
delineated and documented job description, describing the role and
responsibilities among which is implementing the hospital’s bylaws
with the help of the others heads of departments, divisions and services

Guiding measures:
21.1 Medical staff organization, functions and responsibilities are
defined and documented in bylaws.
21.2 A qualified medical staff director manages the hospital medical
staff.
21.3 The medical staff director has a delineated and documented job
description.
21.4 The medical staff director and heads of medical department ensure
the implementation of the medical staff bylaws.
HC 22. The hospital has medical committees that are chaired by the medical
staff director or as delegated. [GL-10]
Committees are the operating structures of the hospital. Among the
responsibilities of the medical staff director is ensuring the
5
establishment of the different medical committees of which some are
obligatory and others essential to help in the decision-making,
reviewing and supervising the programs/plans/processes in the
hospital. The members of each committee are carefully selected to

38
 ensure a balanced and multidisciplinary team with complimentary
qualifications in relation to the purpose of each committee. The terms
of reference for each committee includes but not limited to, the
purpose of the committee, the functions, the structure and working
methods including reporting structure, meeting frequency, chair and
committee members names, roles and responsibilities of the members,
policies that may apply, obligations, date of assignment, date of
committee members’ reassignment and process review.
Guiding measures
22.1. The hospital has the following, but not limited to, medical
committees including the head of departments:
22.1.1. Mortality and morbidity committee
22.1.2. Medical review committee
22.1.3. Medical Record Committee
22.1.4. Credentialing Committee
22.1.5. Occupational health and safety committee
22.2. Terms of reference of the medical committees are delineated and
documented.
HC 23. A standardized process for medical staff (i.e. all physicians, dentists and
professions licensed to practice independently without supervision)
credentialing is delineated.
Employing qualified staff is vital to provide high quality, safe care.
While this is crucial, it is critical to validate the competency of
6 healthcare providers via standardized process/procedure. Credentialing
is the process of verifying qualifications to ensure current competence
to grant privileges.
The term credentialing should involve verification of education,
training, experience, and licensure to provide services prior to the
employment or appointment of the medical staff.
Guiding measures:
23.1 There is a standardized process to manage medical staff
credentialing.

23.2 Medical staff allowed by laws and regulations to work

independently are listed.
COR
23.3 Qualifications (i.e. education, licensure, registration) and
credentials mandated by the law and the hospital are verified from
the original source and kept in the medical staff’s file (with
reference from the ministry of health and the Lebanese order of
physicians).

HC 24. There is a process to appoint medical staff.

The hospital has a process to appoint medical staff which includes
5
reviewing the credentials and attaining approval from the governing
body. The process must be in line with the hospital’s bylaws and

39
 nation’s regulations (delineating the required credentials, privileges)
and documented for all medical staff appointments. Unsupervised care
is only allowed for fully credentialed medical staff. Meanwhile,
supervised care is allowed under strict privileges limitations and
documented method and frequency of supervision.
Guiding measures:
24.1 Medical staff appointment is suggested by the credentialing
committee and approved by the governing body.
24.2 Medical staff appointment is in line with laws and regulations.
24.3 Medical staff can only provide unsupervised care if all credentials
are verified, otherwise, medical staff can provide supervised care
once licensure and/or registration have been verified.
24.4 Supervision method and frequency are documented in the
personnel file, as per applicable laws and regulations.
HC 25. Medical staff has defined clinical privileges (with the collaboration of the
Lebanese order of physicians).
The hospital must have strict policies about clinical privileges and
regulations of services as a manner of controlling the skill-set and
6 competencies of staff, to ensure safe delivery of care. All medical staff
working in a hospital are only allowed to provide care for which they
have clinical privileges. These privileges must be clearly described,
evaluated and updated for every medical staff on a regular basis. In
specific cases temporary privileges are given on emergency basis.
Guiding measures:
25.1 There is a policy and procedure to describe clinical privileges.
25.2 There is a policy to grant temporary or emergency privileges.
25.3 Medical staff provides services only within their hospital clinical
COR privilege.
25.4 Clinical privileges are regularly evaluated (at least every 3 years)
and updated.
25.5 Clinical privileges are provided for the medical staff and for any
regulated health professional.
HC 26. The performance of medical staff is continuously monitored and
evaluated.
To maintain clinical privileging, thus continuous provision of quality
care, every medical staff’s performance must be evaluated every 3
years (or as defined according to the requirements and complexity of
the service). The evaluation is based on pre-defined criteria and
6 process, several sources of information (satisfaction surveys,
complication/medical error rates, mortality/morbidity rates, amount of
continuous education etc.) done by multiple healthcare providers that
are in close collaboration with the medical staff. All decisions taken
based on these performance evaluations (extension of privileges,
withdrawal, request for further training, supervised provision of
service…) must be shared with the member of the medical staff,

40
 documented in the personnel file, and any decision on privileges shared
with all concerned.
Guiding measures:
26.1 There is an ongoing standardized process (i.e. using multisource
feedback) to evaluate the performance of medical staff.
26.2 The department/service/unit leaders in collaboration with the
COR
medical director evaluate periodically, at least every 3 years, the
performance of the medical staff.
26.3 Actions taken after performance evaluation are documented in the
personnel file.
HC 27. There is a process to reappoint and renew the medical staff’s privileges.
Reappointment and renewal of medical staff privileges process is
implemented to ensure that the credentials and qualifications of the
5 medical staff are still intact. This includes that all services provided by
the medical staff and performance evaluation reports are cleared by
privileging, the credentials of the staff remain valid, and the health of
the staff permits them to provide care.
Guiding measures:
27.1 Evidence that medical staff privileges are reassessed and renewed
at least every 3 years.
27.2 Evidence of medical staff reappointment and/or privilege renewal.
HC 28. A standardized process for allied healthcare workers (i.e. psychologist,
pharmacist, physiotherapist; excluding medical staff) credentialing is
delineated.
Similar to medical staff; allied healthcare workers, identified in hospital
policies, including psychologists, pharmacists, and physiotherapist must
be credentialed in a standardized process. For each of the allied
5 healthcare workers, a list of qualifications and credentials must be clear
and stated for any new employee. The validity and credibility of the
qualifications (diplomas, licensure, registrations…) must be checked
and verified from the issuing institution, to provide adequate safe care
avoiding any legal implications. The process should include verifications
of the validity of the required qualifications by law. Once verified these
documents are kept in the personnel file.
Guiding measures:
28.1 There is a standardized process to manage credentialing of allied
healthcare workers (i.e. psychologist, pharmacist, physiotherapist)
credentialing.
28.2 Qualifications (i.e. education, licensure, registration) and
credentials mandated by the law and the hospital are verified from
the original source for all staff members, including full time, part
time, visitor and locum, from the original source and kept in the
personnel file.
28.3 Qualifications and credentials are documented and kept in the
staff’s medical file.

41
Information Management (IM)
Introduction
The Information Management chapter relates to the practice of acquiring,
analyzing and protecting medical information vital to providing quality patient
care.
Information planning, handling and reporting requirements to ensure security,
integrity and usefulness of data elements and information are addressed as well
as the manpower and policies needed to for the management of patient medical
data/records and administrative documents.
The Information Management chapter targets the following sections:
 Privacy, confidentiality, security and integrity of information
 List of standardized diagnosis codes, procedure codes, and approved
symbols, abbreviations and definitions
 Health information system consistent with quality and patient safety
 Information in the medical records is comprehensive to facilitate the
continuity and coordination of care
 Medical records are centralized and completed in an organized manner
 Retention and release of medical records follow policies

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

42
Standards
Risk
Standard and Guiding measures
Score
IM 1. Internal and external needs assessment is performed while planning and
developing the health information system.
The development of a health information system should first assess
the current internal practices (including information need, flows,
reporting, etc.) within the hospital and then scale it up to external
factors/requirement that should be considered within the health
4
information system.
Internal and external needs assessment can be done formally through
meetings, or informally through issues/needs that are brought up to
management. The hospital needs to take into consideration any
requirements assigned by an external regulating body (i.e. Ministry of
Public Health…).
Guiding measures:
1.1 The hospital assesses the needs of the clinical and the managerial
services while planning and developing the processes.
1.2 External organization (Ministry of health, accrediting bodies, etc...)
requirements/needs are considered during the planning phase of the
information system.
IM 2. The hospital ensures privacy, confidentiality, security and integrity of
information.
To ensure a proper diagnosis and treatment, healthcare professionals
need to base their clinical decisions on information retrieved from the
patient.
For this reason reliability of information and its protection are key
5 elements in the patient-physician relationship as it guarantees patients’
privacy. Thus, only authorized staff should have access to the data and
information of the patient.
Moreover, the hospital should monitor any breach to confidentiality and
avoid any reoccurrence to this breach, and have a valid plan B for any loss
of information in case of disaster.

Guiding measures:
2.1 A written process that complies with applicable laws and regulations is
in place to protect the confidentiality, security, and integrity of data and
information.
2.2 Appropriate levels of security and confidentiality for data and
information with its corresponding measures are identified and
documented via a process.
2.3 Access to different categories of data and information is limited only to
the authorized staff.

43
 2.4 Monitoring compliance is ensured via a specified process by a delineated
safety coordinator.
2.4.1 Incidents related to breaching confidentiality are reported,
analyzed and actions are taken accordingly.
2.4.2 Measures to protect data and information in case of disasters are
tested, evaluated and improvements are made accordingly.
2.4.3 The hospital has a system to avoid redundancy
IM 3. The hospital abides by a list of standardized diagnosis and procedure
codes.
Standardized diagnosis and procedure are translated into codes that
are used in healthcare to group diseases and describe a patient’s
medical condition and the provided therapy.
Coding allows creating a uniform a standardized and common language
5
among healthcare providers.
The hospital should define the medical staff and committees that will
implement, adapt and approve the diagnosis and procedures codes in
line with the national standards.
Utilization of the codes should also be monitored to check for
compliance, deviation or non-compliance.
Guiding measures:
3.1 The medical staff and other organizational structures (medical review
committee and pharmacy and therapeutic committee) are involved in
developing and approving the list based on national standards.
3.2 The list of standardized diagnosis and procedure codes is reviewed
periodically by the medical staff executive committee.
3.3 The use of standardized diagnosis and procedure codes are monitored.
IM 4. The hospital abides by a list of standardized symbols, and definitions.
The use of standardized symbols and definitions should facilitate
communication of information.
The hospital should define the medical staff and committees that will
5
develop and approve the list of symbols and definitions in line with the
national standards.
Utilization of the symbols is monitored to check for compliance, deviation
or non-compliance and report them.
Guiding measures:
4.1 The medical staff and other organizational structures (medical review
committee and pharmacy and therapeutic committee) are involved in
developing and approving the list based on national standards.
4.2 The list of standardized symbols and definitions is monitored and
reviewed periodically by the medical staff executive committee.
4.3 The use of non-approved symbols and definitions is reported to the
medical staff executive committee and documented actions are
implemented.
IM 5. The hospital implements a health information system consistent with
4 quality and patient safety.

44
 The health information system should help enhancing the quality and
safety of the provided health care services as it works on integrating
data from various processes and services, increases adherence to
guidelines, improving surveillance, and decreasing medication errors.
The implementation of a health information system should be
previously planned and tested to ensure the process before its
implementation and further evaluated to identify strengths and areas
of improvement for the system regarding patient safety.
The health information system should also allow extraction of data to set
indicators of performance that could be defined either by the hospital or
required by national authorities (MoPH) to whom those indicators could
be reported.
Guiding measures:
5.1 The health information technology needs are anticipated while planning
for the information management processes.
5.2 Clinical and managerial staff, as well as the information technology
stakeholders’ opinions and concerns, are integrated into the process of
selecting and using the health information technology system.
5.3 The health information technology system is tested before being
implemented.
5.4 The organization evaluates the health information system based on
principles of effectiveness and ability to maintain patient safety.
5.5 The hospital creates and maintains through its information system, sets
of indicators on quality and patient safety, performance, utilization and
health status which are defined by and reported to the ministry of public
health when required.
IM 6. The operation of the management information system is maintained at
the period of expected and unexpected downtime.
With the increased reliance on the health information systems, a
downtime may have negative effect on the processes of care if the
hospital is not prepared to deal with it.
Thus, it should assess the risk of occurrence, the impact of downtime,
4 and consequently develop a plan for a backup process for
data/information
The staff should be trained to deal with the downtime to safeguard a
regular patient care processes ensuring that the patients’ information
and services are safe and not affected by the downtime.
The challenges and areas for improvement of this procedure should be
documented.
Guiding measures:
6.1 The organization has an implemented process for data and information
backup.
6.2 Hospital staff is informed and trained on the procedures and forms to be
filled during downtime period.
6.3 Patient’s information is documented during the downtime period.

45
 6.4 The downtime system is tested for its effectiveness, reports are
evaluated to identify the deficiencies and improvements are made
accordingly.
IM 7. The organization ensures adequate information is present in the medical
records to facilitate the continuity and coordination of care.
The medical record should contain all the relevant data of the patient’s
6 stay in line with the hospital’s policy.
This documentation starts with identification and should also include
diagnosis, treatment and major landmarks of the stay.
Filling should be done according to a standardized coding system.
Guiding measures:
7.1 The medical record contains information necessary to identify the
patient based on the patient identification policy.
7.2 Information relevant to the patient’s diagnosis is present in the medical
COR
record using standardized diagnosis codes when indicated.
7.3 Proper documentation is in place to justify the treatment, its course and
outcomes.

IM 8. The medical record for patients admitted to the emergency department

contains information related to the time of admission/discharge,
treatment course, and patient condition.
In case of an admission to the hospital through emergency department,
the medical record should contain all the relevant information room
5 concerning his stay.
Thus, should be documented with the time of admission, triage results,
treatment course, and recommendations for patient and healthcare
providers, patient condition upon transfer to another department,
discharge (when the patient is discharged) and follow up instruction and
recommendations.
Guiding measures:
8.1 Information related to the time of admission and the time of discharge is
in place.
8.2 Information related to triage results are documented.
8.3 The treatment course and the recommendations after its termination
are documented in the medical record.
8.4 Patient’s condition is mentioned upon discharge in the medical record.
8.5 Medical record upon discharge contains follow-up instructions.
IM 9. The hospital identifies those who are authorized to access and make
entries in the medical records.
The hospital should have a policy to regulate the authorization of
individuals to access a medical record.
4
The implementation of the policy should preview evidence of a proper
training of staff member on how to make an entry on a medical record.
The process should also preview identification of internal or external
(hacking) breaches and consequent corrective measures
Guiding measures:

46
 9.1 There is a policy in place to identify the authorized individuals who are
eligible to access the information and those who can make entries by an
official stamp (in the absence of stamp, the name should be written
clearly), written signature and initials, or by computer entry if present.
9.2 The author, date and time of each entry are identified.
9.3 There is evidence that the authorized individuals receive training on
proper documentation and order entries.
9.4 A process is in place specifying the proper correction of entries.
IM 10. Medical records are available in one central place and filed in an
organized manner.
The hospital should have a process to keep the medical records
available in an organized manner and easily accessible, at any time in
3
by only authorized persons.
The records should also contain inside of them sections for medical
notes and orders, nursing notes, parameters, laboratory, imagery,
procedures, surgical interventions, discharge summary, etc,,
Guiding measures:
10.1 There is a process to ensure that past and current medical records are
available and easily accessible by the authorized staff when needed at
any time
10.2 Medical records are organized into sections (for example, doctors’ order,
nursing notes, lab tests, etc...).
10.3 The sections and information inside sections are organized in a
chronological order.
IM 11. A discharge summary is present in the records of all discharged patients
Discharge summaries are critical in the continuity of care and
documentation of the patients’ stay at the hospital.
4
They should be filled in a manner that highlights the main diagnosis,
medical, any intervention or procedure as well as the patient’s
condition and instructions upon discharge.
Guiding measures:
11.1 The discharge summary contains: reason for admission, diagnoses,
course of treatment, medication list, list of implantable medical devices
used and their identification, name of responsible doctors, summary of
surgeries or procedures done, patient’s condition at the time of
discharge, medication to be taken at home and special considerations.
IM 12. Retention of medical records follows specific policy.
The hospital should abide by the laws and regulations and reflect
those laws within the hospital’s policies.
If laws and regulations on medical record retention do not exist, the
4 hospital should develop its own policy
The policy could include where the medical records will be retained,
the time frame to retain them, how they will be discarded, and
contingency plan if the medical records were lost or deteriorated
before the discarding timeframe.
Guiding measures:

47
 12.1 The retention of medical records abides by applicable laws and
regulations and based on hospital’s policies and procedures.
12.2 The information inside the medical record is discarded appropriately
when the retention period is complete.
12.3 A process for safe storage of medical records to protect from loss and
deterioration
IM 13. The release of medical records follows specific applicable laws and
hospital’s policies.
The hospital should abide by the laws and regulations on the release
of medical records and reflect those laws within the hospital’s
policies.
If laws and regulations on release of medical records do not exist, the
4
hospital should develop its own policy
The hospital’s policy should include the information that can be
released, the person responsible to approve the release and the
process to access to info and release it.
It is the hospital’s responsibility to ensure that the information is
released only to the properly authorized person.
Guiding measures:
13.1 The hospital has a process to release medical records for patient care
purposes (Inpatient, outpatient and Emergency department) as well as
for non-patient care purposes (e.g., research, utilization management,
quality improvement, morbidity and mortality, and governmental
requests).
13.2 The approval for the release of medical records for non-patient care
purposes is in place.
IM 14. Medical records are checked for its completeness.
The hospital should define policies and procedures to reviewing
medical records regularly, at least on a quarterly basis, by a
4 multidisciplinary team regarding the quality and consistency of filling
content.
The results of the review should also be shared and analyzed to decide
on corrective actions and improvement plans.
Guiding measures:
14.1 Medical records of the discharged and/or active patients are reviewed at
least quarterly or as per applicable laws and regulations and based on
hospital’s policies and procedures.
14.2 Reviewing of the medical records’ content is multidisciplinary involving
physicians, nurses and other authorized staff.
14.3 Medical Records are reviewed for their timeliness, legibility,
completeness and content as required by laws and regulations and
based on hospital’s policies and procedures.
14.4 The results of the checking process are analyzed and corrective actions
are taken accordingly.

48
Facility Management and Safety (FMS)
Introduction
The Facility Management and Safety chapter addresses the hospital and facility
structures, safety measures for staff, patients and resources as well as the
management plans and programs. Staff orientation and involvement in safety
planning, orientation and drills are specified. Leadership support and
commitment is highlighted as one of the key elements in the implementation of
the FMS chapter
The chapter also addresses Leadership and Planning, Safety and Security,
Hazardous Materials, Disaster Preparedness, Fire Safety Medical Technology,
Utility Systems, Facility Management Program Monitoring, and Staff Education.
The Facility Management and Safety chapter targets the following sections:
 Facility management and safety program(s) development
 Hospital plans and budgets for upgrading or replacing key systems,
buildings, or components.
 Program to ensure a safe physical facility through inspection and
planning
 Program to provide security for patients, families, staff and visitors.
 Radiation hazards safety
 Emergency management program to respond to emergencies,
epidemics, internal and external disasters, and bomb threats
 Fire and non-fire emergencies prevention, early detection, and
suppression
 Medical technology inspection, testing, and maintenance
 Staff attainment of safe and effective patient care facility
Each standard was supported by a corresponding set of guiding measures that
further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

49
Standards
Risk score Standard and Guiding measures
FMS 1. The hospital complies with laws and regulations regarding facility
management.
Hospital infrastructure and clinical operations byproducts and
wastes are subject to a number of nationally applicable laws and
5
regulations (e.g. on radiation safety, medical waste, oxygen
generators, fire safety) that should be known, implemented and
verified by the hospital’s facility management departments and the
executive management.
Guiding measures:
1.1 The executive management and the involved professionals know the
applicable laws and regulations and other requirements related to
hospital’s facility and hospital’s policies and procedure.
1.2 The applicable laws and regulations regarding facility management
are implemented by the hospital’s executive management.
FMS 2. Facility management and safety program(s) is (are) developed by
the hospital executive management.
The department(s) involved in Facility Management and Safety
(FMS) need to elaborate detailed programs relative to all areas of
5
FMS. These programs should describe the existing systems, as well
as their preventive maintenance plan and servicing, their risk
management plan with response to certain potential faults or
extreme cases that could arise.
Guiding measures:
2.1 The documented and the approved program(s) address(es),but not
limited to, the following areas:
2.1.1 Safety of the building
2.1.2 Security
2.1.3 Radiations
2.1.4 Hazardous materials
2.1.5 Fire safety
2.1.6 Medical technology
2.1.7 Utility systems
2.2 The program(s) is (are) up-to-date and fully implemented.
2.3 The program(s) involve(s) regular testing, inspection and
maintenance in all areas from (2.1.1) to (2.1.7).
2.4 The hospital has a process in place to update/upgrade the existing
program(s) at least annually or when necessary or replace it (them)
2.5 Policies, procedures and performance will be reviewed to identify
opportunities for improvement
2.6 The hospital executive management ensures the compliance of the
independent entities (when present) with the components of the
program(s) mentioned from (2.1.1) to (2.1.7).

50
 2.7 If one or more of the above mentioned program measures is (are)
outsourced, the qualification of the third party shall be carried out
in respect to contract/agreement in place showing responsibility of
parties
2.8 Requirements for programs dealing with extreme and urgent
situations are in place.
2.9 The hospital has a medical device ageing management plan to
monitor, service, and if necessary replace components to prevent
obsolete equipment.

FMS 3. A safety committee is in place to provide oversight of the facility

management and safety program.
Facility management and safety handles a complex environment
involving multiple departments and users from different disciplines.
3 Therefore, a multidisciplinary safety committee constituted from
the involved departments and user representatives should oversee
the FMS program, raise and discuss any concerns, report any
incidents/problems, as well as identify any risks or hazards in the
hospital infrastructure or equipment.
Guiding measures:
3.1 The safety committee is multidisciplinary involving representatives
from relevant departments such as safety, security, housekeeping,
infection control, risk management, biomedical engineering,
laboratory, medical staff (including staff from the emergency
department), nursing, radiation safety, maintenance, and quality
management.
3.2 The committee performs regular and as needed safety tours for
identifying risks and hazards related to the facility and evaluating
the staff knowledge, as per policies and procedures.
3.3 The results of the tour are evaluated and corrective and preventive
actions are taken accordingly.
FMS 4. One or more individuals oversee(s) facility management and safety
program(s) during its planning and implementation.
Depending on the hospital capacity and infrastructure, FMS can be
managed by one or more individuals, in one or more specialized
departments.
4
These individuals need to have the necessary technical background
and experience, in addition to management skills/experience, in
order to oversee and guide the application of the FMS program in its
different aspects (maintenance, risk management, education and
training, project management).
Guiding measures:
4.1 The individuals are qualified by education, training and experience.
4.2 Evidence of training and experience of the individual(s) is
documented.

51
 4.3 Planning and implementation of the program includes, but not
limited to, the following:
4.3.1 All aspects of the program, such as developing plans and
providing recommendations for space, technology, and
resources.
4.3.2 Implementing the program.
4.3.3 Educating staff and new orientees.
4.3.4 Testing and monitoring the program.
4.3.5 Periodically reviewing and revising the program.
4.3.6 Providing annual reports to the governing body on the
effectiveness of the program
FMS 5. The hospital plans and budgets for upgrading or replacing key
systems, buildings, or components based on facility inspection and
hospital’s policies and procedures to ensure safety and security of
the facility.
Systems maintenance (including replacement of obsolete or
dysfunctional systems or facilities) is key to ensure safe continuity of
5
operations and prevent disruptions and other risks (physical, safety,
and even legal risks) for the hospital staff, patients, visitors and
operations. Therefore, maintenance and replacement costs should
always be provisioned in yearly budget planning and in supplier or
outsourced contracts when maintenance cannot be entirely
provided internally.
Guiding measures:
5.1 The plan for budgeting meets applicable laws and regulation and
hospital’s policies and procedures.
5.2 Resources are provided by the hospital to ensure safety and
security.
FMS 6. The hospital plans and implements a program to ensure a safe
physical facility through inspection and planning.
Physical safety in the hospital facilities is one important aspect of
FMS and needs to be ensured by design and through regular
rounding from the responsible department/staff.
Important physical safety measures/systems include those
important for patient safety (nurse call system on bedside and in
patient toilets, bed barriers for patient fall prevention, absence of
5
elevated steps between room and toilet entrance, non-slippery
ground, distance of bed from toilets, appropriate lighting etc.),
personnel and visitor safety (stairs and corridor handles, proper
internal and external lighting, waiting rooms for patients and
families, etc.) and facility safety (surveillance cameras with
recording capacity installed in main areas of the hospital and in
parking, fire alarm system and components, emergency exits,
proper warning and directive signs, etc.)

52
 Patient areas of the hospitals should be accessible to vulnerable
individuals and individuals with special needs.

Guiding measures:
6.1 Current inspections of the hospital’s physical facilities are
documented by the responsible department/staff
6.2 The program includes assessing safety and security of patients and
staff during times of construction, renovation or demolition, and
implementing strategies to reduce risks in collaboration with the
infection prevention and control team.
6.3 The hospital designs the work area to ensure safety through the
following:
6.3.1 Natural surveillance through use of equipment and
attendance by safeguards to minimize/eliminate risks
related to the physical environment.
6.3.2 Continuous maintenance of grounds and
machines/equipment.
6.3.3 Installation of proper internal and external lighting.
6.3.4 Allocation of specific rest rooms for staff.
6.3.5 Ensuring a well-lit, safe, and a protected staff parking.
6.3.6 Proper establishment of waiting areas in terms of furniture
and placement of doorways.
6.4 Safety measures and equipment are available to ensure safety of
patients and staff
6.5 Special parking spots, wheel chairs, handrails in the corridors and
stairs are present to ensure safe hospital environment to the
vulnerable and individuals with special needs.
6.6 Warning and directive signs are present throughout the hospital to
ensure safety.
FMS 7. The hospital plans and implements a program to provide security for
patients, family caregivers, staff and visitors.
Security services are needed to ensure physical safety of personnel,
physicians, patients and visitors, through restricting access,
4 identifying and handling potential threats from individuals. They are
in charge to ensure that hospital accessibility policies (e.g. visiting
hours, number of patient visitors/accompaniment and related
conditions) are respected through their presence and regular
rounding in the hospital premises.
Guiding measures:
7.1 The hospital ensures a secure environment through monitoring and
inspecting security areas.
7.2 Staff and other individuals entering the hospital’s identified
restrictive areas are properly identified.
7.3 The security risk areas are identified, documented and continuously
monitored to prevent the access of the public.

53
 FMS 8. The hospital ensures that all staff is safe from the radiation hazards.
[HC-12]
Radiation safety concerns all hospitals equipped with X-Ray emitting
equipment (Conventional radiology equipment, CT-Scanners,
Interventional radiology equipment, etc.) and nuclear medicine
devices.
Exposure of personnel, visitors and patients to dangerous
radiation/radioactive levels can lead to carcinogenic effects, and
therefore all preventive measures (lead walls, lead aprons,
gonad/thyroid shields, dose minimization, etc.) should be applied
6
by the hospital in compliance with the national regulations on
radiation safety and recommendations of the Lebanese Atomic
Energy Commission.
Regular measurements of personal radiation dosimeter levels for all
concerned workers is important to quantify their exposure, and
radiation leak tests are important to perform during facility
radiation safety audits.
Training on the different risks related to X-Ray radiation and
handling radioactive and nuclear materials is performed to all
concerned personnel, and documented.
Guiding measures:
8.1 A radiation safety policy is developed and implemented.
8.2 Radio-active materials are properly labelled, and safely and securely
stored and discarded.
8.3 Nuclear materials are handled safely by qualified staff as per
hospital’s policies and procedures.
COR
8.4 The availability of lead aprons and gonad/thyroid shields to cover
patients and staff needs is ensured at all times.
8.5 Testing of the personal radiation dosimeters is conducted every 3
months, results are evaluated and actions are taken when test
results exceed permissible levels.
8.6 Training on radiation hazards is documented
FMS 9. Patients and staff are protected from unnecessary laser beams
exposure, when applicable. [HC-13]
There are several types of surgeries which could use lasers in the
operating room. In this case, laser-safe eye protection with
appropriate wavelength and optical density must be worn by all
5
health care workers in the room, as exposure to high level lasers
may cause depigmentation, severe burns and possible damage to
underlying organs. The design and construction of the interventional
room should ensure that laser beams are not reflected inside and
outside the room.
Guiding measures:
9.1 Staff is provided with protective eye goggles.
9.2 Warning signs are available in areas where laser is used.

54
 9.3 Rooms where the laser procedures are performed, is free from
refractive surfaces as per hospital’s policies and procedures and/or
manufactures’ recommendations.
FMS 10. The hospital has a program in place for the inventory, handling,
storage, and use of hazardous materials.
Hazardous materials are substances that could harm human health
or the environment if not handled the right way. There are many
different kinds of hazardous materials, including: chemicals (such
as some disinfectants and cleaning agents), drugs (such as
chemotherapy agents), radioactive material that is used for x-rays
or radiation treatments, biological material that may carry harmful
germs, or medical gases used for anesthesia.
These materials need to be stored in certain conditions so as to
4 prevent certain risks (flammability, contamination, etc.) and some
require official licensing or auditing from the relevant authorities.
Documented training about storage, handling of hazardous
materials, in addition to post-exposure signs/symptoms and
treatments should be performed to all concerned staff.
Material Safety Data Sheets (MSDS) containing necessary safety
hazards for each material and how to deal with a contamination
situation should be available in storage areas, concerned
departments where these materials can be used and in the
Emergency Department and regularly updated.
Guiding measures:
10.1 The program establishes and implements:
10.1.1 Safe handling, storage and use of hazardous materials and
wastes.
10.1.2 Proper protective equipment and procedures and the
proper use of spill kits.
10.1.3 Proper labelling of hazardous materials and wastes.
10.1.4 Documentation requirements, including any permits,
licenses, or other regulatory requirements.
10.2 Evidence of staff education and training on signs and symptoms of
exposure to hazardous materials and the appropriate treatment
according to Material Safety Data Sheets (MSDS).
FMS 11. A program for control and disposal of hazardous materials and
wastes is in place.
Spills of and exposures to hazardous materials need to be
promptly reported to the risk management/ patient safety team
6
so that an investigation could be performed regarding the incident
and the risk factors involved.
Procedures regarding safe handling, spill containment should be
accessible to concerned staff at all times. When possible spill kits

55
 should be available so as to standardize and improve accessibility
to proper protective equipment and all items used for spill control.
Finally, hazardous wastes raise an environmental impact issue that
need to be managed in a professional way so as to lower the
involved risks.
Training on the aforementioned themes needs to be performed to
all concerned staff.
Guiding measures:
11.1. The hospital has a reporting and investigation mechanism for spills,
exposures, and other incidents.
11.2. The hospital ensures proper management of spills and exposures,
COR including the use of proper protective equipment.
11.3. Current Information related to safe handling, spill-handling
procedures and procedures for managing exposures of hazardous
material are accessible at all times.
11.4 Evidence of staff training on dealing with hazardous wastes.
FMS 12. An emergency management program is developed, maintained
and tested to respond to emergencies, epidemics, internal and
external disasters, and bomb threats
An emergency management plan is an integrated planning
approach to any realistic internal or external threats to an
organization including natural disasters, terrorist attacks, and any
other incidents that could threaten the operational capacity of a
6 hospital, such as a high influx of patients or an epidemic outbreak.
Such a plan should address the following themes: determination of
the types of disasters with their likelihood and consequences, the
pre-disaster planning phase including elaboration of
procedures/training/simulation, disaster procedure activation and
communication, disaster team and chain of command with defined
roles and responsibilities, hospital capacity increase options,
triaging of patients and zoning according to patients’ condition.
Guiding measures:
12.1 A process exists to properly identify the impact of each type of
disasters on care and services.
12.2 The program identifies the response to emergencies including the
following:
12.2.1 Determining the type, likelihood, and consequences of
hazards, threats, and events.
12.2.2 Determining the hospital's role in such events.
12.2.3 Communication strategies for events.
COR 12.2.4 Managing of resources during events, including alternative
sources.
12.2.5 Managing of clinical activities during an event, including
alternative care sites.
12.2.6 Identification and assignment of staff roles and
responsibilities during an event

56
 12.2.7 Managing emergencies when personal responsibilities of
staff induce conflicts with the hospital's responsibility for
providing patient care.
12.3 The program is tested annually, outcomes are evaluated and
improvements are made accordingly.
FMS 13. The hospital develops and implements a program for prevention,
early detection, and suppression in response to fire and non-fire
emergencies.
A hospital fire emergency program should be elaborated,
implemented and regularly tested in order to ensure a prompt
response to risk of fire in the hospital.
5 This program should identify the risk of fire in the different areas
of the hospital, distribution smoke detectors and fire extinguishers
as well as distribute and display the proper instructions.
Upon notification of a fire risk or occurrence, the program should
specify the steps and responsibilities regarding the incident
management, including fire and smoke containment and the
evacuation procedure through safe fire exits.
Guiding measures:
13.1 The hospital has a program to ensure that inhabitants inside the
facility are safe from fire, smoke or other non-fire emergencies.
13.2 Fire risk is assessed and documented.
13.3 The hospital ensures the early detection of fire and smoke.
13.4 The program/strategy/plan includes fire and smoke containment.
13.5 Safe fire exits are not obstructed or locked, and clearly illuminated
with exist signs as per hospitals’ policies and procedures.
13.6 “No smoking” policy is strictly implemented inside the hospital and
applied to all staff, patients and visitors.
FMS 14. Fire and safety program is tested on regular basis, including any
devices related to early fire detection/suppression.
Regular technical verification of the correct functioning of the fire
alarm system (smoke detectors, control panel, notification
devices, and other components) needs to be implemented and
5 documented.
Fire drills should also be implemented in order to familiarize and
reinforce proper practices (including proper use of the fire
extinguishers), evacuation procedure and routes whenever a fire
alarm sounds. Fire drills are required at least annually for most
facilities.
Guiding measures:
14.1 Evidence that fire drills are conducted regularly through different
time periods, in all departments and to all staff on regular basis,
corrective action are documented and improvements are made
accordingly.
14.2 Staff demonstrates the proper actions taken in case of fire including
the use of different kinds of fire extinguishers.

57
 14.3 Inspection, testing, and maintenance of equipment and fire
detection/suppression systems are done on regular basis and
properly documented, corrective actions are documented and
improvements are made accordingly.
FMS 15. The hospital develops and implements a program for inspecting,
testing, and maintaining medical devices and equipment and
documenting the results.
Medical equipment should have a complete maintenance history,
showing all episodes of preventive and corrective maintenance
since its acquisition.
Preventive maintenance and calibration lower the probability of
equipment faults and optimizes costs and equipment availability
and needs to be determined according to the equipment’s age,
condition and to the manufacturer’s recommendations.
Given the relatively high number of medical equipment in most
6 hospitals, planning and management of the preventive
maintenance activity of medical equipment should be done using
an information system containing the inventory of all of the
equipment, and if possible permitting direct documentation in the
system of maintenance actions and associated internal and
external reports.
In order to derive best results for equipment performance and
safety, training should be done for each type of equipment both to
the biomedical engineering team and the concerned users. The
latter need to promptly report any faults, misuse or adverse
clinical events related to the equipment performance.

Guiding measures:
15.1 Hospital executive management develops policies and procedure to
ensure the quality and safety involving medical devices and
equipment usage.
15.2 The hospital shall have an organized list of approved medical
devices based on the medical devices registered at the Ministry of
Public Health.
15.3 Hospital has a standardized procurement process for medical
equipment.
15.4 Hospital has an information system to manage the inventory and
the maintenance activities of medical technology
15.5 Inspection and testing of a medical technology is performed and
COR
according to its age, use, and manufacturers’ recommendations and
after the introduction of new equipment.
15.6 Preventive maintenance and calibration are conducted based on
the manufactures recommendation and properly documented.
15.7 Equipment maintenance and repairs are documented at all times.
15.8 Evidence that staff is trained and qualified for the medical
technology services being provided.

58
 15.9 Evidence that staff is trained to report medical errors and near
misses related to the use of medical devices.
15.10 Evidence that hospital staff is trained to safely operate medical
equipment.
FMS 16. The hospital has a process in place that handles expired/outdated
and damaged implantable medical devices
Implantable medical devices (IMD) are implantable biomedical
devices placed in the human body during surgery or other clinical
intervention to serve a specific function. Commonly used IMDs
include artificial joints, breast implants, bone, muscle, and joint
fusion hardware, implanted vascular access devices, vascular
stents and pacemakers.
As these devices are mostly invasive, and some controlling vital
6 functions, any errors or malfunctions can induce severe clinical
adverse events. Hence, such devices should be monitored and any
errors, near misses and adverse events should be promptly
reported to the hospital patient safety department and to all
relevant entities as per national regulations.
While the use of expired/outdated IMDs is still controversial,
especially in the context of countries with limited resources, the
hospital needs to ensure a process to identify expired/outdated
IMDs and decide about criteria for disposal or limited use, in
compliance with ethical frameworks and national regulations.
Guiding measures:
16.1 The hospital identifies expired/outdated or damaged implantable
medical devices through a specific process.
COR 16.2 The hospital abides by a process for the disposal of the expired/
outdated implantable medical devices.
16.3 The hospital has a process to identify, monitor and report medical
errors and near misses related to implantable medical devices
FMS 17. A system for monitoring and acting on medical technology hazard
notices, recalls, reportable incidents, problems and failures, exists.
Medical equipment problems need to be systematically
documented including all investigations and interventions
performed, in order to identify recurrent failures or
incidents/trends/ suboptimal performance, and engage
accordingly appropriate actions to prevent patient safety
5 incidents.
When safety incidents related to equipment happen, they need to
be promptly reported to the risk management/patient safety
department(s) for investigation and recommendations. Critical
equipment (such as respirators, anesthesia machines, patient
monitors, etc.) should have back-ups in the event of prolonged
downtime of failed equipment, to prevent shortages that may
affect patient safety and quality of care.
Guiding measures:

59
 17.1 Investigating and following-up on equipment failures follows a
specific process.
17.2 History record for the maintenance schedule, failure incidence, and
repairs done, is in place.
17.3 Reporting death, serious injuries or any incident related to medical
technology follows a certain process.
17.4 A back-up for critical equipment exists in periods of prolonged
downtime as per hospital’s policies and procedures.
FMS 18. The hospital develops and implements a program for effective and
efficient operation of the utility system.
Utility systems (such as electricity, water, chillers, steam boilers,
etc.) are critical to ensure normal operations in the hospital.
Therefore, regular inspection of these systems and all of their
components is important to ensure they are functioning properly.
A maintenance program including daily inspection of certain
components and weekly or monthly inspection and maintenance
for other components should be rigorously planned and
implemented by the facility management team. The frequency of
inspection and maintenance depends on the utility system’s age
and condition, as well on its criticality. Sufficient capacity in terms
4
of technicians should be available in order to perform the
inspection, preventive and corrective maintenance. Availability of
a Building Management System integrated with major utilities can
provide instantaneous monitoring and alerts to the maintenance
team in case of faults or incidents.
In the event of a fault or incident, and especially in urgent
situations, access to the map distribution of the utility systems, as
well as the clear labeling of their components, controls and
connections, can become of major importance, highlighting the
need for clear system labeling and availability at all times of the
system inventory, status and map distribution.

Guiding measures:
18.1 The hospital has inventory for its utility systems and their respective
map distribution.
18.2 Utility systems and components are inspected, tested, maintained
and improved when necessary.
18.3 All the operational components of the utility systems are identified
through documented inspections and maintenance.
18.4 The documented intervals for inspecting, testing and maintaining all
operating components of the utility systems on the inventory are
based on specific criteria.
18.5 Utility system controls are properly labelled.
18.6 The hospital has adequate number of qualified staff to manage the
utility system.

60
 FMS 19. Clean water and electrical power are available at all times and
alternative resources of water and power supply exist in period of
system disruption, contamination or failure.
Backup sources for main electrical current (for example fuel
powered hospital generators backed up by Uninterrupted Power
Supply system) and water (artesian wells and/or backup
reservoirs) are required to ensure continuous supply of power and
water to hospital services.
These alternative sources should be tested regularly, with a
frequency to be set with regards to the frequency of the power or
water supply failure.

In the hospital context, a significant number of critical

departments (ER, ICU, Operating Rooms, Dialysis, etc.) and support
6
departments (Pharmacy, Laboratory, Medical Imaging, etc.) are
completely dependent on the availability of the electric current to
ensure patient and material safety.
In case of major power failure or fuel shortage for generators, such
pre-designated critical areas and services should be given priority
in matter of power and water supply.

A minimal stock of fuel should be stocked in the hospital to ensure

continuity of service ideally up to a week in case of general fuel
shortage. Installation of solar powered energy with or without
batteries could minimize to a certain extent reliance on fuel, and
contribute to ensure power to most critical areas during the
shortage period.

Guiding measures:
19.1 Clean water and electrical power are available 24 hours per day, 7
days per week.
19.2 A back up electrical system is in place and tested regularly.
19.3 Areas and services which are at the greatest risk are identified in
case of power failure and water interruption or contamination.
19.4 Alternative resources of water/electrical power are tested at least
COR
bi-annually or more frequently if required by local laws and
regulations, manufacturers’ recommendations, or conditions of the
source of water/electricity and the results of the testing are
properly documented.
19.5 The hospital ensures the availability of necessary amount of on-site
fuel to operate the emergency source of power in case it is fuel-
dependent.
FMS 20. Water quality is monitored by designated individuals or
authorities.
5 Water fed into the hospital through pipelines need to run through a
number of different filters in addition to chlorination before being
used in hospital departments.

61
 Physicochemical and microbiological analysis of water used in the
hospital is required at least quarterly to prevent contamination of
patients and personnel by pathogens and chemical agents (e.g.
mercury, chlorine, nitrate), documented and any discrepancy with
regulatory requirements identified and corrected.
As for dialysis water, monthly testing for chemical contaminants
(TDS, total chlorine, endotoxin) and microbiological contaminants is
performed as per regulatory requirements to prevent any adverse
patient outcomes from waterborne pathogens and endotoxins.

Guiding measures:
20.1 Monitoring water quality, including the water used in renal dialysis,
is done at least quarterly or more frequently based on local laws
and regulations, conditions of the sources for water, and the results
of the testing are properly documented.
20.2 Evidence of a double reverse osmosis system and an endotoxin-
retentive filter.
20.3 Evidence that water fed into the hospital through pipelines is
disinfected by chemical or heat.
20.4 Evidence of regular testing of dialysis water quality for bacterial and
chemical contaminants (TDS, total chlorine, endotoxin monthly)
20.5 The outcomes of testing water quality are evaluated and actions are
taken accordingly.
FMS 21. The hospital develops and implements a program for operating
the medical gas system.
Provision of medical gases, such as oxygen (O2), carbon dioxide
(CO2), nitrous oxyde (N2O) and compressed medical air, needs to be
continuous since its disruption can lead to clinical adverse events or
prevent clinical activities.
Therefore, testing medical gas (regarding criteria such as purity,
static pressure and pressure variation with increased flow) is
conducted regularly and properly documented. Existence of
6 sufficient stock for the different medical gases should be verified
including secondary oxygen cylinder ramps for the medical oxygen
system. In case of oxygen concentrators, initial and regular
certification should be performed according to regulatory
standards.
Emergency shut-off valves should be available in all units, because
in the event of a fire, it is important to shut off the oxygen supply to
an area on fire.
FMS technicians in addition to concerned staff in clinical wards
need to be trained on closing the shut-off valves when needed.
Guiding measures:
COR
21.1 Testing medical gas is conducted regularly and properly
documented.

62
 21.2 The hospital ensures that the central station for medical gases is
safe and secure.
21.3 Emergency shut-off valves are available in all units of patient care.
21.4 Trained staff is/are responsible for closing the shut-off valves when
needed.
FMS 22. A plan for heating, ventilating and air conditioning is in place.
Heating, Ventilation, and Air Conditioning (HVAC) systems in the
hospital allows for optimal conditions of temperature and
humidity for patients rooms and other critical departments (OR,
stock rooms, pharmacy, etc.) , in addition to ensuring proper air
5
flow direction, circulation and pressure gradients to minimize
contamination between isolated and clean areas .
Inspection and regular controls of the HVAC system performance
needs to be available at all times in designated units and
departments.
Guiding measures:
22.1 A preventive maintenance plan is performed periodically for
heating, ventilating and air conditioning.
22.2 Proper air flow design is ensured in the operating rooms, isolations
rooms and central sterilization department.
22.3 Control of temperature is ensured at all times in all units and
departments
22.4 Control of humidity is ensured at all times in designated units and
departments.
FMS 23. The hospital ensures the design of a proper sewage handling and
disposal.
Discharging wastewater generated from the hospital into the
municipal sewage system needs to be done after adequate
pretreatment to minimize the risk of environmental contamination
3
with hazardous and infectious waste, and this process needs to be
elaborated in a hospital procedure.
This pretreatment could include acid–base neutralization, filtering
to remove sediments, or autoclaving samples from highly
infectious patients.
Guiding measures:
23.1 Sewage is handled and disposed in a safe and sanitary manner, as
per hospital policies and procedures.
FMS 24. The hospital implements a program for managing laundry services.
Instructions about correct washing processes according to the
laundry equipment’s manufacturer’s recommendation need to be
communicated to laundry staff, in order to prevent faults with
4
the machines.
Laundry equipment are regularly inspected and tested to prevent
faults and downtimes, and water density regular measure
recommended to optimize equipment performance.

63
 Guiding measures:
24.1 Policies and procedures are in place to ensure proper
implementation of the program.
24.2 Laundry equipment are regularly inspected and tested.
24.3 Proper linen handling is ensured by all staff.
24.4 The washing process must be clearly documented and follow the
manufacturers' instruction for specific washing loads.
24.5 Clean and disinfected linen transport vehicles are covered during
transport of linen.
FMS 25. Staff is educated, trained and evaluated for their role in attaining a
safe and effective patient care facility. [HC-14]
Staff knowledge about a number of facility management themes
such as fire safety, medical gases, waste management, and correct
manipulation of equipment and utility systems is important in
order to optimize their response to a number of emergency
5
situations in addition to improving the maintenance and
preventing incidents and faults with these systems.
Hence, targeted FMS training should be delivered to concerned
hospital staff regarding these aforementioned themes, and
testing/competency tests performed to ensure the information is
well assimilated.
Guiding measures:
25.1 Education is provided annually on comprehensive facility
management and safety programs.
25.2 The staff’s knowledge about their roles in different facility
management and safety programs is tested.
25.2.1 Staff demonstrate/describe their role in response to fire,
actions taken to eliminate or minimize fire and properly
report.
25.2.2 Staff demonstrate/describe their role in disposing medical
gases and hazardous materials and wastes.
25.2.3 Staff is trained to operate medical technology/utility
systems.
25.3 Testing, results of the testing, and training are properly
documented.
FMS 26. Indicators of the facility management programs are collected and
analyzed.

FMS processes are critical for the hospital operations and need to
be monitored regularly in order to recognize early trends or
5 performance problems.

Indicators for performance monitoring could include a list of

outcome indicators (such as maintenance costs as percentage of
asset value, mean maintenance response time per issue criticity,
equipments/systems with more than X repeated faults/year, fire

64
 false alarm rate, etc.), and a list of process indicators (such as on-
time preventive maintenance according to schedule).

Discussion of indicator results ought to be done at the leadership

level of the department and also quarterly at the hospital
management level in order to engage appropriate improvement
actions, with a timely feedback of results and action plans to the
concerned teams.

Guiding measures:
26.1 Monitoring indicators are collected, analyzed, outcomes are
evaluated and corrective actions are taken accordingly.
26.2 Medical technology, equipment, and systems are upgraded or
replaced based on the monitored indicators.
26.3 Reports on monitoring indicators are properly communicated with
the hospital executive management on quarterly basis.

65
 Quality and Risk Management

Medication Management and Safety

(MM)
Introduction
The standards in the Medication Management chapter provide a safe and
effective approach for the medication management process and aim at reducing
medication errors and near misses. They address the steps from planning,
selecting, storing, preparing to administering medications and monitoring their
clinical effects/side effects.
The Medication Management chapter targets the following sections:
 Planning medication management processes
 Selecting medications
 Storing medication
 Ordering and transcribing
 Preparing and dispensing
 Administering medication
 Monitoring of the medication effects
 Evaluating the medication management processes

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

66
Standards
Risk
Standard and Guiding Measures
Score
MM 1. The hospital plans each step of the medication management process.
Medication management is important in assessing medication
consumption and adherence for patients with chronic illnesses, in
order to avoid multiple prescriptions. It is based on the patient –
practitioner relationship, which aids in decision making and involves
the patient in the medication process.
The medication management process used by health organizations to
ensure safe use of medicines, including: selecting, prescribing,
6
preparing, dispensing, administering and monitoring of medicines.
The medication management process begins with a decision on
appropriate medication and recording the medication order.
Healthcare practitioners performing these tasks include, but not
limited to, physicians, pharmacists, and nurses.
Due to the high risk of error in the medication management process,
it is critical to integrate a medication management system within the
risk management policies.
Guiding measures:
1.1 The medication management system has clear policies and
procedures regarding selection and procurement, storage, ordering,
transcribing, preparing, dispensing and administration of medications,
COR and monitoring for medication-related adverse events.
1.2 There is a written/electronic information system that supports safe
medication management processes.
1.3 Risk management policies dictate medication management system.

MM 2. Medication management is well aligned with applicable laws and

regulations and headed by a qualified and registered pharmacist.
Issuing medicines is mainly done by pharmacists – dispensing
medicines to patients or their care givers. This requires ensuring the
right medicine is selected or manufactured, labelled clearly; and the
medicine issue is recorded.
Administering the medicine requires that nurses follow a process to
ensure accurate and safe administration – ensuring the right
5 medicine is used by the right patient.
The pharmacy and therapeutic committee is composed of actively
practicing physicians, other prescribers, pharmacists, nurses,
administrators, quality-improvement managers, and other health
care professionals and staff who participate in the medication
management process. The pharmacy and therapeutic committee
should serve in an evaluative, educational, and advisory capacity to
the medical staff and organizational administration in all matters
pertaining to the use of medications.

67
 The committee should be responsible for overseeing policies and
procedures related to all aspects of medication use within an
institution, should be responsible to the medical staff, and its
recommendations are subject to approval by the organized medical
staff as well as the administrative approval process. The
committee’s organization and authority should be outlined in the
organization’s medical staff bylaws, medical staff rules and
regulations, and other organizational policies as appropriate.
Medication errors, including those made in prescribing, dispensing,
and administration are a common and preventable cause of patient
harm.
The hospital should orient new staff about the medication
management system and its processes and train the staff on how to
report medication errors and near misses.
Guiding measures:
2.1 A registered and qualified pharmacist heads the pharmacy
department with specified and regularly updated authorities and
responsibilities delineated.
2.2 A clear hospital structure depicts all the services and the healthcare
professionals involved in the medication management processes.
2.3 Provision of information and access to policies and procedures for
those involved in medication use is maintained at all times.
2.4 The pharmacy and therapeutic committee has delineated roles and
responsibilities which are reviewed and evaluated on regular basis.
2.5 The hospital performs orientation to the new staff about the
medication management system and its processes, trains the staff
how to report medication errors and near misses.
2.6 The hospital evaluates the effectiveness of the training activities
related to medication management.
MM 3. The hospital has a process to manage and ensure proper
antimicrobial prescription and limit overuse and misuse of
antimicrobials [IPC-28]
The misuse of antimicrobials leads to adverse health effects and
causes anti-microbial resistance. Managing the varied problems
associated with antimicrobial resistance will require a coordinated
response. Proper antimicrobial prescription is achieved by selecting
the correct dose, duration and route of consumption.
6
The Centers for Disease Control and Prevention (CDC), as well as
other organizations and experts, recommends various steps that
health care practitioners and facilities can pursue to ensure proper
prescription and limit overuse and misuse of antimicrobials, such as
adopting an antibiotic stewardship program; improving diagnosis,
tracking and prescribing practices; optimizing therapeutic regimens;
and preventing infection transmission.

68
 The hospital should educate patients about the proper use of
antimicrobials with proper documentation in the medical record,
upon discharge.
Education can be, not limited to, implementing campaigns among
medical professionals and organizations regarding antimicrobial
overuse and misuse. Such campaigns can raise awareness about the
proper use of antimicrobials and alleviate the overall overuse.
Guiding measures:
3.1 Certain antimicrobials are prescribed according to evidence-based
practice.
3.2 Antimicrobial prescriptions are reevaluated every 72 hours.
3.3 The hospital evaluates or ensures at least once a year, the
implementation of the recommendations and the pertinence of the
prescriptions.
COR
3.4 The hospital educates the patients about the proper use of
antimicrobials with proper documentation in the medical record,
upon discharge.
3.5 The hospital guides the physicians and the healthcare workers to
restrict the overuse/misuse of antimicrobials through setting specific
policies.
3.6 The hospital has indicators to measure antimicrobial prescriptions.
MM 4. Clinical pharmacists are involved in direct patient care to optimize
medication therapy, as per hospital policies and procedures and
applicable laws when available.
Clinical pharmacists play a vital role in health care, since they
enhance the quality of treatment and health services delivered to
the patients by improving the prescription quality. Also, clinical
5
pharmacists help nurses and providers in further education related
to medication management which assists in the increasing the
quality, safety and efficiency of care.
Integration of clinical pharmacists within the hospital practices
supports an interdisciplinary approach in medication therapy that
optimizes safe and effective medication use.
Guiding measures:
4.1 Policies and procedures are in place for clinical pharmacists to provide
direct patient care to the greatest extent possible in both inpatient
and outpatient settings.
4.2 Critical areas are identified where clinical pharmacy specialists should
be available during interdisciplinary rounds to intercept preventable
medication adverse events, provide medication therapy monitoring
and assessment, medication counseling and other patient care
activities that are documented in the medical record, when needed.
4.3 Clinical pharmacists actively work as a part of the hospital to develop
and implement policies and procedures that provide safe and
effective medication use for the patients.

69
 MM 5. There is a set of policies for managing high-alert/high-risk and
control narcotics and controlled medications.
High-alert or high-risk medications are medicines that can cause
serious harm on one’s health if misused. Patients consuming drugs,
as well as their providers, should be careful when it comes to the
uptake of high-risk medicines since the difference between their
efficacy and potency is minor. So, even a minimal increase in their
consumption imposes a high risk for fatal consequences.
Policies for managing high-alert/high-risk and control narcotics and
6 controlled medications should be in place in order to improve
medication safety and the quality of health care and patient
management.
Narcotic substances can be from plant origin such as cannabis and
opium or synthetic like methadone. These drugs can be very helpful
and beneficial for many patients with severe and chronic conditions;
however, if not properly prescribed they can have harmful health
effects and can lead to addiction.
Narcotics substances should be managed and controlled by abiding
to the applicable laws and regulations.
Guiding measures:
5.1 There is a list of high-alert/high-risk medications that is updated on
regular basis.
5.2 The policy identifies the individuals involved in managing the high-
alert/high-risk medications.
COR 5.3 Access to the high-alert/high-risk medications is limited to the
authorized staff based on hospital policies.
5.4 Information about high-alert/high-risk medications is available at all
times.
5.5 Managing controlled and narcotics substances abide by the applicable
laws and regulations.
Selecting medications
MM 6. The hospital develops a process for selecting, procuring stocked
medications and securing its availability in times where medications
are not stocked or when the pharmacy is closed.
The hospital should create a process for medications that are not
stocked or available to the hospital when the pharmacy is closed.
5 The process should mention the people who are authorized to take
actions in this situation.
The selection and procurement of drugs depends on certain drugs;
their dosages and available financial resources. The process includes
estimating the quantity needed, estimating the prices of different
dosages, etc.
Guiding measures:
6.1 An on-call pharmacist is available and responds to requests on a
timely basis when the pharmacy is closed.

70
 6.2 A list of staff authorized to access pharmacy is in place when the
pharmacy is closed.
6.3 The hospital provides a list of medications that is accessible by non-
pharmaceutical authorized staff when the pharmacy is closed.
6.4 The pharmacy provides access to specifically authorized staff to
limited emergency medications.
6.5 Evaluation and improvement of the dispensing system, when the
pharmacy is closed, is done on regular basis.
6.6 A plan is in place to replenish the acute shortage of medications.
MM 7. The hospital has an organized medication list.
The hospital should have a list process of creating the most accurate
list possible of all medication. The hospital’s medication list,
including hazardous and look-alike-sound alike medications, is
reviewed and updated periodically and as needed based on pre-set
criteria, via a process of selecting, approving and purchasing non-
formulary medications. Hospitals must develop a list of hazardous
drugs with hospital wide procedures for receiving, compounding,
dispensing, administering, and disposing of these hazardous drugs.
4
Keeping an organized medication list and showing it to practitioners
is highly important, since it provides them with significant
information that assists in the enhancement of patients’ health and
prevention of potential adverse health effects.
Drug product shortages can adversely affect drug therapy,
compromise or delay medical procedures, and result in medication
errors. Thus, strategic planning is required for managing drug
product shortages and informing related practitioners to prescribe
an alternative.
Guiding measures:
7.1 The hospital’s medication list (formulary), including hazardous and
look-alike-sound alike medications, is reviewed and updated
periodically and as needed based on pre-set criteria, via a process of
selecting, approving and purchasing non-formulary medications.
7.2 A process is in place to inform all healthcare professionals involved in
medication use about any changes in the medication list including
drug shortage.
7.3 Once presented and approved by the pharmacy and therapeutics
committee, the newly introduced medications are monitored and
evaluated, based on hospital policies, for their usage and their
adverse effects using a standardized tool.
Safe and Proper Storage
MM 8. The hospital has a process for storing medications in a safe and
proper manner.
5 The hospital should have a process for properly storing medication.
Careful arrangement of medication storage in the pharmacy and

71
 throughout the hospital can help reduce the risk of medication
errors.
Storage areas should be monitored for expired medications and
appropriate temperatures. Separate medication storage areas exist
for look-alike and sound-alike, same medications with different
dosages or concentration and high alert/high-risk medications with
special warning signs. Access to secured medication areas are
limited to authorized personnel.
Guiding measures:
8.1 Storage areas of controlled medications meet the applicable laws and
regulations.
8.2 Medications are stored in a secured area with access to the
authorized staff.
8.3 Medications are stored under appropriate conditions to ensure drug
stability including refrigerated medications and medications stored in
the clinical service areas.
8.4 Content, warning signs and expiry dates are properly labeled on the
stored medications.
8.5 Separate medication storage areas exist for look-alike and sound-
alike, same medications with different dosages or concentration and
high alert/high-risk medications with special warning signs.
8.6 The pharmacy staff performs regular inspection of the medication
storage areas.
MM 9. Storing medications that require special handling follows a specific
process.
Medications with special handling should be well stored in
designated areas that comply with the standards of medication
storage. Also, a dedicated staff member(s) will be assigned for
handling those drugs in order to avoid any hazard.
5
A process should exist for handling and storing chemotherapy and
anesthetic agents, radioactive, and investigational medications.
Sample medications should also be handled based on a process. An
automated system and method for storing, dispensing, and
inventorying medications and for analyzing inventory data to detect
diversion would be considered useful according to research.
Guiding measures:
9.1 Storing medications has a well-established and implemented process.
9.2 A process exists for handling and storing sample medications.
9.3 The pharmaceutical staff follows regulations and instructions for
storing chemotherapy and anesthetic agents to prevent adverse
effects.
9.4 The hospital implements a process for storing radioactive and
investigational medications.
9.5 The process is evaluated and improvements are made accordingly.

72
 MM 10. Emergency medications are accessible and secured outside the
pharmacy area.
Emergency medications are the use of drugs for treating patients
that require urgent and direct medication. It is important to have a
specialized practitioner that provides right emergency medication
and right dosages of drugs to improve patients’ health in critical
6 conditions.
A process should be in place in order to ensure that emergency
medications are accessed by authorized staff, and that all
medications are secured and protected from theft or loss.
The hospital should also identify a process to ensure that emergency
medications are being periodically inspected and checked for expiry
and damage.
Guiding measures:
10.1 Emergency medications are secured and protected from theft or loss.
10.2 Emergency medications are accessed by authorized staff.
10.3 The list of emergency medications is reviewed and updated regularly
by the healthcare professionals involved in medication management.
10.4 A process exists for inspecting the emergency medications
COR
periodically, identifying the expired or damaged medications and
replacing them, based on hospital’s policies and procedures.
MM 11. The hospital has a process in place that handles expired/outdated
and damaged medications.
The hospital should have a process to identify expired/outdated or
damaged medications. Expired and damaged medications should be
properly handled and disposed by specialized staff members in
6 order to avoid any undesired results and to ensure safety.
Applicable laws and regulations of disposing, controlled substances
and hazardous drugs should be in place in order not to pose a threat
to both the health care system and to the environment.
A process is in place for informing healthcare providers involved in
medication management about the expired/outdated medications.
Guiding measures:
11.1 The hospital identifies expired/outdated or damaged medications
through a specific process.
11.2 The hospital follows applicable laws and regulations of disposing,
COR controlled substances and hazardous drugs.
11.3 The hospital abides by a process for the disposal of the expired/
outdated medications.
11.4 There is a process for informing healthcare providers involved in
medication management about the expired/outdated medications.
Ordering and transcribing
MM 12. Safe prescribing and ordering of medications is guided by policies
6 and procedures with emphasis on elderly, newborns, special care
units and specific conditions.

73
 The hospital should develop and implements a uniform and safe
process for prescribing, ordering and transcribing of medications.
The process should provide a patient’s medication history to
pharmacists, consumers, and health care providers, while protecting
patient privacy.
The hospital should have a policy regarding pharmacist verification
of the medication order prior to dispensing medications on the
medical administration record
Periodic reviews to monitor medication errors and near misses
should be conducted regularly in order to make necessary
improvements.
Guiding measures:
12.1 A safe process for prescribing, ordering and transcribing of
medications is established and implemented in the hospital.
12.2 A policy about non-formulary order processing is in place.
12.3 Pharmacist verification of the medication order for completeness
and appropriate review is conducted regularly, based on hospital
COR
policies, prior to dispensing medications on the medical
administration record.
12.4 Prescribing and transcribing of the medications is recorded on the
medical record.
12.5 The hospital performs periodic reviews to monitor medication
errors and near misses and make necessary improvements.
MM 13. Accurate and complete information about patient’s medications
follows a specific process.
Preventing harm from medications, or adverse drug events, should
remain a top patient safety across the continuum of care for
patients.
6
Medication reconciliation process should be performed during
admission, and discharge, and the documented medication list must
be shared with the healthcare providers, the pharmacy and patient.
This process is done to avoid medication errors such as omissions,
duplications, dosing errors, or drug interactions.
Guiding measures:
13.1 A policy is in place to manage medication reconciliation.
13.2 Medication reconciliation process is performed during admission,
and discharge, and the documented medication list is shared with
the healthcare providers, the pharmacy and patient.
13.3 Monitoring and evaluating the process are done to ensure
compliance and necessary improvements are made accordingly.
COR 13.4 The medication’s name and the time of administration of the
medications, upon admission, are documented in the medical
record.
6 MM 14. Elements of complete order or prescription are identified.

74
 Ordering or prescription errors are failures in the prescribing process
that lead to or have the potential to lead to harm to the patient and
are committed by credentialed providers, including physicians,
nurse practitioners, physician assistants, privileged pharmacists, and
others. Common ordering errors include omission, incomplete and
unclear orders, wrong drug, wrong time, wrong dose, wrong dosage
form, patient allergy, and wrong patient.
Prescription and medication orders can be handwritten, typed,
preprinted, verbal, or entered into a computer program and
submitted to the pharmacy by the care givers, computer, or other
electronic means.
A process should be in place for managing verbal and telephone
orders in a safe way including security and control criteria. Verbal or
telephonic medication orders should be reserved only for situations
in which it is impossible or impractical for the prescriber to write the
order or enter it into the computer.
The hospital should implement a process for monitoring the
accuracy and completeness of the orders. Although requirements
might slightly vary for what information to be contained on a
prescription, in general, it must contain the following information:
the name of the patient, drug name, drug strength, drug dosage
form, quantity prescribed directions for use, and the name, address,
and signature of the prescriber.
Guiding measures:
14.1 Elements of complete orders are:
14.1.1 The data for identifying the patient (i.e. Patient triple name,
date of birth, and patient’s medical record number).
14.1.2 The essential elements of all orders or prescriptions (date
and time, medication name, dosage, route of administration,
frequency of administration, any special instructions for
holding or adjusting dosage, and physician’s signature).
14.1.3 Whether or when indications for use are required on a PRN
(Pro Re Nata, or “as needed”) or other medication orders.
COR 14.1.4 The weight-based or otherwise adjusted orders.
14.2 The order or prescription is free of unapproved abbreviations and
dose designations.
14.3 A process is in place for stopping any illegible prescriptions and
orders.
14.4 There is a process for managing special orders such as emergency,
standing, or automatic stop orders.
14.5 The hospital implements a process for monitoring the accuracy and
completeness of the orders.
14.6 Audits on medication orders are done periodically to ensure
compliance and improvements are made accordingly.

75
 14.7 There is a policy for managing verbal and telephone orders in a safe
way including security and control criteria.
14.8 All patients should have allergy information accessible at all times
to the pharmacist prior to verifying or dispensing any medication
order.
14.9 Independent dual verification is performed by physicians for
calculating the weight-dependent medication dosages for the
newborns and specific drugs, and properly documented.

Preparing and dispensing

MM 15. A licensed pharmacist ensures the accuracy and the appropriateness
of the prescriptions and medication orders.
Prior to dispensing the prescription or medication order, the
pharmacist’s responsibility is to evaluate the prescription or
medication order for appropriateness. This includes ensuring the
6 correct drug, dose and dosage form, frequency, route of
administration, duration of therapy, and indication. Additionally,
the patient’s profile is evaluated for therapeutic duplication, drug
allergies, drug interactions, laboratory data, etc. this process will
help ensure that the benefits of the therapy are maximized and the
potential for harm is minimized.
Guiding measures:
15.1 A health record containing information specific to each
patient (i.e. allergies, diagnosis, patient’s weight, age, pregnancy
and lactation status, drug duplication, according to patient’s age, to
liver and renal insufficiency) along with patient’s medication profile
are available at all times to ensure and enhance the reviewing
process of medication orders before dispensing and
administration.
15.2 A process is in place to manage communication between
pharmacists, nurses and prescribers regarding the appropriateness
of the order.
15.3 The pharmacist reviews prescription and medication orders within
the hospital prior to dispensing and administering medications,
COR
according to hospital policies.
15.4 An online drug information source is available and accessible to
review medication interactions, drug information and minimum and
maximum doses of high-alert/ high-risk medications.
15.5 Drug information books/references are present in order to conduct
a thorough medication review in case of downtime.
15.6 Orders containing high-alert/ high-risk medications, chemotherapy
and medication containing dosages are reviewed independently by
qualified personnel throughout the process.
MM 16. The hospital prepares and dispenses medications in a safe and
5
appropriate environment.

76
 It is important to dispense medications in a safe and appropriate
environment to avoid drawbacks and unnecessary injuries. Factors
associated with dispensing errors may be communication failures,
problems related to package labels, work overload, the physical
structure of the working environment, distraction and interruption,
the use of incorrect and outdated information sources and the lack
of patient knowledge and education about the drugs they use, etc.

Implementing safe, organized, and efficient drug-dispensing systems

is essential for controlling costs and assuring that the medical
prescription is safely followed as requested within the appropriate
deadline. An appropriate dispensing system is an important ally for
the prevention or reduction of medication errors by helping to
minimize dispensing error opportunities in a pharmacy. At present
there are various types of dispensing systems for medical
prescriptions within a hospital.

Preparing and dispensing radioactive and chemotherapy

medications should follow a specific process and be handled by
qualified staff.
Guiding measures:
16.1 Preparation and dispensing of medications follow specific local laws
and regulations.
16.2 The hospital performs regular cleaning according to safety
measures of the medications’ preparation areas.
16.3 The hospital meets the infection control criteria while preparing and
dispensing medications.
16.4 Medication preparation areas are maintained with appropriate
lighting, temperature, humidity and ventilation.
16.5 Qualified staff prepares chemotherapy medications in a separate
preparation area with a 100 percent externally-vented biohazard
hood using protective equipment and verified by pharmacist.
16.6 Preparing and dispensing radioactive medications follow a specific
process.
16.7 Preparing sterile products and intravenous mixtures, when
applicable, is done by qualified staff under aseptic technique and
verified by pharmacist.
16.8 Preparing compounding and extemporaneous formulation, when
applicable, follows a specific process.
16.9 Staff is trained on preparation of medications under sterile
conditions.
16.10 The pharmaceutical staff maintains current record for compounded
and repackaged medications, when applicable.
16.11 Safe recycling of returned (un-used) sterile preparations follows
international guidelines.

77
 MM 17. The hospital ensures the implementation of dispensing medication
process.
The dispensing process includes receiving and validating
prescription, understanding and interpreting prescription, preparing
5
and labeling, making a final check, recording action taken, and
delivering the medicine to the designated patient. Regular detection
of medication errors provides a platform to implement corrective
measure in the medication management system.
Guiding measures:
17.1 All medications are labeled in a standardized format before
dispensing and administration.
17.2 Dispensing of medications is done in a timely manner.
17.3 Pharmacist visually inspects medications prepared in the pharmacy
and verifies the medication order against the prescription or order.
17.4 Dispensing is done for a period that does not exceed 24 hours and a
process exists for dispensing emergency medications.
17.5 The dispensing process is evaluated regularly to detect errors and
make improvements accordingly.
MM 18. The hospital ensures proper, safe and timely transportation of
medications.
Proper, safe and timely transportation of medication is essential to
provide timely delivery of medications and to increase patients’
health and enhance healthcare services. Unsafe and untimely
transportation may cause contamination of medications, delayed
5
care delivery, and delayed medication uptake.
Any authorized staff member, who is involved in the transportation
of medication, accepts responsibility for the safekeeping of those
medications whilst in their possession. A process should be in place
to manage items requiring refrigeration, dangerous and toxic
medication, and returned medications.
Guiding measures:
18.1 A process is in place to ensure safe and timely delivery of
medications from the point of preparation till the point of
administration.
18.2 Transporting refrigerated medications follows a specific process.
18.3 The hospital applies safety and security measures during the
transport of dangerous and toxic medications including biologically-
derived products and drugs that contain radioactive materials.
18.4 A process is in place to manage the returned medications.
18.5 The transportation process is evaluated periodically to detect errors
and make the improvements accordingly.
Administration
MM 19. The hospital identifies the authorized staff permitted by laws and
regulations to administer medications.
5
Drugs must be prepared and administered in accordance to laws and
regulations. The hospital’s medical staff must approve policies and

78
 procedures for medication administration, consistent with the
requirements. Authorized people must have a clear job description
stating medication administration.
Guiding measures:
19.1 There is a clear job description for the staff authorized to administer
medications.
19.2 Those who are permitted by licensure, laws and regulations can
administer medications.
19.3 A process exists to set limits related to time, high alerts, and special
population consideration, on the administration of medication when
indicated.
MM 20. Verification of medications against the order or prescription process
precedes the administration of medications.
The hospital should have a standardized timing for medication
administration.
Appropriate timing of medication administration must consider the
complex nature and variability among medications; the indications
for which they are prescribed; the clinical situations in which they
are administered; and the needs of the patients receiving them.
6 Verification of the medication’s expiry date and inspection of the
medication for loss of integrity or stability is done before
medication is being administered. Verification is done by authorized
staff based on the
Right medication, right dose, right time, right route, and right
patient.
Double checking on the high-alert/high-risk medication before
administration is performed by nurses in order to prevent
medication errors.
Guiding measures:
20.1 The hospital has a standardized timing for medication
administration.
20.2 Verification of the medication’s expiry date and inspection of the
medication for loss of integrity or stability is done before medication
is being administered.
20.3 Staff verifies the medication using the 5 rights (right medication,
right dose, right time, right route, and right patient).
COR
20.4 Nurses perform independent double checking on the high-alert/high-
risk medication before administration.
20.5 Administered medications are properly documented in the medical
record.
20.6 Traceability of administration of medications is verified with a legible
time, name and signature of the person having administered the
medications.

79
 MM 21. Proper education is given primarily to patients and family
caregivers (when needed) about medications before they are being
administered and upon discharge.
Proper patient-caregiver communication can help patients more
confidently manage and take their medications. Authorized staff
must give information on the medications given before the initial
5
dose and when the dose is adjusted. The authorized staff educate
patients and families, before leaving the hospital, about ways to
ensure compliance and prevent medication adverse for the home
medications. They should also ensure that the patients and their
families understand the information given and respond to their
questions and concerns through proper documentation.
Guiding measures:
21.1 The authorized staff gives information on the medications given
before the initial dose and when the dose is adjusted.
21.2 The authorized staff educate patients and families, before leaving
the hospital, about ways to ensure compliance and prevent
medication adverse events (adverse drug reaction or medication
errors) for the home medications.
21.3 The authorized staff ensures patients and families understand the
information given and respond to their questions and concerns
through proper documentation.
21.4 The information given is properly documented in the medical
record.
MM 22. The hospital develops and implements a process for managing self-
administered medications and medications brought from home.
The hospital has a process for identifying patients who perform self-
administration of medications. In such cases, patients are
5
responsible for the storage and use of these medications. The
hospital should provide the healthcare professionals involved in
medication use with information about medication brought by the
patient or from outside the hospital.
Guiding measures:
22.1 The hospital has a process for identifying patients who perform self-
administration of medications.
22.2 The hospital establishes and implements a process of proper
identification and safe storage, and monitoring the side effects of
medications and medications brought by the patient or from
outside the hospital by a licensed pharmacist as per hospital policy.
22.3 The hospital provides the healthcare professionals involved in
medication use with information about medication brought by the
patient or from outside the hospital.
22.4 Sample medications are not allowed to be administered in the
hospital setting.
22.5 Medications brought from home are not allowed to be
administered unless prescribed by the treating physician.

80
 Monitoring
MM 23. Patients are monitored for medications’ effects following
medication administration.
An essential component of the medication process related to the
administration of medications to ensure adequate patient
monitoring and detection of occurring undesirable side effects
following medication administration.
There should be a process to monitor patients before, during, and
after medication administration. Nurses should assesse vital signs,
6
lab values, ability to swallow, and patients’ self- report of health.

The hospital should have a procedure in place to report and increase

compliance with reporting adverse events in order to ensure quality
improvement and accountability responses. A consistent approach
to adverse event reporting should be identified in which health care
professionals and/or health care institutions provide factual and
timely reports of adverse events to the relevant authorities.
Guiding measures:
23.1 The hospital maintains the availability and accessibility of returning
patient’s information regarding previous adverse effects.
23.2 The hospital has a process for monitoring the side/clinical effects of
administered medications on the patient.
23.3 The hospital has a procedure in place to report adverse events.
23.4 The trained staff abides by policies and procedures to ensure the
documentation of the medication’s side/clinical effects and adverse
drug reaction on the medical record.
COR
23.5 The hospital identifies the adverse effects of medications that
should be recorded in the medical record and those that should be
reported to the hospital in a timely manner.
23.6 The hospital has a process to perform analysis (i.e. root-cause
analysis) of the reported medications adverse events.
23.7 A process is developed to increase compliance with reporting the
adverse effects of medications.
23.8 Evidence of improvements is done to mitigate the adverse effects of
medications.
MM 24. The hospital has a process to identify, monitor and report
medication errors and near misses.
Any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the
control of the health care professional, patient, or consumer is
6
referred to as medication error.
Identifying, monitoring and reporting medication errors and near
misses are important in ensuring patient safety. Healthcare workers
are expected to learn from errors and near misses in order correct
faults and improve safety. A process for reporting must be identified

81
 by the hospital in addition to the staff involved in the review of
medication errors and near misses.
A root cause analysis method, in which a secondary analysis of data
from a previously existing investigation is performed, must be
conducted for future improvement of the medication processes and
identification of factors that contributing to error occurrence.

Guiding measures:
24.1 Audits on the medical records are performed on regular basis, at
least yearly.
24.2 The hospital has a policy in place to handle medication errors.
24.3 The hospital has a process for reporting and acting on medication
errors and near misses on time.
COR 24.4 The hospital identifies the staff involved in the review of medication
errors and near misses.
24.5 The hospital regularly reviews the incidents of medication errors
and near misses using root cause analysis, for the future
improvement of the medication processes.
24.6 The staff is informed, on regular basis, about risk reduction
strategies regarding medication errors and ways to report them.
Evaluation
MM 25. A quality improvement program is set by pharmacy and
therapeutics committee to evaluate the medication management
system.
A committee responsible for managing drug related issues for the
hospital should be initiated to steer and evaluate the medication
management system.
The pharmacy and therapeutics committee is multidisciplinary and
5
composed of healthcare providers who are involved in the use of
medications, and they are responsible for determining the drug
formulary of their institution.
The pharmacy and therapeutics committee should regularly collect
data to identify outcomes and areas for improvement and takes
actions accordingly in addition to monitoring of the process and
outcome indicators specific to medication management.
Guiding measures:
25.1 Evaluation of the medication management system is conducted by
the pharmacy and therapeutics committee and properly
communicated with the hospital executive management regularly.
25.2 The pharmacy and therapeutics committee performs regular
monitoring of the process and outcome indicators specific to
medication management.
25.3 The pharmacy and therapeutics committee regularly collect data to
identify outcomes and areas for improvement, and takes actions
accordingly.

82
25.4 The hospital performs quality control over outsourced components
(i.e. devices, medication) of the medication management, when
applicable.

83
Infection Prevention and Control (IPC)
Introduction
The Infection Prevention and Control chapter aims at reducing the risk of
infection and ensuring patient and staff safety. The hospital has to
collaboratively ensure the proper development, implementation and evaluation
of the infection prevention and control plan that constitutes the focus of the
standards.
The Infection Prevention and Control chapter targets the following sections:
 Establishing policies and procedures
 Ensuring staff education
 Reducing healthcare-associated infections
 Cleaning and sterilizing medical devices
 Managing wastes properly
 Ensuring sharp safety
 Providing food safety
 Complying with hand hygiene
 Maintaining clean physical environment
 Monitoring quality indicators

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

84
Standards
Risk
Standard and Guiding measures
Score
IPC 1. The infection prevention and control program is managed by (a)
qualified healthcare professional(s).
Elaborating and managing an infection prevention and control
program requires in addition to a general clinical expertise and a
5 broad knowledge in infectious diseases, to be knowledgeable in
domains such as epidemiology, biostatistics, data mining and analysis,
in addition to specific skills such as a good sense of observation,
critical thinking, investigational techniques and good communication
skills.
Guiding measures:
1.1 A job description of the head of the infection prevention and
control program is in place with specific functions and
responsibilities.
1.2 The qualifications of the head/infection prevention and control
practitioners are based on education (i.e. Master in Public Health,
CIC certification) and/or training and years of experience.
IPC 2. The policies and procedures related to Infection prevention and
control are developed based on applicable local laws and regulations,
up-to-date knowledge and latest evidence-based standards and
practices.
Given the international prevalence and burden of healthcare acquired
infections it is important that such a process be controlled according
to best practice in quality improvement (such as for example the
5 PDCA cycle), and that procedures be elaborated according to local
laws/regulations, the latest practice recommendations and evidence,
in collaboration with relevant stakeholders in order to maximize
adherence to recommendations.
As knowledge in this domain is quickly advancing, these procedures
should be reviewed at most every 3 years, be easily accessible to staff,
regularly audited, and corrective actions identified and implemented
in order to maintain the required quality system.
Guiding measures:
2.1 Infection prevention and control policies and procedures are
established in collaboration with all the relevant internal and
external stakeholders when applicable.
2.2 Access to the Infection prevention and control policies and
procedures is ensured at all times.
2.3 Policies and procedures are updated at least every 3 years and
when needed, based on the latest practices (i.e. CDC, APIC),
regulations and standards.

85
 2.4 Audits are performed to monitor compliance with policies and
procedures, outcomes are evaluated and improvements are made
accordingly.
2.5 Relevant information is reported to the designated authority as per
applicable laws and regulations.
2.6 Infection prevention and Control policies and procedures specific to
each department are in place.
IPC 3. The infection prevention and control plan is supported by the hospital
executive management and a documented annual resources planning
should exist and regularly reviewed.
Implementing and maintaining an efficient infection prevention and
control program requires deployment of qualified resources that need
to dedicate time for tasks such as regular surveillance of patients with
multidrug resistant organisms, analysis and investigation of HAIs,
auditing of prevention procedures and policies, elaboration of new
procedures, training and education of staff, internal and external
reporting, etc.
Staffing for infection control cannot rely solely on bed numbers or
patient census but rather must reflect the scope of the program,
characteristics of the patient population and the workload involved.
5 Using standard staffing methods such as the World Health
Organization’s Workload Indicators of Staffing Need (WISN) method
can help indicate more precisely the number of required
professionals.
In addition to the dedicated staff for implementing the program, the
IPC department should be authorized to deploy some resources (for
example, environmental microbiology cultures) required in order to
apply the program.
Finally, access to certain reports and information in the hospital
information system is required for efficient surveillance and
evaluation by the IPC team. Surveillance being one of the most time
consuming tasks of the IPC team, using methods to optimize data
access can optimize the IPC time consumption and eventually the
staffing.
Guiding measures:
3.1 The hospital has an adequate number of healthcare workers and
resources necessary to run the program.
3.2 The hospital executive management provides access and facilitates
the use of hospital information system by the Infection prevention
and control team.
3.3 The hospital executive management is accountable for ensuring
that infection prevention and control systems are in place for
monitoring the quality of clinical practice and for assuring that care
is being delivered to patients safely and effectively by healthcare
workers.

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 IPC 4. The hospital has an infection prevention and control team/committee
to collaborate and coordinate the Infection prevention and control
plan.
The elaboration and evaluation of the IPC program should be
managed by a multidisciplinary team or committee representative of
5
the main disciplines and departments involved (medical, nursing, IPC
professionals, etc.).
Inclusion of members of the executive committee should help to
enforce the recommendations of the team and facilitate their
practical implementation.
Guiding measures:
4.1 The infection prevention and control team/committee is
responsible for managing the Infection prevention and control plan.
4.2 The infection prevention and control team/committee is
multidisciplinary involving physicians, nurses, qualified Infection
prevention and control professionals and others.
4.3 The infection prevention and control team/committee meet
regularly based on their term of reference.
4.4 The hospital takes into consideration the input of the occupational
health and safety program when developing the plan.
4.5 Evaluation of the infection prevention and control plan is
conducted, outcomes are analyzed and improvements are made
accordingly.
IPC 5. The hospital develops and updates an annual Infection prevention and
control plan.
The Infection Prevention and Control plan should be developed
5
annually, based on an updated assessment of the different infectious
risks and HAI prevalence, audit results, in addition to specific
performance metrics and hospital priorities.
Guiding measures:
5.1 Patient and healthcare workers safety measures are addressed in
the annual plan.
5.2 Healthcare workers and patient/caregiver/next of kin education
measures are addressed in the annual plan.
5.3 The hospital identifies the significant healthcare-associated
infections, processes and devices associated with risk of infections
as part of the annual plan.
5.4 The plan is implemented and evaluated annually by the infection
prevention and control team, changes are identified and
improvements are made accordingly.
IPC 6. The healthcare-associated infections are addressed by a hospital
program to reduce the risk of infection among patients and healthcare
workers.
5
Prevention of healthcare-associated infections and mitigation of
outbreaks of infectious diseases and organisms are among the most
important themes that should be addressed by the IPC program. A

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 data driven risk assessment approach is recommended in order to
prioritize efforts and evaluate the results of potential interventions.
Additionally, there exists a mechanism of communication to relevant
stakeholders with regards to any outbreaks/healthcare associated
infections.
Guiding measures:
6.1 The infection prevention and control program is based on risk
assessment, applicable local laws and regulations, current scientific
knowledge and practice guidelines.
6.2 The program incorporates a system to investigate the outbreaks of
infectious diseases, outcomes are evaluated and improvements are
made accordingly.
6.3 The hospital has a clear communication strategy to disseminate
information related to healthcare-associated infections.
IPC 7. The hospital has a comprehensive plan to manage outbreaks.
Outbreaks of infectious diseases or organisms are among the most
critical events that can occur in hospitals, since their consequences
can be serious both on the concerned patients and on the hospital
overall. A critical step is the early identification of the outbreak, when
6 its control is still possible or relatively feasible. This would require a
system that could reliably detect such outbreaks and a detailed
methodology to confirm the outbreak occurrence and subsequently to
analysis its transmission mechanisms and identify the necessary
actions to limit and stop the outbreak.

Guiding measures:
7.1 The hospital develops an outbreak rapid identification and response
system applicable to laws and regulations to identify and respond to
outbreaks.
7.2 Policies and procedure to manage outbreaks are available and
accessible.
7.3 Policies and procedure to manage outbreaks are reviewed after
each outbreak (if needed) to make the necessary improvements.
COR 7.4 The roles and the responsibilities of the healthcare workers involved
in managing the outbreaks are identified through specific policies
and procedures.
7.5 Healthcare workers are properly trained to manage outbreaks.
7.6 Outbreaks are communicated internally and externally to the
designated authority via specific channels.
IPC 8. The hospital has a surveillance program for the healthcare-associated
infections.
Ventilator Associated Pneumonia (VAP), Central Line Associated
5 Bloodstream Infections (CLABSI), Catheter Associated Urinary Tract
Infections (CAUTI) and Surgical Site Infections (SSI) figure among the
most prevalent and clinically significant Healthcare Associated
Infections (HAI). These HAIs have been thoroughly studied,

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 preventive interventions have been identified and their outcome well
evaluated in the literature. Therefore, a regular measurement and
surveillance of such HAIs should be a key to lower their incidence and
to identify the impact of any preventive measured implemented.
Direct feedback to concerned departments is important for
awareness and for joint elaboration of relevant corrective and
preventive actions.
Guiding measures:
8.1 A surveillance system is in place to detect, track and investigate the
sources of healthcare-associated infections.
8.2 The infection prevention and control team/committee implement a
surveillance program based on major Infection prevention and
control risks identified in the hospital and its environment.
8.3 Surveillance reports are generated on a quarterly basis and properly
communicated with the relevant departments.
8.4 Review of the surveillance reports is conducted by the related
departments, outcomes are analyzed and improvements are made
accordingly after consultation with the infection prevention and
control team.
IPC 9. The hospital implements proper precaution practices and isolation
measures to prevent transmission of contagious diseases to
healthcare workers and visitors, and to protect the
immunosuppressed population from acquiring infections.
Standard and transmission-based precautions are the cornerstone for
6
preventing and/or breaking the transmission chain for infectious
diseases. These measures to be correctly implemented should also be
accompanied by the availability of well-designed isolation rooms
where such precautions can be ergonomically applied, and for which
the cleaning process is well defined and regularly evaluated.
Guiding measures:
9.1 Policies and procedures exist regarding standard and transmission-
based precautions.
9.2 Isolation measures are applied to all patients having or suspected to
have contagious diseases.
9.3 Immunosuppressed patients are separated from patients with
communicable diseases.
9.4 Each isolation room is equipped with a hand hygiene basin and
COR toilet.
9.5 Rooms with negative pressure ventilation are routinely checked and
monitored based on delineated criteria (i.e. American Institute for
Architects guidelines for isolation rooms) to receive patients with
airborne diseases.
9.6 Transferring patients with Multi-Drug Resistant Organisms (MDRO)
within the hospital or to other facilities follows a specific policy.
9.7 Cleaning of the isolation rooms follows evidence-based guidelines
for Infection prevention and control.

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 IPC 10. The hospital implements a process for managing acute flow of
patients with airborne infections.
Airborne transmitted infections (such as tuberculosis, COVID19, etc.)
cases are intended to be admitted to negative-pressure ventilated
5 rooms in the hospital. However, in the event the number of
incoming patients exceeds the capacity of such rooms, a process
should be available to ensure minimal safety conditions within
normal rooms, and concerned healthcare workers should be aware
of such a process through an education session.
Guiding measures:
10.1 The hospital has a process in place to manage patients with
airborne infections in case where the negative pressure rooms are
not available.
10.2 Healthcare workers are educated, tested and audited to ensure
compliance with the process, outcomes are evaluated and
improvements are made accordingly.
IPC 11. All healthcare workers are involved and educated about infection
prevention and control measures and practices; patients, family
caregiver and visitors are informed about such measures and
practices.
As IPC procedures concern all hospital staff, it should be important
5 that continuous training be given to all staff regarding basic IPC
measures so that this information stays up-to-date. Also, since new
staff could be unfamiliar with hospital IPC procedures, thus
potentially leading to breaches in the prevention measures and
systems, IPC training should be included in the integration period of
this staff.
Guiding measures:
11.1 The hospital performs continuous training and education to
healthcare workers on infection prevention and control, based on
specific a training plan.
11.2 Education is given to healthcare workers based on the significant
trends and rates of infection.
11.3 The infection prevention and control orientation program is in place
where the newly involved healthcare professionals attend it upon
hiring.
11.4 Evaluating the effectiveness of the educational sessions for
healthcare workers is performed and improvements are made
accordingly.
11.5 The hospital healthcare workers educate the patients and their
families about the routine practices and the additional precautions
used, in a clear and comprehensible way.
IPC 12. A risk-based documented approach is adopted to reduce healthcare-
5
associated infections.

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 A risk based and data driven approach needs to be adopted in order
to decrease the risk of healthcare associated infections. In fact, each
type of HAI comes with a specific prevalence level and
morbidity/mortality profile. Therefore priorities should be
identified, based on the specific risk profile of these HAIs in the
hospital (as identified by surveillance data, indicator data and risk
management tool reports), and on possible resources and priorities
of the institution. A data driven risk assessment approach is
recommended in order to prioritize efforts and evaluate the results
of potential interventions.
Guiding measures:
12.1 The hospital identifies priorities for reducing the rates of infection
based on data stemming from surveillance of infections associated
with respiratory tract, urinary tract, invasive vascular devices,
surgical site, emerging or reemerging infections in the community
and epidemiologically significant microorganisms (multi-drug
resistant organisms, Clostridium difficile).
12.2 The hospital establishes strategies to reduce the risk of infection
based on the organizational priorities and the trends and the rates
of infections.
12.3 Risk management tools (i.e. FMEA, RCA) regarding infection
prevention and control are applied in the hospital.
12.4 Risk assessment is conducted annually to identify the highest risk
activities and properly documented.
12.5 Risks are managed and mitigated through appropriate strategies
education and change in practice.

IPC 13. Evidence-based interventions are in place to prevent healthcare-

associated infections.
Care bundles include a set of evidence-based measures derived from
years of continuous research in the IPC domain, that need to be
implemented together, to show a significant improvement in
patient care. Together they have a greater effect on the outcome
than the isolated implementation of individual measures.
5
Adherence to bundles (which can be measured by the corresponding
infection rates, audits etc.) helps to deliver consistent and reliable
patient care. The measures included in a bundle also have to be
adapted to the local setting and suited to the patient care culture of
the hospital. Adherence to the bundle should be recorded and
evaluated to ensure compliance by all members of the involved
healthcare team.
Guiding measures:
13.1 The hospital abides by care bundles to prevent Ventilator
Associated Pneumonia (VAP), surgical site infections, Catheter-
Associated Urinary Tract Infections (CAUTI) and intravascular
catheter-associated bloodstream infections.

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 13.2 Indicators on care bundles to prevent Ventilator Associated
Pneumonia (VAP), surgical site infections, Catheter-Associated
Urinary Tract Infections (CAUTI) and intravascular catheter-
associated bloodstream infections are collected, outcomes are
analyzed and evaluated, and improvements are made accordingly.
IPC 14. The hospital has a validated process for cleaning and sterilizing
medical devices within manufacturers’ recommendations.
Cleaning and disinfection of medical device figure among the most
critical IPC processes since they can prevent cross-contamination
6 between patients by infectious organisms. Cleaning and disinfection
methods should abide by IPC guidelines and by the medical device’s
manufacturer’s recommendations. Such processes need to clearly
defined and easily available for all concerned staff, and correct
application regularly audited and measured.
Guiding measures:
14.1 The standardized methods of cleaning and sterilizing the medical
equipment abide by the Infection prevention and control principles
and according to the manufacturer’s method of
COR
cleaning/sterilization of medical devices.
14.2 When applicable, the external service provider, based on a contract,
abides by the hospital’s validated process for cleaning and sterilizing
medical devices, to measure the compliance.
IPC 15. The hospital has a validated process for proper handling of laundry.
Handling and cleaning of hospital laundry prevents cross-
contamination and protects healthcare workers from carrying
6 infectious organisms. The hospital should implement appropriate
IPC measures for laundry handling at all important steps of the
process. Specific attention should be given to the appropriate choice
and dosage of cleaning products.
Guiding measures:
15.1 Laundry department follows the infection prevention and control
COR principles (e.g. CDC guidelines for laundry).
15.2 When applicable, the external service provider, based on a contract,
abides by the hospital’s validated process for proper handling of
laundry, to measure the compliance.
IPC 16. A process is in place to manage expired supplies and reprocessed
devices according to applicable laws and regulations.
In a context of limited resources or product availability, reprocessing
of medical devices could be possible under strict conditions that do
not compromise the patient’s safety, and according to recognized
5 guidelines, standards or studies with sufficient level of evidence.
The items for which reprocessing is possible should be identified as
well as the exact conditions for reuse (including type and modalities
of disinfection), and available evidence and rationale for safe reuse.
Given the residual risk of cross-contamination, a strict traceability of
reuse of these devices should be available (name of patient for

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 which the device was used, date and time of use, identity of
healthcare professional having used it, etc.) for auditing and
investigational uses.
Guiding measures:
16.1 The process specifies the following:
16.1.1 The type of devices that needs and can be reprocessed upon
manufacturers’ recommendations
16.1.2 The maximum time that the used device kept unclean
16.1.3 The maximum number of times the device can be
reprocessed
16.1.4 The patients on whom the devices were used
16.2 The hospital ensures that healthcare workers are competent and
properly trained on policies and procedures for reprocessing the
devices.
16.3 A traceability system of the used devices is in place.
16.4 In case of external service provider, the hospital ensures that a
contract is in place to monitor the quality of the services.
16.5 Risks associated with reprocessed devices are identified and
improvements are made accordingly.
IPC 17. The hospital abides by particular validated requirements to
reprocess endoscopic devices.
Endoscopic investigation and interventions hold a high risk of cross-
contamination between patients, since endoscopes are often reused
for multiple patients within hours or days. Most flexible endoscopes
cannot be heat sterilized and are designed with multiple channels,
which are difficult to clean and disinfect. Therefore inspection,
cleaning and disinfection processes for endoscopes are of
paramount importance and should be performed in accordance with
5
recommendations from recognized IPC institutions (CDC, WHO,
ECDC, etc.) as well as per the manufacturer’s specific
recommendations, so as not to induce technical defects or damages
that could render inefficient or inadequate the cleaning and
disinfection, thus increasing the risk of cross-contamination.
Also, implementation of regular microbiological surveillance of
endoscope reprocessing is appropriate to detect early colonization
and biofilm formation in the endoscope and to audit the efficiency
of this process.
Guiding measures:
17.1 Healthcare workers are trained to inspect the devices for cracks,
clean and disinfect it according to the relevant policies and
procedures.
17.2 Cleaning of the endoscopic devices is done in a separate room
according to procedures and guidelines issued by the Infection
prevention and control standards.
17.3 Proper and appropriate storage of the devices is ensured to reduce
the risk of infection.

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 17.4 The hospital maintains a record of reprocessed devices.
IPC 18. Collaboration exists between the infection prevention and control
program and the occupational health and safety program.
Infected personnel pose a risk of contamination and outbreak of
infectious diseases within the healthcare institution. Therefore the
occupational health and safety program should address these risks
4
in collaboration with the infection prevention and control team.
Policies such as pre-employment examination, preventive measures
to reduce certain risks of infection, confinement post-infection,
return to work, vaccination and regular testing should be elaborated
in collaboration between the OHS and the IPC teams.
Guiding measures:
18.1 Policies and procedures relevant to reducing the risk of infection are
recognized and addressed by the occupational health and safety
program.
18.2 The hospital sets work restrictions in collaboration with occupation
health and safety guidelines to protect healthcare workers, patients
and visitors against transmission of infection.
18.3 Evidence is in place to ensure that healthcare workers are lab tested
and vaccinated on regular basis as per hospital policies and
procedures.
IPC 19. The hospital establishes and implements a process for proper and
safe disposal of infectious wastes to reduce infection.
Waste produced by clinical operations and holding infectious risk
needs to be decontaminated before being treated. Therefore,
5 proper triaging and processing of hospital waste need to abide by
applicable laws and regulations. Also, disposal of body fluids and
blood components need to done in a way that minimizes the
infectious risk of these components before they join the wastewater
collection system.
Guiding measures:
19.1 The hospital complies with applicable local laws and regulations for
handling, treating and disposing of the infectious wastes, and
periodic audits are done by the ministry of environment.
19.2 A contract is done with an agency to dispose medical waste or done
in-house.
19.3 The healthcare workers are trained on the handling and the
disposing of infectious wastes, blood and blood components.
19.4 Blood/body fluids spill kits are present in clinical areas.
19.5 A policy is in place to manage the operations in the mortuary and
the post-mortem area.
IPC 20. The hospital reduces the risk of infection through proper handling
and disposal of sharps.
5 Handling of sharps and needles are potential sources of
contamination for staff from infected patients, and should be
disposed in special puncture-proof and leak proof containers. Any

94
 sharp or needle injuries be evaluated and managed according to
procedure to rule out any infectious risk from the patient, but also
reported and analyzed as to identify the gaps in practice or in
knowledge that can lead to better prevention of such incidents.
Such types of incidents should be monitored as an OHS
performance objective, and regular trainings and refreshers
provided to concerned staff.
Guiding measures:
20.1 The hospital reduces the risk of sharps and needle-related injuries
and infections through implementing evidence-based practices.
20.2 Safely engineered (puncture-proof and leak-proof) devices are used
as part of the hospital’s occupational health and safety program to
collect sharps and needles.
20.3 Disposal of sharps and needles follows safe and appropriate
disposal procedures.
20.4 There is a system in place to report sharp and needle-related
injuries.
20.5 The hospital performs root-cause analysis of the reported sharp and
needle injuries, as per hospital policies and procedures.
20.6 The hospital abides by proper and safe injection practices.
20.7 The hospital trains the healthcare workers on proper and safe
handling of needles and sharps.
20.8 An evaluation process is in place to identify the effectiveness of the
intervention done to reduce the sharp and needle-associated
injuries.
IPC 21. The hospital abides by food safety standards to reduce the risk of
food-borne diseases. [OTHER – 7]
Due to highly susceptible and frail populations among hospitalized
patients, such as the elderly, outbreaks of nosocomial food-borne
infections can add to the morbidity of these patients. Food-borne
bacteria can multiply rapidly if food is not maintained at certain
appropriate temperatures for refrigeration and hot holding, and if
there are delays between food preparation and distribution. Also,
dishwashers need to reach thermal disinfection temperatures to
sufficiently reduce the pathogens.
5 Most nosocomial food-borne pathogens are spread by the fecal-oral
route. The primary source of outbreaks may be contaminated
food/water, and infected/colonized patients, visitors, staff, or food
handler. Therefore, food handlers must be aware of high standards
of personal hygiene and perform hand hygiene and sanitation
appropriately and in the right indicated moments.
These and other potential hazards need to be addressed in a
systematic way by the hospital in order to prevent and control such
risks related to food-borne infections. Hazard Analysis Critical
Control Point (HACCP) is recognized as an effective food safety
assurance system and can be used to attain standards specific to

95
 food safety such as Food Code (US food standards by FDA) and
Codex Alimentarius (International Food Standards by FAO/WHO).
Regular inspections and audits by the IPC team should be performed
to monitor the implementation of this program.
Guiding measures:
21.1 The hospital abides by Hazard Analysis and Critical Control Points
(HACCP) to ensure clean and appropriate environment for safe food
handling.
21.2 Preparation of food is done using proper sanitation measures and
under appropriate room temperatures, and audits are conducted to
test the compliance.
21.3 Sanitation measures are implemented in the kitchen.
IPC 22. The hospital follows measures to reduce the risk of infection during
renovation, demolition and reconstruction, as per hospital policies
and procedure.
Renovation, demolition and reconstruction projects raise concerns
about contamination of workers, patients and personnel by
aspergillus and other fungi, whose spores can be dispersed on dust
or dirt particles when floors, walls, and ceilings are penetrated, and
5 can remain suspended in the air for prolonged periods of times.
Immuno-compromised persons are vulnerable to aspergillus and
other fungal infections which can in some cases increase their risk of
mortality.
Therefore the IPC team needs to know beforehand of such projects
in order to assess the associated risks and recommend actions that
can be taken to enhance personnel, workers, patients and visitor
safety, and verify their implementation.
Guiding measures:
22.1. The Infection prevention and control team is consulted when
renovation, demolition or reconstruction occurs.
22.2. An infection control risk assessment (ICRA) is done and signed prior
to renovation, demolition and reconstruction.
22.3. Actions based on the infection control risk assessment are
implemented
IPC 23. The hospital ensures the correct usage and availability of personal
protective equipment, soap and hand antiseptics.
Use of appropriate Personal Protective Equipment (PPE) and hand
hygiene are fundamental elements needed to apply standard and
transmission-based precautions.
Trainings regarding the correct use of PPE, as well as the indications
5
and technique of hand hygiene should be provided to all concerned
healthcare workers, as well to visitors when applicable. Availability
of PPEs and hand hygiene solutions should be available in sufficient
quantities at all times and in all points of care. However,
requirements can adapt to scenarios of contingency and crisis based
on a risk assessment and evidence-based approach.

96
 Guiding measures:
23.1 Appropriate usage of the personal protective equipment is guided
by policies and procedures that are addressed by the hospital’s
occupational health and safety program.
23.2 Healthcare workers are competent and trained about using the
appropriate personal protective equipment, when indicated.
23.3 Visitors are informed about using the personal protective
equipment to reduce the risk of infection.
23.4 Personal protective equipment is available at any point of care,
when indicated.
23.5 The hand and surface disinfectants are available at each point of
contact
23.6 Hand disinfecting and hand washing facilities are equipped with
antiseptic soap/ hand rub solutions, disposable towels and a foot-
pedal bin.
IPC 24. The hospital ensures proper hand hygiene practices. [QMPS-18]
Hand hygiene is one of the most important measures to apply in
order to limit healthcare associated infections. Yet conformity of
healthcare workers with hand hygiene remains very challenging for
most hospitals.
6
Trainings and refreshers about the indications and proper
techniques of hand hygiene need to be accompanied by regular
objective (with minimal observation bias) audits to monitor
compliance.

Guiding measures:
24.1 Hand hygiene guidelines are up to date and are implemented.
24.2 Healthcare workers comply with the guidelines related to hand
hygiene.
24.3 Healthcare workers and visitors have access to hand washing sinks
or alcohol-based hand rubs at all times.
COR 24.4 Proper instruction is available to instruct the healthcare workers
and visitors about the proper hand hygiene technique.
24.5 Reminders showing the proper hand washing technique and usage
of the alcohol-based hand rubs are posted throughout the hospital.
24.6 Audits are done, within a year timeframe, to monitor the
compliance with hand hygiene policy, outcomes are evaluated and
improvements are made accordingly.
IPC 25. The central sterilization services abide by the Infection prevention
and control measures.
The Central Sterilization Service Department (CSSD) aims to ensure
5 disinfection and sterilization of reusable material so as to eliminate
the risk of cross-contamination by instruments and medical devices.
The functional areas of the CSSD: decontamination, preparation and
packaging, sterilization and sterile storage should be separated.

97
 One-way flow of items between soiled and clean work areas and
sterile storage gains to be implemented.
Policies and procedures for proper disinfection and sterilization of
devices should be elaborated based on IPC recommendations,
taking into consideration the manufacturer’s recommendation of
the device. CSSD workers should be well trained regarding these
policies and procedures, as well on applying specific safety
measures relative to the department.
Guiding measures:
25.1 The healthcare workers of the central sterilization department are
qualified, certified or received training on proper sterilization and
disinfection.
25.2 Areas, where items are decontaminated, are physically separated
from areas where items are sterilized, packaged and stored.
25.3 The hospital ensures that healthcare workers’ safety measures are
implemented in the central sterilization department.
IPC 26. The hospital environment is clean and disinfected.
Transmission to a patient of nosocomial pathogens existing in the
close environment of another infected patient is one mode of
contamination that needs to be seriously addressed through
effective cleaning and disinfection of the contaminated physical
environment.
5 Procedures should be elaborated specifying the high, middle and
low risk areas of the hospital and the associated cleaning products
that should be used in each area, in addition to the case of cleaning
infected patient rooms, and indications of room culturing.
The IPC team needs to monitor and assess the environmental
cleaning process, through observation audits and other techniques if
necessary (e.g. microbiological cultures, ATP testing, etc.)
Guiding measures:
26.1 There are policies and procedures for cleaning and disinfecting the
physical environment.
26.2 The hospital assesses the risk of infection and classifies the areas to
be cleaned accordingly.
26.3 The Infection prevention and control team is responsible for
performing environmental microbiological cultures when necessary.
26.4 In case of external provider, the hospital monitors the quality of the
services provided to ensure compliance (i.e. second party audit and
contract of how to abide by procedure) and adherence to the
standards of practice.
IPC 27. The Infection prevention and control process is part of the overall
hospital’s quality improvement and patient safety program.
Quality indicators relative to the HAI prevention program need to be
4
defined in order to monitor the rates of HAIs, results of which need
to be analyzed in order to derive appropriate actions and later on
measure their impact on the outcomes.

98
 Such indicators gain to target the essential problematic areas
according to the risk assessment method applied by the IPC team.
Indicators can span all three categories: outcome, process and
structure.
Examples of outcome indicators include rate of selected categories
of HAIs, process indicators include the conformity rate of hand
hygiene, and structure indicators could include the level of
consumption of hydro-alcoholic solutions per department type and
1000 patient-days.
Guiding measures:
27.1 There is evidence that indicators related to the healthcare-
associated infections are collected.
27.2 Indicators related to the healthcare-associated infections are
analyzed and monitored.
27.3 Results of the indicators’ management are communicated to the
healthcare workers, physicians and hospital executive management
on quarterly basis, and improvements are made accordingly.
IPC 28. The hospital has a process to manage and ensure proper
antimicrobial prescription and limit overuse and misuse of
antimicrobials. [MM-3]
Overuse of broad spectrum antibiotics (BSA) is linked to the
emergence and selection of multidrug resistant organisms.
Therefore, restricting use of BSA needs to be ensured through the
6
strict implementation of a prescription policy applicable to all
hospital physicians.
Awareness about antimicrobial correct indications and correct-
indication level of prescriptions is important, and data about the
pertinence of the antimicrobial prescriptions needs to be analyzed
and shared with key stakeholders.
Guiding measures:
28.1 Certain antimicrobials are prescribed according to evidence-based
practice.
28.2 Antimicrobials prescription is reevaluated every 72 hours.
28.3 The hospital evaluates or ensures at least once a year, the
implementation of the recommendations and the pertinence of the
prescriptions.
COR
28.4 The hospital educates the patients about the proper use of
antimicrobials and with proper documentation in the medical
record, upon discharge.
28.5 The hospital guides the physicians and healthcare workers to
restrict the overuse/misuse of antimicrobials through setting
specific policies.
28.6 The hospital has indicators to measure antimicrobial prescriptions

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Quality Management and Patient Safety
(QMPS)
Introduction
The Quality Management and Patient Safety chapter addresses the hospital’s
responsibility in ensuring quality at the level of patient care. To have an effective
continuum in quality management and patient safety, the hospital should
implement collect, analyses and communicate data related to quality
improvement and patient safety. Moreover, adverse-events, near-misses and
sentinel events are major events that may jeopardize patient safety, thus the
hospital is required to have a mechanism to prevent and manage their
occurrence.
The Quality Management and Patient Safety chapter targets the following
sections:
 Quality management and patient safety plans/programs
 Risk management program
 Data collection, analysis and communication
 Sentinel, adverse and near-miss events
 Patient identification
 Handover communication
 Verbal and telephone orders
 Reporting of critical diagnostic test results
 Safeguard correct site, procedure and patient during surgery
 Procedure time out
 Fall prevention
 Hand hygiene
 Concentrated electrolyte control and management
 High alert medications management

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

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Standards
Risk
Standard and Guiding measures
Score
QMPS 1. Quality management and patient safety programs/plans are
supported and implemented by designated qualified individuals.
The quality and patient safety programs/plans ensure that the safety
of patient care is secured and there is continuous quality
improvement overseeing all areas of the healthcare facility. This
plan/program should be developed by qualified personnel/team, in
coordination with the executive management, addressing high
priority/high risk issues, while going in line with the hospital’s
4 strategic plan. It is important that this program/plan’s objectives are
evaluated on a regular basis via meetings by a designated
multidisciplinary quality and safety committee, selected key
performance indicators and reports presented to the committee and
governing body. The qualified personnel/team are responsible to
oversee, facilitate the implementation and integration of the plan in
various departments, help foster an organizational safety culture
(using validated tools such as the AHRQ Patient Safety Culture
survey) and guide the consequent improvement actions.
Guiding measures:
1.1. The quality management and patient safety plans are revised
annually and support the hospital-wide strategic plan.
1.2. A qualified individual with relevant experience, education and
training is designated to guide the quality management and patient
safety plan
1.3. The hospital has a multidisciplinary committee with a delineated
term of references that address patient safety and quality
improvement issues and supports in coordination with the quality
management and patient safety coordinator/manager to implement
plans in this regard.
1.4. The quality management and patient safety committee support
departments/units/services in the implementation of quality
management and patient safety activities.
1.5. Patient safety culture survey using a validated tool is conducted
every 2 years and consequent improvements are implemented.
1.6. Evidence of staff training on quality management and patient safety
by qualified professionals is conducted and documented in the
personnel files.
1.7. On a regular (at least twice a year) basis, the quality management
and patient safety coordinator/ manager reports key performance
indicators to the hospital executive management.
5 QMPS 2. Continuous quality improvement and patient safety is implemented.

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 Continuous Quality and safety improvement in health care is a
structured organizational process that involves staff (clinical, non
clinical, technical etc.), policies/procedures/processes, physical
environment and products/materials, working together to
implement the set quality and safety improvement objectives. Such
objectives once planned, are implemented, evaluated and
documented for traceability and assessment purposes. The hospital
must have a defined and validated performance improvement
approach, made known and acquired to staff, to improve clinical
outcomes and patient experiences and reduce organizational costs.
Examples of such tools include PDCA cycles, process maps, fishbone
diagrams, run charts, etc.
The continuous quality improvement and patient safety approach
should also be guided by risk management processes/data (proactive
and reactive), which will help in placing effective strategies and
improvement projects addressing hospital wide risks which can have
an impact on the quality and safety of care, while setting priorities
for each project according to the risk assessment. At least one
hospital-wide improvement project’s impact must be evaluated by
the quality and safety committee per year, driving the
implementation of the identified improvement objectives in a
continuous manner.

Guiding measures:
2.1. Quality improvement and patient safety improvements (i.e. people,
policy and/or procedure and/or process, place, product, price) are
planned, implemented evaluated and documented.
2.2. The hospital uses a defined and validated performance
improvement approach.
2.3. Based on risk management processes, effective improvements are
documented.
2.4. The quality and patient safety committee analyze the impact of at
least one hospital-wide priority improvement project per year.
QMPS 3. Data is collected to support quality and patient safety.
Data highly contributes to the improvement of patient safety and
quality by identifying gaps and key causes in an objective manner,
assessing quality of provided services etc. in order for safety
improvement interventions will be developed. The hospital has a
standardized, uniform manner of collecting data, by trained
4
personnel; using evidence based key performance indicators set by
the executive management in coordination with the quality and
patient safety department. Such indicators should reflect the quality
and safety of care provided and covers the structure, process and
outcomes of the hospital’s clinical, non-clinical, administrative and
patient safety areas, collected on a regular basis.

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 The data collected must be validated using a defined process, upon
which it is analyzed by the concerned stakeholders in coordination
with quality and safety professionals, resulting in final conclusions
and recommendations for improvement.
Guiding measures:
3.1. Data is collected by trained individuals.
3.2. There is a uniform process to collect data on quality and patient
safety.
3.3. Hospital executive management defines a set of most recent
evidence-based key performance indicators focusing on major
clinical and management areas and patient safety.
3.4. The characteristics of indicators are documented which consist of;
indicator definition, sample size, inclusion and exclusion criteria,
target, methodology, frequency and result.
3.5. The indicators cover structure, process and outcome of clinical and
non-clinical areas.
3.6. Quality and patient safety indicators are collected on a regular
basis.
3.7. The hospital has a process to validate data which is described in the
data collection policies and procedures.
3.8. Patient’s confidentiality is preserved if quality and patient safety
indicators to be provided to external institutions/databases, based
on applicable laws.
QMPS 4. There is a process to analyze quality and patient safety data.
For the institution to benefit from the collected data, the data must
be validated and analyzed by qualified, experienced individuals with
the relevant experience, using statistical tools and other established
data analysis methods, including trending and benchmarking. Results
of this analysis should be presented to the hospital executive
4 management/governing body as part of the hospital-wide dashboard
in addition to the concerned departments. This information is then
used to assess any current areas for improvement, and help set
subsequent quality and safety priorities/objectives. The hospital
should be ready to provide data required by the Ministry of Public
Health, or external organizations, as per applicable laws and
regulations.
Guiding measures:
4.1. Data is analyzed by qualified individuals with appropriate
knowledge, experience and skills.
4.2. Data is analyzed using statistical tools and techniques, when
appropriate.
4.3. Hospital-wide dashboard includes quantified quality and patient
safety indicators.

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 4.4. Analyzed and validated data is communicated to Ministry of Public
Health and/or external institutions when required by laws and
regulations.
4.5. Data analysis results are reported to the hospital executive
management and to the concerned departments/units and
committees.
4.6. Hospital executive management uses the results of the data
analysis to prioritize quality management and patient safety
projects, develop the strategic and the operational plan and
improvement processes.
4.7. Evidence of data trending and benchmarking is available for
improvement purposes.
QMPS 5. A risk management program/strategy/plan is implemented.
The risk management plan/program in hospitals plays a vital role in
detecting, monitoring, mitigating and preventing risks from affecting
the quality of care and services and causing harm; and goes hand-in
hand with the hospital’s quality and safety program/plan. It follows
an established well defined risk management strategy of identifying
and managing risks (identify, assess, treat, monitor and report risks)
based on reactive and proactive risk assessment methodologies.
Qualified personnel by education, experience and training must
guide and facilitate the risk management program/plan, in addition
aid in the training of staff on the risk management principles to aid in
4 achieving the institution’s risk management objectives in a collective
manner.
Actions integrated within the risk management
program/strategy/plan should cover all areas of the institution
(clinical, managerial, financial, occupational) and may be directed
toward the patient (provision of adequate care, decision support),
staff (training, availability of policies/protocols), organization and
facility (improved leadership/guidance, proactive risk assessment),
and toward therapeutic agents and equipment (regular audits,
forcing functions). Results and improvements must be documented
and communicated to the concerned personnel and executive
management.
Guiding measures:
5.1. The hospital has a multidisciplinary committee of qualified
individuals with relevant experience, education and training,
designated to guide the risk management program/strategy/plan
and is defined by name and function.
5.2. A qualified individual with relevant experience, education and
training is designated to guide the risk management
program/strategy/plan
5.3. Hospital managerial, clinical and financial risks are identified and
managed through risk management framework based on a

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 proactive systematic framework consisting of; risk identification,
risk analysis, risk evaluation and risk control.
5.4. Evidence of staff training on risk management.
5.5. Risk management results and improvements are documented
5.6. Risk management results and improvements are communicated to
hospital executive management and relevant staff members.
QMPS 6. The hospital uses a defined and standardized process for identifying
and managing Sentinel Events.
A sentinel event is a patient safety related event that may result in
death, permanent or severe temporary physical or psychological
harm or life-saving intervention.
It is vital that staff is aware what constitutes a sentinel event and
what are the types of events that should be reported. Thus the
hospital should have a defined list of such sentinel events,
accompanied by a standardized process/policy to identify, analyze,
and manage such events, made aware to all hospital staff.
6 Due to the severity of such events, and to avoid the recurrence of
further events, the hospital must have a clear policy with defined
timeframes for the reporting (within 48 hrs.) and analysis (within 45
days) of such events to ensure prompt, timely actions. Analysis must
include a multidisciplinary team in order for effective and valid
improvement actions to be placed.
Actions taken to address these events are documented, reported to
and evaluated by the hospital executive and quality and patient
safety committee. Evidence of this evaluation should be kept
(meeting minutes, reports, indicator data, root cause analysis reports
etc.)
Guiding measures:
6.1. Sentinel events have been defined in hospital policies including a list
of types of events that are considered sentinel and should be
reported.
6.2. The hospital uses a standardized process for identifying and
managing sentinel events.
6.3. There is a standardized process to report sentinel events to hospital
executive management within 48 hours of the internal notification
COR of the event.
6.4. A multidisciplinary team performs a root cause analysis of the
sentinel event within 45 days from the date of the internal
notification of the event
6.5. Evidence that the hospital executive management and quality
management or patient safety committees implemented and
evaluated the actions taken on the result of the root cause analysis.
6.6. Corrective and preventive action plans are implemented to prevent
further sentinel events.

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 6.7. Quality management and patient safety committee reviews and
updates the patient safety incident process and reports to hospital
executive management annually.
QMPS 7. The hospital uses a defined process for identifying and managing
Adverse Events.
An Adverse Event is defined as any injury caused by medical
management rather than by the underlying disease or condition of
the patient and does imply harm (AHRQ).
Such events and their types must be defined in a hospital policy,
6 which also describes how and when they should be reported, in
addition to the approach and/or tools used to analyze such events.
Systematic approach to reporting and analyzing adverse events aids
in fostering a culture of safety, where results of the analysis are fed-
backed to the concerned stakeholders and relevant corrective,
preventive improvement actions are documented, implemented and
evaluated.
Guiding measures:
7.1. Adverse events have been defined in hospital policies including a list
of types of events that are considered adverse and should be
reported
COR 7.2. The hospital has a uniform process for reporting adverse events
7.3. Adverse events are analyzed using specific tools (i.e. Root cause
analysis)
7.4. Corrective and preventive action plans are documented,
implemented, and evaluated.
QMPS 8. The hospital uses a defined process for identifying and managing
Near-Misses
Near misses are incidents that did not cause patient harm, but could
have if not for timely detection and interventions done by healthcare
professionals.
Using a defined process for identifying, reporting and analyzing near
5 misses is vital in healthcare facilities as it ensures the improvement
of quality and safety of the care provided to the patient and culture
of the institution. As well as constituting an integral component of
the organization’s risk management program/plan. Thus all
corrective, preventive improvement actions must be documented,
implemented and evaluated, while being reported to the executive
management and quality and safety committee.
Guiding measures:
8.1. Near-Miss events have been defined in hospital policies including a
list of types of events that are considered near-miss and should be
reported
8.2. The hospital has a uniform process for reporting near-misses.
8.3. Evidence of near-misses analysis.
8.4. Corrective and preventive action plans are documented,
implemented, and evaluated.

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 8.5. Hospital executive management assures a process for the
investigation of near-miss events
QMPS 9. Prospective analysis is performed on patient safety-related issues.
A prospective analysis, such as the failure mode and effects analysis
(FMEA) is an essential component of the risk management strategy
to proactively identify, mitigate or prevent safety risks of a certain
5
process or department. It is a structured, analytical tool to help
identify hazards in each step of the process and identify relevant
preventive and corrective actions in a standardized documented
manner.
Guiding measures:
9.1. Prospective analysis (i.e. failure mode effect analysis) is done on at
least one of the priority risk processes, annually.
9.2. Evidence of result analysis and action plan and/or decisions taken.
9.3. Evidence of documented and implemented improvements
QMPS 10. There is a process to communicate patient-related information and
variation of care to patients and family caregivers. [PFR-13]
In the spirit of having patients at the center of their care and
decision making, the hospital has a policy ensuring information
relevant to the patients’ care are regularly documented and
transmitted to them or their family especially when there is a
4
change from a pre-discussed plan. Disclosing patient information
(which may include sensitive information such as serious diagnosis
or prognosis) must only be done by designated, trained qualified
staff, reflected by hospital policies/procedures. Evidence of training
ins available in addition to patient/family support
services/resources (e.g. psychological, spiritual etc.)
Guiding measures:
10.1. The hospital has a documented policy and/or process that is
implemented and regularly updated to disclose information to
patient and family members
10.2. Designated staff are trained on disclosing information to patients
and family members
10.3. Resources (i.e. psychological support) are available to support
patients and family after information is disclosed, when needed.
10.4. The variation of care to patient is documented in patient medical
file.
QMPS 11. The hospital has a standardized process to identify patients.
As the international patient safety goal 1, correct patient
identification should be the precursor to all other care acts, and it is
imperative hospitals have a clearly defined procedure or policy
6
describing how patients should be identified, when and what tools or
criteria must be present to identify patients, in addition to
accounting for situations with any patient-related vulnerabilities or
status (for e.g. newborns, unconscious, mentally disabled). At least

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 two identifiers, which do not change throughout the patient’s course
of care or subsequent admissions, must be used to identify patients
every time. For example, full name and date of birth or medical file
number. Compliance to patient identification is measured, for e.g.
through audits, observations, etc. and any misidentification incidents
are to be reported, documented and corresponding corrective or
improvement actions set and evaluated.
Guiding measures:
11.1. Patient identification measures are documented in policies and
procedures that include but not limited to; patients with similar
names, unconscious patients, newborn and mentally disabled
patients.
11.2. Patient identification by at least two identifiers (the patient’s room
number or location cannot be used for identification).
COR 11.3. Patient identification is conducted prior to treatments and
procedures.
11.4. Patient identification compliance rate is annually measured and
documented.
11.5. Patient identification incidents are documented and evaluated
11.6. Improvements are documented and required policy and/or
procedure and/or process changes are made to maintain the
improvements.
QMPS 12. The hospital has a standardized process for handover communication
used between shifts, units and transfers.
Hospitals have a standardized process for handover communication
used between shifts, units and transfers. Due to the risk of
miscommunication, it is vital standardized tools are used, which are
also clear and legible. Examples include the SBAR or I-PASS tools. This
6 is important for the effective and safe continuity of care among
providers. Such tools aid the provider in communicating the patient’s
history, current situation, assessments, associated risks to address,
pending tests/acts and recommendations to follow with every
change of shift, unit or transfer. Compliance to handover
communication must be monitored and evaluated periodically to
account for any areas of improvement.
Guiding measures:
12.1. There are standardized methods, tools or forms used by staff for
handover communication (i.e. Situation, Background, Assessment,
and Recommendation-SBAR).
12.2. Care documented in patient medical records is clear,
COR
understandable and legible.
12.3. Handover processes are regularly revised and improved when
needed.
12.4. Handover compliance rate is monitored periodically based on
hospital policies and procedures.

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 QMPS 13. Verbal and telephone orders are carried out in a safe way for critical
and lifesaving orders
Verbal and telephone orders are those given by an authorized
healthcare professional to a qualified staff member who has the
approval to receive and record them based on local laws/regulations
and hospital policy. The hospital has a policy to define which specific
situations allow for verbal and telephone orders (for e.g. lifesaving
emergencies or sterile conditions), the method of such
6
communication in addition to who is authorized to give/receive such
orders.
To account for any poor verbal transmission/hearing or poor
handwriting, such orders must be “repeated back” (in case of verbal
orders) or “read-back” (in case of telephone orders) before the order
is administered, to avoid any errors in communication. Both types of
orders must be documented in the file and marked for a repeat or
read back.
Guiding measures:
13.1. The hospital has a policy to manage verbal and telephone orders.
13.2. Verbal and telephone orders are documented in the patient records
13.3. Verbal and telephone orders are read back by the healthcare
COR personnel receiving the order.
13.4. Read back verbal and telephone orders are marked read back once
documented.
13.5. The policy is annually evaluated and improvements are
implemented and documented.
QMPS 14. Reporting of critical (life-threatening) diagnostic test results follow a
delineated process.
Reporting of critical (life-threatening) diagnostic test results in a
timely, safe and effective manner is critical for safe patient care.
Hence, there exists a clear policy/procedure specifying what
diagnostic test result levels are considered critical/life threatening
(for e.g. laboratory values, imaging results), how this result is
6
communicated, by and to whom, and any escalation pathways if
needed. Each defined critical level is defined by the concerned,
qualified professionals as per international guidelines and
internal/local epidemiological data, and is reviewed annually.
Evidence of evaluating the process can be through review of files,
data collection, audits, system tracer, observations etc. and any
improvement actions identified and implemented
Guiding measures:
14.1. The hospital has a process on reporting critical diagnostic test
results.
COR 14.2. Each diagnostic test has a defined critical level that is reviewed
annually and when needed.
14.3. The treating physician is responsible for reporting and documenting
any result to his patients or their family members.

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 14.4. The hospital defines to whom the critical results are reported.
14.5. The critical test results are reported using the verbal and telephone
order policy in case of emergency.
14.6. Evidence of process evaluation and improvement implementation.
QMPS 15. The hospital implements standardized processes to safeguard
correct-site, correct-procedure, and correct-patient surgery. [ASC-11]
Wrong patient, procedure and site are never events and should not
be accepted. Therefore, a standardized documented procedure
starting from the patient’s room until induction should be
mandatory, with several safety steps. In the patient’s room, a
member of the surgical team who is familiar with the patient and
surgery , should mark the limb or site of surgery, confirming it with
the patient or legal guardian, associated documents and using an
approved and standardized marker and method ( i.e. : check with
6 clear initials ).
Upon arrival to the operating area and then entering the operating
room until the induction time, multiple steps and verifications checks
should be implemented by several members of nursing, surgical and
anesthetic personnel. A Final check before surgical start, “procedure
time out” is obligatory.
All these steps are documented in the patient’s record.
This process must be evaluated regularly, and this can be done using
audits, observations, file reviews audits on the entire process must
be conducted and any non-compliance documented with
improvement projects and targets implemented and rechecked.
Guiding measures:
15.1. The hospital has a standardized process that is implemented before
induction of anesthesia in surgical procedures that consists of
preoperative verification, site marking and procedure time-out.
15.2. Preoperative verification is implemented using a checklist and
consists of:
15.2.1. Patient identification
15.2.2. Patient consent form
15.2.3. The procedure being performed
15.2.4. The site and side on which the surgery is being performed
COR
15.2.5. Laboratory test and images
15.2.6. Disclosure of any implants or prosthesis
15.2.7. Prophylactic antibiotic (if any)
15.2.8. Other concerns related to surgeon or anesthesiologist (i.e.
allergies, blood loss, difficult airway)
15.3. One of the individuals performing the procedure utilizes a
standardized mark, as per hospital policies and procedures, to
identify the surgical site to be operated.
15.4. Patients and/or family member and/or next of kin are involved
during site marking in the patient’s room.

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 15.5. Compliance rate to preoperative verification processes and timeout
procedure is regularly (within a year timeframe) measured and
documented.
15.6. Evidence of process evaluation and improvement implementation.
QMPS 16. A procedure time out process is implemented before the initiation of
the surgery. [ASC-13]
A “time out “procedure is the final step of the preoperative checklist
6
before starting surgery. A final check for correct patient-procedure-
site and implants. This step should be performed by all involved
health care personnel (circulating nurse, anesthetist and surgeon).
Guiding measures
16.1. Timeout is conducted in the location of the surgery, with the whole
surgery team present (i.e. surgeon, nurse and anesthetist),
immediately before starting the procedure and after the
administration of anesthesia.
16.2. The timeout is implemented to verify the patient and the surgery,
and consists of:
16.2.1. Verifying the correct patient identification
COR 16.2.2. Verifying the correct side and site of the procedure with site
marking
16.2.3. Verifying the correct patient position
16.2.4. Verifying the availability of the correct implants/devices
16.2.5. Verifying that the preoperative verification checklist has
been completed
16.3. The timeout procedure is documented.
16.4. Evidence of process evaluation and improvement implementation,
when needed.
QMPS 17. The hospital implements a process to prevent patient falls.
As an international patient safety goal, the prevention of patient falls
is central to ensuring safe patient care and reducing risks of further
morbidities, length of stay and even mortality.
There is a clear procedure/policy for the timely assessment and re-
assessment of patient fall risks (based on standardized criteria, using
6 evidence- based assessment tools such as the Morse fall risk
assessment tool, John Hopkins assessment tool), preventive
measures/precautions to be taken according to each patient’s fall
risk level and immediate actions/interventions required in the event
of a fall. Measuring and documenting fall rates, at least annually, is
important to assess and track the quality of fall prevention care
given.
Guiding measures:
17.1. Patients are assessed for the risk of fall upon admission.
17.2. The hospital implements a process to reassess the patients for risk
of falls based on a standardized criterion.
COR
17.3. Patient risk for fall assessment is documented in patient medical
record.

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 17.4. The hospital implements evidence-based intervention for fall
prevention on patients that have been assessed to be at risk for fall.
17.5. Fall rate is measured regularly (within a year timeframe) and
documented.
QMPS 18. The hospital ensures proper hand hygiene practices. [IPC-24]
Hand hygiene is one of the most important measures to apply in
order to limit healthcare associated infections. Yet conformity of
healthcare workers with hand hygiene remains very challenging
6 for most hospitals.
Trainings and refreshers about the indications and proper
techniques of hand hygiene need to be accompanied by regular
objective (with minimal observation bias) audits to monitor
compliance.
Guiding measures:
18.1. Hand hygiene guidelines are up to date and are implemented.
18.2. Healthcare workers comply with the guidelines related to hand
hygiene.
18.3. Healthcare workers and visitors have access to hand washing sinks
or alcohol-based hand rubs at all times where appropriate.
COR 18.4. Proper instruction is available to instruct the healthcare workers
and visitors about the proper hand hygiene technique.
18.5. Reminders showing the proper hand washing technique and usage
of the alcohol-based hand rubs are posted throughout the hospital.
18.6. Audits are done, within a year timeframe, to monitor the
compliance with hand hygiene policy, outcomes are evaluated and
improvements are made accordingly.
QMPS 19. Effective control and management of “at risk” concentrated
electrolytes solutions.
The control and management of “At risk” concentrated electrolytes
solutions is imperative to avoid any errors or adverse events
affecting patient safety. There exists a clear process/policy specifying
the “at risk” concentrated electrolyte solution types, storage location
and conditions, how they are labeled, ordered, prepared, dispensed,
administered and documented in the medical record, to address all
6 the corresponding safety risks that could arise from their use (for
e.g., one storage area, alert labeling, double verification of order and
administration). Such electrolyte solutions must not be found in
regular floor stocks, unless required, to avoid the risk of misuse. The
control and management of such at risk solutions is done in
collaboration with the Pharmacy or any qualified discipline. This
policy and control and management are evaluated annually for any
improvements to be implemented. Such evaluations can be done
through observations, file reviews, audits, incident reporting etc.
COR Guiding measures:

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 19.1. There is a process to store, label, order, prepare, dispense,
administer and document concentrated electrolyte solutions on the
medical record.
19.2. Concentrated electrolytes “at risk” are not found in floor stocks
unless clinically needed.
19.3. The control and management of concentrated electrolytes and
solutions are annually evaluated and improvements are
implemented and documented.
QMPS 20. There is a set of policies for managing high-risk medical devices
High-risk medical devices, such as pacemakers and artificial heart
valves, are devices that help in sustaining human wellbeing, yet may
present a potential risk of harm if misused or managed. For this
6
reason, hospitals must have a list of such devices, accompanied with
a set policy specifying the individuals authorized for access and
management of such devices, diffused to relevant departments and
updated on a regular basis.
Guiding measures:
20.1. There is a list of high-risk medical devices that are updated on
regular basis.
COR 20.2. The policy identifies the individuals involved in managing the high-
risk medical devices
20.3. Access to the high-risk medical devices is limited to the authorized
staff.
QMPS 21. There is a policy for managing high-alert medications.
High-alert medications are medications that endure a high risk of
causing adverse effects on patients if not managed correctly or
safely. Examples include anticoagulants, chemotherapy agents,
insulin and narcotics. The institution has a list of such medications in
the hospital, and this list is made available to all users concerned and
revised regularly by qualified professionals. There should be a clear
policy addressing all the potential safety risks involved at each step
6
from medication ordering, storage, labeling, dispensing, preparing,
administering, monitoring and documenting in the patient’s record.
For example, access should be restricted to authorized staff, storage
well designated, labels clear and highlighted and having a double
independent verification upon preparation and administration to
avoid any prescription, dispensing and administration errors. It is
important to evaluate the compliance to this high-alert medication
policy and address gaps in practice promptly and effectively.
Guiding measures:
21.1. There is a list of high-alert medications that is updated on regular
COR basis.
21.2. The policy identifies the individuals involved in managing the high-
alert medications.

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21.3. A process is present for each phase in managing the high-alert
medications from storing, labeling, ordering, preparing, dispensing,
administering and documenting on the medical record.
21.4. Access to the high-alert medications is limited to the authorized
staff.
21.5. Compliance rate to the policy for managing high-alert medications is
regularly (within a year timeframe) measured and documented.

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 Patient Centered Care

Access and Continuity of Care (ACC)

Introduction
The Access and Continuity of Care chapter aims to promote patient safety
throughout the patient’s continuum of care. This chapter addresses issues of
discharge, transfer and referral. As such, the hospital is expected to define and
communicate the services provided. Healthcare workers are also expected to
screen patients in order to identify their healthcare needs and potential risks
(i.e. functional limitation, nutritional status). This will ensure effective treatment
of patients, based on the hospital’s capacity.
The Access and Continuity of Care chapter targets the following sections:
 Access to care
 Patient screening
 Patient assessment
 Admission, registration and transfer
 Standardization of care
 Patient and family education
 Patient discharge, transfer and referral within/outside the organization

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

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Standards
Risk
Standard and Guiding measures
Score
ACC 1. Services provided at the hospital are defined, communicated and
easily accessible to the patients.
In order to ensure appropriate and timely care is provided, hospitals
should identify all the services available at their own (or affiliated)
4 premises, and establish a process to convey these services to the
public.
Hospitals should also ensure services are available for special needs
patients (mobility impairment, hearing...) and translation services if
needed.
Guiding measures:
1.1. The services provided at the hospital are identified.
1.2. The hospital has a delineated process to communicate its services
to the patients, families and community.
1.3. The hospital develops and implements a process to provide services
to patients with special needs (i.e. hearing impairment) or language
barriers.
ACC 2. Critical patients at the emergency room are given priority and
stabilized prior to indicate transfer.
Emergency room triage procedures should follow evidence-based
literature and in line with the hospital’s other policies and services
available. The triage protocols should be documented and taught to
qualified triage health care workers (triage nurse, emergency room
6
physician …). They ensure that all documentation related to the triage
process, diagnostic tests and therapies done in the emergency
department are in the patient’s file prior to transfer to another
service / hospital or discharge. All triage protocols should follow the
laws and regulations, guaranteeing first line treatment and
stabilization in life threatening conditions, until transfer.
Guiding measures:
2.1. The hospital has a documented and implemented evidence-based
triage, based on hospital policy and procedure.
2.2. Triage staff is trained on the prioritization criteria and triage process
(i.e. Australasian Triage Scale (ATS), Canadian Triage and Acuity
Scale (CTAS), National Triage Scale Based Manchester Triage Scale,
COR
Emergency Severity Index (ESI))
2.3. Patient full triage assessment is documented in patient’s medical
record.
2.4. Treatment for life-saving conditions is provided regardless of ability
to pay, as per laws and regulations, and documented for patients
prior to transfer.

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 2.5. Documented stabilization treatment and diagnostic tests are
transferred with the patient to receiving unit/organization.
ACC 3. Patients are screened to identify their health care needs.
All patients regardless of the major complaint should be screened for
their health care needs to assess if the hospital is capable of providing
such care. This screening process should be well documented in policy
and applied to all patients. The results of the diagnostic and necessary
5
screening test should be delivered in a timely fashion and in
accordance with an established process (i.e.: critical values
reporting…) to the medical team managing the patient. They decide
based on these results and the hospital’s capacity and services if the
patient should be admitted, transferred or discharged.
Guiding measures:
3.1. The hospital has a policy and/or procedure on patient screening
prior to admission.
3.2. Screening results are used to determine the patient health care
needs and its alignment with the hospital mission and services.
3.3. Patients are transferred if the hospital cannot provide the necessary
services and the appropriate setting for care.
3.4. The test results are delivered to the healthcare professional in
charge of the patient through a specific process, to determine if the
patient will be transferred, referred or admitted.

ACC 4. Upon admission, patient preventive, palliative, curative, and

rehabilitative needs are assessed.
A detailed, thorough care plan should be completed before admission.
5 All the patient’s needs should be discussed with the patient and his
family, documented with all suggested management plans. The care
plan should be revisited and adjusted routinely and when needed
according to the patient’s changing health status.
Guiding measures:
4.1 Preventive, palliative, curative, and rehabilitative needs are
assessed upon admission in collaboration with the patient and
family.
4.2 Patient care needs are prioritized and documented.
4.3 Care is planned to meet patient’s needs.
ACC 5. Functional limitations (i.e. risk for fall) are assessed upon admission.
Patient safety, possible risks and functional limitations (risk for fall,
swallow, psychosis …) are assessed upon admission and whenever the
patient’s condition requires it due to a change in his overall status.
5 Such assessments have to follow a hospital procedure that is well
documented and implemented by the relevant health care personnel.
Once risks are identified, a predetermined interventions to mitigate
such risk are put in place and their implementation is documented in
the patient’s record (bed rails, warning signs, special diet, …)

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 Guiding measures
5.1 The hospital has a policy and/or procedure to assess functional
limitation
5.2 The assessment is performed, when needed and documented by
qualified individuals.
5.3 Targeted interventions are implemented and documented.
ACC 6. Nutritional status and other special needs are assessed upon
admission.
The nutritional status and needs of patients are assessed by qualified
personnel (nutritionist) for predetermined. According to the patient’s
5
health condition and in collaboration with the medical team, a
nutritional plan is set to meet the current needs of the patient. Such
plan is documented in the records and reassessed routinely or when
needed to remain relevant with the patient’s needs and health status
Guiding measures
6.1 The hospital has a policy and/or procedure to screen for nutritional
status
6.2 The hospital has a policy to assess nutritional status.
6.3 The assessment is performed, when needed and documented by
qualified individuals.
6.4 Targeted interventions are implemented and documented.
ACC 7. Pain is assessed upon admission and interventions are implemented
accordingly.
Pain control is an essential element in patient care. Hospitals should
establish policies where each admitted patient is screened for pain
regardless of initial complaint.
6 In such cases, a dedicated pain team or, if not established, a qualified
personnel in pain management should assess the pain and discuss
with the patient or legal guardian all the possible management
protocols.
A pain management plan is documented in the patient’s record with
defined targets that should be reassessed routinely.
Guiding measures:
7.1 The hospital has a policy and/or procedure to screen for pain.
COR 7.2 The hospital has a policy and/or procedure to assess pain.
7.3 The assessment is performed, when needed and documented by
qualified individuals.
7.4 Targeted interventions are implemented and documented.
ACC 8. The patient’s initial assessment is documented in the medical record.
Documented Patients assessment is an essential part of medical
management and the patients’ medical records. All assessments
(medical, nursing, specialty…) should be completed within a set time
5
frame depending on the patient status.
Upon admissions, the medical team, after the initial assessment
should, in collaboration with the patient and his family, elaborate a
management care plan. Such plan, documents the proposed

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 investigative, diagnostic and therapeutic care procedures while
setting outcome goals and therapeutic targets with a tentative
discharge date.
All care plans, must be regularly updated based on patient’s status,
treatment results and change in outcomes.
Guiding measures:
8.1 The hospital has a policy for patient initial medical and nursing
assessment.
8.2 Nursing assessment is completed and documented within 12hours
from admission or earlier (before end of shift), as per patient
condition.
8.3 Medical assessment is completed and documented within 24hours
from admission or earlier, as per patient condition.
8.4 Further discipline assessment (nutritional assessments, functional
needs) is assessed when necessary, within 48 hours from request.
8.5 A multidisciplinary plan of care is completed and documented
within 24hours from admission by engaging the patient and family.
8.6 Assessments performed at the hospital 30 days prior to admission,
due to a previous hospital admission, can be used and updated.
8.7 A plan of care contains the proposed care and desired/measurable
outcomes when applicable.
8.8 The plan of care is developed and documented in the medical
record in collaboration between the patient and/or the family
and/or next of kin and continuously updated as needed.
8.9 The care plan sets an expected discharge date within 24 hours of
admission.
ACC 9. Patient admission, registration and transfer policies and/or
procedures and/or processes, are delineated.
Patients flow into, intra and from the hospital must be standardized
5
and controlled by procedures.
Policies should cover all types of admissions (elective, through
emergency and emergency only hospitalizations)
Guiding measures:
9.1 There is a standardized outpatient registration process and
inpatient admission process.
9.2 There is a delineated process to admit emergency patients.
9.3 There is a delineated process to manage patients for observation in
the emergency room.
9.4 There is a developed and implemented policy and procedure to
transfer patients within the hospital and to other institutions.
ACC 10. There is a clear continuity of patient’s care plan throughout their
hospital stay.
Patient care is a complex management undertaking involving several
6
health care personnel encompassing both nursing and medical teams,
from different medical and non-medical specialties, and nearly always
changing between multiple shifts from the same specialty.

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 To ensure continuity of care, all relevant information must be
transmitted between all the different teams, written documented
handovers between shifts for nursing staff and for the different
medical teams of the same or different specialties.
The Hospital must provide all health care personnel the different tools
to assist in a more standardize efficient handover and transfer of care.
All patients must be under the care of a leading physician, relevant to
their admission complaint, and who has the ultimate responsibility for
their care.
Any transfer of care between physicians must follow a well-
documented policy, ensuring acceptance by the receiving physician
for both management and the transfer of accountability. A detailed
transfer note from the sending team describing the status of the
patient with an updated care plan from the receiving team has to be
in the patients’ records.
Guiding measures:
10.1 There is a process for ensuring continuity of care during transitions
and handoffs between shifts and between different
departments/units/services.
10.2 Each patient has a qualified (licensed, credentialed and relevant)
COR attending physician responsible for the patient’s care.
10.3 Transfer of responsibility and accountability among physicians is
delineated in policies and procedures.
10.4 The hospital has tools to support the continuity of care (i.e. care
plans, information technology, handoff checklist, discharge
summary, guidelines).
10.5 There is a collaborative care arrangement with mental health
specialist for urgent in-hospital mental health consultation
ACC 11. Patient assessment is an ongoing process that begins before the
patient is admitted and continues throughout hospitalization
The hospital has policies and procedures dictating patients’
5 continuous medical and nursing assessment. Policies determine the
intervals of assessment depending on the unit where the patient is
(Critical vs Regular floor). These daily Follow up notes should be in the
medical records.
Guiding measure:
11.1 The hospital has defined intervals to reassess patients (i.e. after
treatment, in case of complications).
11.2 Patient medical reassessment is performed every 24hrs (including
weekends and holidays).
11.3 Nursing reassessment is performed every shift.
11.4 Reassessment is documented in the patient’s medical record.
ACC 12. Patient flow strategies are developed and implemented throughout
5 the hospital to ensure patient safety and minimize delays in patient
care

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 Patients flow and bed management are allocated to a specific heath
care worker who should liaise with both medical and nursing
administrations , ensuring regular or ad hoc meetings in case of bed
shortage whether in the emergency rooms or the hospital with
backed up patients admissions. Written policies and procedures
should elaborate all possible solutions and strategies either to
facilitate the hospital’s bed capacity and patients admissions from
emergency room or ton how to increase the ER’s bed capacity and if
needed ensure transfer of stabilized patients to another institution.
Guiding measures:
12.1 Patient flow strategies are developed and implemented.
12.2 The hospital develops and implements policies and/or procedures
to manage patients at the emergency room if no bed is available
(i.e. bed cleaning or bed capacity planning).
12.3 Patient flow strategies are reviewed and updated every 2 years.
ACC 13. Clinical guidelines on common diagnosis are developed and/or
adapted and implemented.
To achieve a standardized care for common pathologies allowing
efficiency and best possible care, each specialty must have clinical
management guidelines for at least 5 of their most common
diagnoses (STEMI, heart failure, stroke...).
These guidelines should follow international, national and evidence
5 based medicine while being in line with the hospital’s logistical
capabilities. These guidelines must be approved by all the relevant
medical staff, disseminated to all the concerned medical, nursing and
paramedical personnel.
A regular audit ensures the guidelines are accurately implemented
and updated when needed and on regular basis. Patients falling under
the management criteria for these guidelines must have them
documented in their medical records
Guiding measures:
13.1. Clinical guidelines emphasize every year on at least five of the
hospital common diagnosis and are identified, adapted, and shared
among the concerned staff.
13.2. National and/or evidence-based clinical guidelines are
implemented, when applicable.
13.3. Implementation protocols/pathways of the guidelines are
documented and disseminated.
13.4. Implementation is monitored and guidelines are assessed for their
appropriateness
13.5. Clinical guidelines /pathways are updated when applicable.
13.6. Clinical protocols/pathways are documented in the patient’s record.
ACC 14. There is defined criteria to admit, discharge and/or transfer patients
to specialized (i.e. psychiatric units) or intensive care (i.e. neurologic
5
intensive care unit, intensive care unit, pediatric intensive care unit,
coronary care unit, recovery room, neonatal care unit) units.

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 Any admissions into or discharge from a specialized or critical unit
whether from/to the emergency room or regular floor, must follow a
documented criteria based checklist ensuring a standardized protocol.
The transfer decision is based on predefined criteria and implemented
by a multidisciplinary team whose members differ according to the
status/age/diagnosis of the patient. Medical and nursing staff must be
taught and trained on the application of these transfer guidelines with
regular audit on the proper application and if needed modification
and updating.
Guiding measures:
14.1. A multidisciplinary team (including staff from the intensive care/
specialized units) develops criteria for patient
admission/discharge/transfer to and from specialized/intensive care
units.
14.2. The criteria for patient admission/discharge/transfer to and from
specialized/intensive care units are documented and processes are
implemented.
14.3. Staff is trained on the implementation of the criteria.
ACC 15. Patients and family caregivers are provided with education on the
patient’s care.
Patients and/or their family members when needed, have to be an
integral part of the treatment decision and overall care. A critical part
of such collaboration is patient/care giver education. Information
concerning the different aspects of treatment (medications, side
5 effects, drug-drug interactions ...), daily care (pain management, diet,
rehabilitation...).
In cases where decisions affecting a patient’s life (Do not resuscitate,
Do not intubate…) must be always taken after a thorough explanation
and a multidisciplinary family meetings while following the laws,
hospital’s internal regulations concerning this subject. Such education
must be documented and kept in the patient’s file.
Guiding measures:
15.1 Patients and family caregivers are educated on the following, when
relevant:
15.1.1. Safe medication use
15.1.2. Medication side effects and medication interaction.
15.1.3. Safe medical device use.
15.1.4. Adequate diet.
15.1.5. Pain management
15.1.6. Rehabilitation techniques.
15.1.7. Do not resuscitate orders.
15.2 Education is documented and provided during the patient’s stay at the
hospital.
ACC 16. Discharge is done to meet the patient’s need for the continuity of
5
care.

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 Patients discharge planning should starts soon after admission and be
documented in the care plan, updated throughout the patients’ stay
according to their status. The discharge plan is decided in
collaboration with the patients and their family while taking into
consideration their care needs after discharge (home nursing care,
physical rehabilitation…).
A detailed discharge summary is a critical document, signed by the
managing physician and given to the patient upon the discharge. This
summary contains all the pertinent information from the time of
admission, through the hospital’s stay with all the relevant and
significant findings, diagnostic and therapeutic procedures. The
summary also notes the patients’ status upon discharge, if they need
further care in another institution or can be discharged home. The
summary contains the post discharge care plan that was explained to
the patients and /or their care givers. A copy of the discharge
summary is signed and kept in the patient’s medical records.
Guiding measures:
16.1 Discharge is planned upon admission and updated along the care
continuum.
16.2 A documented discharge plan is developed and implemented for
patients approved to leave the hospital.
16.3 Upon admission patient’s need for support services and/or medical
services is identified.
16.4 The patient and/or family and/or next of kin take part in developing
the discharge planning.
16.5 A discharge summary of the patient’s care and condition is
developed and signed by the most responsible physician,
containing:
16.5.1 Reason for admission
16.5.2 Patient history
16.5.3 Significant findings
16.5.4 Patient diagnosis
16.5.5 A brief summary of care provided (procedures and
treatments performed, and medications administered).
16.5.6 Patient condition at discharge
16.5.7 Care instructions (i.e. diet, medication use, medical device
use, rehabilitation technique, pain management and seeking
urgent care).
16.5.8 Follow-up instructions and care
16.6 A detailed discharge summary is given to the patient.
16.7 A copy of the discharge summary is added to the patient’s medical
record.
ACC 17. Transfer/referral is done to meet the patient’s need for the continuity
of care.
5
If the patient’s discharge condition requires a transfer to another
institution or a specialized care facility (rehabilitation center, elderly

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 care facility, palliative care facility, post spinal cord injury center…),
such transfer has to be documented in the patient’s care plan after
discussion in a multidisciplinary meeting with the patient or care
givers. Such decision should be based on the patients’ overall status,
medical needs, social situation and the receiving facility’s services. A
detailed discharge summary detailing the patient’s stay from
admission to discharge is given to the patient, focusing on the
required care plan after discharge and what is require from the
receiving institution. Patient safety during transfer has to follow a
preset protocol and discussed when the discharge decision is taken
and updated on the day of discharge. The hospital has to ensure the
safest transfer conditions based on the patient’s status and medical
needs (oxygen, specialized medical or paramedical personnel...) such
conditions have to be relayed to the team or organization responsible
for transportation (red cross, army ambulance services, private
ambulance services …)
Guiding measures:
17.1 Transfer/referral is planned upon admission and updated along the
care continuum, when needed.
17.2 Upon admission, patient’s need for support services and/or medical
services is identified.
17.3 The patient and/or family and/or next of kin take part in developing
the transfer/referral planning.
17.4 A transfer/referral summary of the patient’s care and condition is
developed and signed by the most responsible physician,
containing:
17.4.1 Reason for admission
17.4.2 Patient history
17.4.3 Significant findings
17.4.4 Patient diagnosis
17.4.5 A brief summary of care provided (procedures, tests,
treatments performed, and medications administered).
17.4.6 Patient condition at discharge
17.4.7 Care instructions (i.e. diet, medication use, medical device
use, rehabilitation technique, pain management and seeking
urgent care).
17.4.8 Follow-up instructions and care
17.5 A detailed transfer/referral summary is given to the patient.
17.6 A copy of the transfer/referral summary is added to the patient’s
medical record.
17.7 The hospital has a policy and/or procedure to ensure patient safety
during transfer/referral.
ACC 18. Patient’s leave against medical advice is guided by a delineated
process.
5
Every attempt should be taken to prevent a patient’s leave against
medical advice. The care team should do all efforts to understanding

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 and document the reason for the AMA and the ensuing possible risks
which should have been thoroughly explained to the patient. If the
patient is deemed a risk for himself or the population (suicide
attempt, sexually transmitted disease…), the law allows the sharing of
patient’s information with the relevant authorities. All these
situations and required actions are well documented and delineated
in policies and procedures that help the health care workers manage
such stressful situation with the least risk for the patient. A patient
signed detailed AMA has to be kept in the medical records and if not
possible due to patient refusal, policy should determine who needs to
document the incident and be kept in the patient’s records.
Guiding measures:
18.1. The hospital has policies and/or procedures and/or processes to
guide notified/non-notified patient’s leave against medical advice.
18.2. Evidence of informing the patient about the risks following
inadvisable leave.
18.3. Patients discharged against medical advice who are a threat to
themselves or to the public (i.e. with infectious diseases) are
reported to relevant authorities, as required by laws and
regulations.
18.4. Against medical advice decision and reason are documented in
patient’s medical record

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Patient and Family Rights and Education
(PFR)
Introduction
The Patient and Family Rights and Education chapter focuses on providing care
while ensuring that the patient’s rights are preserved. The chapter tackles
safeguarding patient’s spiritual, cultural and psychological beliefs and privacy,
confidentiality and dignity. The chapter also sheds light on the patient and
family’s right to choose the treatment path. This is complemented by assuring
that the patient has received adequate education regarding their diagnosis and
treatment.
The Patient and Family Rights and Education chapter targets the following
sections:
 Spiritual, cultural and psychological beliefs assessment
 Privacy, confidentiality and dignity
 Protection of patient’s belongings
 Physical and verbal assault
 Patient education
 Patient and/or family and/or next of kin’s right to refuse/discontinue
treatment and/or resuscitation and/or withdraw life support
 Pain management
 End of life care
 Safe seclusion and restraint
 Feedback and complaint process
 Informed consent
 Organ donation
 Human-based research
 Patient education
Each standard was supported by a corresponding set of guiding measures that
further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

126
Standards
Risk
Standard and Guiding measures
Score

PFR 1. The patient’s privacy, confidentiality and dignity are preserved.

The hospital ensures through policies, personnel training, digital and
physical security that the patient’s data are kept confidential with clear
guidelines on granting information access. All efforts, through
5 architectural design, physical separations and health care workers
interactions, should be done during the patient’s stay to ensure
protection of the patient’s privacy and dignity. Systematic preemptive
policies and immediate action are in place to look for or tackle any active
breaches in the patient’s privacy protection.
Guiding measures:
1.1. Hospital executive management develops policies that ensure
confidentiality, privacy and dignity throughout the patient care.
1.2. Patient’s privacy is maintained throughout the patient’s care (i.e.
tests, treatments, physical assessments, transportation within and
outside hospital).
1.3. Patient’s confidentiality is maintained throughout the hospital
medical record and information technology system
1.4. Facility and unit design respect patient confidentiality and privacy.
1.5. Hospital executive management monitors breaks in patient privacy
and confidentiality and addresses gaps in a proactive manner.
PFR 2. Patient’s belonging in the hospital are protected against theft or loss.
The staff informs the patients if possible, or their family members, what
to do with their valuables (jewelry, phones etc.) and what is the
hospital’s responsibility towards them, either during their emergency
room stay or upon their inpatient admission to the hospital or during
4 any applicable outpatient procedure. In case the patient is incapacitated,
whether planned (sedation) or urgent (sudden deterioration or transfer
to higher level of care), or away from his/her possessions; the hospital
has preset procedures and chain of custody protocols on where and who
has to safe keep these possessions, who to return them to (for e.g.
death, intubated etc.) and how to document this process.
Guiding measures:
2.1. The hospital has a policy and procedure that states its responsibility
towards patient’s possessions.
2.2. The hospital has a policy on protecting the patient’s belongings in
cases where patients are incapable (i.e. confused, elderly, children,
comatose) of protecting them against theft or loss.
2.3. Patients and/or family and/or next of kin are informed regarding
the policies on possessions.

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 PFR 3. Patients are protected from physical or verbal assault.
Hospitals need to ensure security for their patients and health care
workers while they are on the premises. Health care workers (HCW)
need to be trained on detecting signs of assault especially for the fragile
5
groups of patients (children and elderly). In assault cases (expressed or
detected), policies and procedures are in place for accurate and proper
examination by qualified personnel (i.e. sexual assault), documentation,
protection and if needed reporting in accordance with the current laws.
Guiding measures
3.1. There is a policy and procedure to protect patients in the hospital
from physical and verbal assault.
3.2. Patients suspected to be victims of physical and verbal assault are
assessed and assessment is documented in medical record
3.3. Documented interventions are provided to patients subjected to
assault.
3.4. Documented protection from further assault.
PFR 4. Patients are well informed about their condition.
The Lebanese law related to patients’ rights and informed consent (Law
574 Feb 2004) protects their right to access and keep private all
information related to their health condition. Health care workers have
5 to be knowledgeable of when and which information can be withheld
from the patients in accordance with the law (article 3). A
comprehensive care plan has to be routinely established, updated,
documented and communicated with patients being in the center of the
health care decision making.
Guiding measures:
4.1. The hospital has a process on providing patients with information
on their health condition.
4.2. The hospital has a process on providing the patient with
information on financial implications of care.
4.3. The hospital has a policy on providing family or next of kin with
information on patient’s medical condition in case it is medically
inadvisable to inform the patients themselves.
4.4. Patients are provided with information on their condition and plan
of care, as per hospital policies and procedure including:
4.4.1. Their diagnosis
4.4.2. Test results
4.4.3. Proposed treatments
4.4.4. Alternative treatments
4.4.5. Benefits, harms and possible complications of treatments
4.4.6. Expected outcome of care
4.4.7. Patient’s physician
4.4.8. Possible results of non-treatment
4.5. The hospital has a process in case the patient request further
information regarding their condition and treatment.

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 4.6. Patients have the right to decide on the information that will be
provided to the family, when applicable.
4.7. Information disclosure to patient and/or family is documented in
the patient’s medical record, as per hospital policies and procedure.
PFR 5. The patient and/or family caregivers and/or next of kin have the right to
refuse/discontinue treatment and/or resuscitation.
In accordance with Article 7 of the 574 law, hospitals must inform
patients and their designated health care proxies (family member, next
5 of kin...) of the rights to refuse or withhold care (treatment,
resuscitation …) at any time during their hospitalization, in addition to
the outcome of these decisions. The hospital ensures presence of
procedures and qualified healthcare workers HCW to discuss implement
and document such cases and decisions made in the medical record.
Guiding measures:
5.1. The hospital has policies and procedures regarding
sustaining/discontinuing from providing treatment.
5.2. The hospital has policies and procedures regarding sustaining from
providing resuscitation.
5.3. The hospital has policies and procedures to assess the rights of
family and/or next of kin to be provided with information, make the
decision of refusing/discontinuing treatment and/or resuscitation
on behalf of the patient.
5.4. Patients and/or families and/or next of kin are informed about the
patient’s right to refuse/discontinue treatment.
5.5. Patients and/or families and/or next of kin are informed about the
patient’s right to refuse/discontinue resuscitation.
5.6. Patients and/or families and/or next of kin are informed about the
outcomes of their own decisions on refusing/discontinuing
treatment and/or resuscitation and/or life support.
5.7. Patients and family decision is documented in the patient’s medical
record.
PFR 6. Patient’s rights to pain assessment and management.
In line with a zero-pain healthcare culture, hospitals put in place
procedures where HCW are trained and encouraged to continuously
assess and anticipate a patient’s pains and management needs by
providing various evidence based assessment tools such as the numeric
rating scale (NRS), visual analog scale (VAS), pain assessment in
5
advanced dementia scale (PAINAD) in adults, or neonatal/infant pain
scale (NIPS) for pediatric patients, including specific tools (ex: CPOT)
adapted to pain measurement in unconscious patients (intubated,
sedated, …) A qualified multidisciplinary pain management team is
necessary to establish pain management protocols and be consulted in
complex cases.
Guiding measures:
6.1. The hospital has policy and procedures for pain assessment and
management.

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 6.2. Patient’s right to pain assessment and management is supported
6.3. Healthcare providers are qualified by training and/or experience to
assess, support and manage pain.
6.4. The hospital uses different pain assessment tools adapted to
patient needs and comprehension (psychological, mental and
emotional state).
6.5. Pain management interventions are documented in patient’s
medical record.
PFR 7. Patient’s rights to end of life care are met.
End of life care must be provided by qualified members with
multidisciplinary specialties (pain specialists, physicians with experience
5 in palliative care, psychologists, grief counselors, religious chaplain etc.)
to meet the needs of patients, families and even health care providers.
For e.g an end of life/palliative care team of assigned disciplines can be
established and consulted when necessary.
Guiding measures:
7.1. There is a multidisciplinary approach to ensure that the patient’s
need for end of life care is met.
7.2. All healthcare providers involved in the care of patients have
documented training on providing end of life care to provide
psychological support to patients and family.
PFR 8. Seclusion and restraint are used in a safe manner. [OTHER-15]
Such behavioral management interventions should be used as a last
resort to control a behavioral emergency. Indications for
5 seclusion/restraint must be clearly defined in hospital policy/procedure,
diffused appropriately and documented in the file when occurring. Such
interventions should not be sustained longer than they should, and thus
must be reassessed daily.
Guiding measures:
8.1. The hospital has a policy and procedure for the use of seclusion and
restraint.
8.2. The use of seclusion and restraint are justified and documented in
patient records.
8.3. The need for seclusion and restraint is valid for a predefined limited
time and its need is reassessed every 24 hours.
PFR 9. Patient experience surveys are conducted regularly.
Regular patient experience surveys need to be conducted by qualified
personnel (ex: Quality department analysts). Results and identified
5 action plans are discussed on the concerned department level and on
the hospital executive management level with set targets for
improvement that are followed up by concerned department heads and
by the quality department.
Guiding measures:
9.1. Evidence of regular patient satisfaction survey.
9.2. Evidence of documented result analysis and action plans.

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 9.3. Results are communicated to hospital executive management and
staff.
9.4. Improvements are documented and implemented.
PFR 10. The feedback and complaint process is explained to patients and
families.
Patient and families have a right to voice their feedback/complaints,
and should be informed about the means to undertake it. Hospitals
have a dedicated procedure on how to deal with patient complaints,
and must facilitate this process. For ex. Having a dedicated patient
4
affairs/complaints office with whose patients and families have a clear,
easy and well-established two way path to communicate complaints
and receive feedback for actions taken. These complaints are dealt
with through preset procedures developed by a multi-departmental
committee that meets cyclically or when needed to analyze them and
set appropriate improvement actions.
Guiding measures:
10.1. The hospital has a committee designated to manage in
collaboration with the hospital executive management, patient
complaints and communicate improvements and solutions to
patients and families.
10.2. There is a policy and procedures to deal with patient’s and families’
feedback and complaints.
10.3. Patients and families are informed about means to voice their
concerns.
10.4. Evidence on improvements based on patient and family feedback.

PFR 11. The hospital ensures that patients receive information about their
rights and responsibilities.
Patients and health care workers must have access to the hospital’s
statement on the patients’ rights and responsibilities (Hospitals can
5 customize their own statement while abiding by the Law 574).
Statement should be easily accessible for patients and staff, and be in
both digital (website) and physical forms. Hospitals designate by
procedure when and which qualified personnel should inform and
explain the statement to the patients and their families.
Guiding measures:
11.1. There is a process to inform patients about their rights and
responsibilities.
11.2. Patients and families are explained about their rights and
responsibilities as per hospital policies.
11.3. Patient rights and responsibility statement is posted in the patient’s
room.
11.4. Patient rights and responsibility statement is available for staff at all
times.

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 PFR 12. Patient informed consent is obtained prior to surgery, invasive
procedures and high-risk treatments designated by the hospital, as per
applicable laws and regulations.
All invasive procedures and high-risk treatments (chemotherapy,
transfusions...) need to have a prior signed consent. The consent form
must be standardized with room for customization according to the
procedure and in a language understood by the patient or the signee
6
(Arabic and English/French).A well-defined procedure determines
when consent is needed, who among the HCW is allowed to take it and
who besides the patient if needed has authority to sign on his/her
behalf. A qualified medical personnel well versed in the procedure
(benefits, alternatives, risks, complications...) must make sure the
patient or the pre-designated proxy have understood the information
in the consent before signing it.
Guiding measures:
12.1. The hospital has a policy and procedure for obtaining informed
consent prior to specific and listed procedures and treatments,
including but not limited to anesthesia, blood and blood products,
procedural sedation
12.2. The hospital has policies and procedures to assess the rights of
family and/or next of kin to provide informed consent, as per
applicable laws and regulations.
12.3. Qualified staff has documented training on obtaining informed
COR
consent.
12.4. The hospital has a standardized informed consent form in a
language understandable to the patient and/or someone to
translate the form.
12.5. Patients and families are informed when an informed consent
would be necessary during the care process
12.6. The individual giving consent’s name and relation to patient is
documented on the consent form and kept in the patient’s medical
record.
PFR 13. There is a process to communicate patient-related information and
variation of care to patients and family caregivers. [QMPS-10]
In the spirit of having patients at the center of their care and decision
making, the hospital has a policy ensuring information relevant to the
patients’ care are regularly documented and transmitted to them or
their family especially when there is a change from a pre-discussed
4
plan. Disclosing patient information (which may include sensitive
information such as serious diagnosis or prognosis) must only be done
by designated, trained qualified staff, reflected by hospital
policies/procedures. Evidence of training ins available in addition to
patient/family support services/resources (e.g psychological, spiritual
etc.)
Guiding measures:

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 13.1. The hospital has a documented policy and/or process that is
implemented and regularly updated to disclose information to
patient and family members
13.2. Designated staff are trained on disclosing information to patients
and family members
13.3. Resources (i.e. psychological support) are available to support
patients and family after information is disclosed, when needed.
13.4. The variation of care to patient is documented in patient medical
file.

PFR 14. Patients are informed about organ donation, if applicable, through
shared decision-making process.
The hospital has a documented policy concerning organ donation. The
procedure designates which HCW can discuss organ donation with
patients or their families either upon their request or if the situation
5
calls for it. The HCW should provide all the necessary relevant
documents and contact information in case organ donation (harvesting
or transplant) is not available in the institution. In such a time sensitive
process, a documented policy stating the members of the team
responsible for intra-hospital and national coordination when needed.
Guiding measures:
14.1. The hospital provides patients and families with an option of organ
donation.
14.2. The hospital provides support in coordination with the national
team for patients and families requesting organ donation and
informs patients and/or family and/or next of kin of outside
resources if organ donation cannot be carried out in the hospital.
14.3. Healthcare providers have document training to provide patients
and/or family and/or next of kin with information on organ
donation.
PFR 15. The hospital implements organ procurement and transplantation,
when applicable, in a safe manner.
Organ procurement and transplantation is a highly ethical and
potentially life-saving process and so must be conducted by
authorized, trained qualified HCW, specified in a hospital
policy/procedure and in accordance with local laws and regulations, to
5
ensure appropriateness and avoid abuse. It is important that said staff
is continuously trained to maintain qualified competencies and
knowledge of required regulations/laws. It is imperative this process is
regularly assessed via specific measurable indicators such as number of
donors, causes for brain death, donor and family satisfaction, time on
waiting list, survival rate, infection rate etc.
Guiding measures:
15.1. The hospital has a designated hospital organ procurement unit that
includes the following but not limited to:
15.1.1. An intensivist

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 15.1.2. A neurologist,
15.1.3. A coroner
15.1.4. A minimum of two Organ Procurement Coordinators (OPC)
clinical supervisors or health professionals from the
Intensive Care Unit (ICU) and the Emergency Room (ER)
15.2. Policies and procedures related to organ procurement, which are
consistent with laws and regulations of NOD-Lb, are developed and
implemented in the hospital.
15.3. Authorized healthcare providers to receive and transplant organs
are delineated in policies and procedures.
15.4. Authorized healthcare providers to conduct transplantation receive
continuous education and training.
15.5. Informed consent is obtained from patient/family/caregiver and
documented prior to performing organ transplantation, as per
hospital policies and procedures.
15.6. Organ procurement and transplantation specific indicators are
collected and used for quality improvement purposes.
PFR 16. Human-based research, when applicable, is conducted based on ethical
guidelines.
The hospital establishes its own Institutional review board (IRB) or
seeks collaboration with other national Institutional review boards and
its activities described in hospital policy/procedure, guided by the
5
principles of the International Conference on Harmonization (ICH)
Good Clinical Practice (GCP) guidelines. The board’s internal
organization, responsibilities and procedural work are documented.
IRB meetings are documented and ensure all research projects abide
by national laws and intra-hospital policies.
Guiding measures:
16.1. Hospital executive management identifies responsible entities (i.e.
Institutional Review Board) that review and monitor the compliance
of human-based research with bylaws, policies and procedures.
16.2. The hospital’s research review board is identified in documents
16.3. The responsibility of the review board/committee is written in
document(s).
16.4. The review board/committee reviews researches, weighs risk and
benefits to subjects and ensures the privacy of subjects is
maintained
16.5. Human-based research is guided by policies and procedures.
16.6. Evidence of informed consents obtained from patients before any
research or trial.
16.7. Evidence of institutional review board (IRB) approval on human-
based research.
EDUCATION
PFR 17. Education related to patient’s care is provided to patients and families.
5 Patient’s education is essential for their involvement in the care plan
and for optimized clinical outcomes. Policies should encourage all

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 hospital departments to prepare easy to explain and understand
educational material targeting the different steps in patient care.
Education is available upon request from patient or families on a
specific topic, and proactively offered throughout the hospital stay
with emphasis on home education. These policies must document and
designate the required training and experience among HCW to qualify
for this task, and provide them if needed. Cyclic audits should focus on
the quality, ease of communication and diversity of available
education.
Guiding measures:
17.1. Policies and procedures supporting patient and family education are
in place.
17.2. Hospital executive management monitors and addresses gaps in
patient and family education.
17.3. Patients and family members education cover diagnosis, treatment
and discharge, such as, but not limited to;
17.3.1. Primary illness and potential complications.
17.3.2. Treatment and procedures including radiological
procedures.
17.3.3. Palliative and end-of-life care.
17.3.4. Medication use, side effects and medication interaction.
17.3.5. Infection control practices, with emphasis on basic hand
washing.
17.3.6. Postpartum education.
17.3.7. Care of babies.
17.3.8. Financial implications of care choices
17.3.9. Informed consent
17.4. Education is provided during the patient’s hospital stay, when
necessary.
17.5. The role of the clinical staff, who are required by hospital policy to
have a job description, (i.e. physicians, nurses, paramedical, etc...)
regarding patient and family education is highlighted in a job
description document/ documented responsibilities.
17.6. All healthcare providers involved in the care of the patient are
trained to provide education to patients and/or families.
PFR 18. Education needs of the patients are assessed and documented.
Educational material must be suitable to the targeted patients’ group
(age, education level…) provided in a language containing easy to
understand medical jargon. HCW are trained to assess the capacities of
the patients and their families to understand the information and adjust
5 it in accordance to their needs. The procedures and policies must have
in place post educational assessments and reemphasis by senior staff
ensuring patients/family comprehension and address any gaps or
misunderstanding.
All these educational meetings must be documented by the caregivers
keeping record of the material explained and given.
Guiding measures:

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 18.1. The patients and/or families educational needs are assessed and
documented based on the following, but not limited to:
18.1.1. Educational level
18.1.2. Emotional barriers and motivations
18.1.3. Physical and cognitive limitations
18.1.4. Language barriers
18.1.5. The appropriateness of the educational materials
provided (i.e. age appropriate material)

18.2. All healthcare providers involved in the care of the patient, plan the
patient and/or family education based on the patient’s needs and
assessment findings.
18.3. Evidence of documented patient and/or family education in medical
record.
18.4. Education is given to family member and/or next of kin in case the
patient is unable or unsuitable to receive or comprehend the
information (child, mentally disabled or comatose patients).
PFR 19. Appropriate educational methods are used to ensure effective patient
and family education.
Patient education is a multidisciplinary task offered by several HCW
from different medical and non-medical fields. Therefore, all care
givers involved should be aware of the educational material given by
5
others in order to prevent conflicting information and ensuring
information are appropriate. Protocols are in place promoting a
collective educational approach with all members discussing and
agreeing on the care plan and the information given to the patients,
and ensuring that the information provided is understood.
Guiding measures:
19.1. Developmentally appropriate education is provided using language
understandable by patient/family.
19.2. Reinforcement of education is provided to patients and families,
when necessary, and documented in the medical records.
19.3. A process is in place to ensure that the education given is
understood by patients and families.
19.4. Education is offered to patient and family, when needed, using a
collaborative approach between the patient’s healthcare givers (i.e.
nurse, physician, nutritionist, physiotherapist …).

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Patient Services
Patient Services: Anesthesia and Surgical Care
(ASC)
Introduction
The Anesthesia and Surgical Care chapter aims to ensure safety throughout the
delivery of anesthesia to patients undergoing operative procedures, in addition
to safeguarding a safe environment for surgeries. The standards are applicable
on all hospital grounds were anesthesia and surgical care services are provided.
The Anesthesia and Surgical Care chapter targets the following sections:
 Anesthesia and surgical care staff qualification
 Anesthesia and surgical care policies and procedures
 Operating room environment
 Pre-sedation assessment, pre-anesthesia, pre-induction
 Patient monitory during and post-anesthesia
 Surgical report and care plan
 Time-out process
 Quality improvement indicators
Each standard was supported by a corresponding set of guiding measures that
further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

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Standards
Risk
Standard and Guiding measures
score
ASC 1. The operating room is operated by qualified staff.
As in all specialized units, all staff should have the necessary and work-
relevant qualifications achieved through education and experience. Staff
4 should have scheduled routine operative care training for new policies,
equipment and surgical procedures. All tasks and roles in the operating
room have to be assigned in a detailed written job description for all
operating room medical and nursing staff.
Guiding measures:
1.1. The operating room is directed by a qualified staff with relevant
experience, education and training.
1.2. The nurse manager at the operating room has relevant experience,
education and training in operative care.
1.3. The nursing staff at the operating room receive ongoing operative
care and equipment training
1.4. Delineation of privileges and responsibilities of physicians and
nurses working in operating room
ASC 2. Policies and procedures to guide patient care in the operating room are
delineated and documented.
All the steps, personnel, and hardware involved in the entire surgical
patient circuit (scheduling, admission, checklist…) with the possible risks
related to operating room functioning (infection control, outbreaks...)
and to surgical procedures and patient safety risk such as correct site,
5
instrument retention…) have to be well defined, documented, with
responsibilities clearly delineated.
There should be a written process defining responsibilities for
dissemination, implementation and auditing of all documentation related
to the functioning of the operating room making sure they are regularly
updated and easily accessible.
Guiding measures:
2.1. Evidence of policies and procedures on, but not limited to:
2.1.1. Scheduling process and priorities, including the
documentation of the list of surgeries and responsible
physicians on the surgical board with weekly revisions
2.1.2. Surgical safety checklist
2.1.3. Handover process between units
2.1.4. Safeguarding correct-site, correct-procedure, and correct-
patient surgery
2.1.5. Prevention of unintentional retention of instruments or
sponges in surgical wounds
2.1.6. Infection control measures in the operating room
2.1.7. Caring for patients with infectious diseases

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 2.1.8. Equipment maintenance
2.1.9. Laboratory specimens, chemicals and blood handling and
storing.
2.1.10. Patient acceptance into operating room
2.1.11. Emergencies including (outbreak management in the
operating room and management of patients with latex
allergy).
2.2. There is a process to ensure that policies and procedures are
documented, disseminated, up to date, implemented and available
for use by all operating room staff.
ASC 3. There is a plan to ensure safe operating room environment.
The operating room has clear procedures for infection control and safety
covering air, water, rooms and equipment safety. Joined procedures with
biomedical, engineering and sanitary departments defining the personnel
5
responsible for infection control of the different equipment in the
operating rooms and detailing specific time frames for cleaning and
disinfecting. A documented record of the periodic checks and any
necessary corrective action taken is available.
Guiding measures:
3.1. There is a policy and procedure to clean and disinfect the operating
room and machines.
3.2. Proper air flow is ensured and documented periodically in the
operating rooms, isolations rooms and central sterilization and
supply department.
3.3. Control of temperature and humidity is ensured and documented
periodically at all times.
3.4. Scrub sinks are available at the entry of the operating room.
3.5. Water control is ensured and documented on regular basis.
3.6. Standard precautions are implemented in the operating room.
ASC 4. The anesthetic and sedation services in the hospital are under the
direction of a qualified and certified anesthetist.
The anesthesia department has documented job descriptions for the
head of department and all members detailing their respective needed
6
qualifications, experiences, roles and services. Among the responsibilities
of the head of department is ensuring all activities and services are
implemented in a standardized manner with well documented and
updated procedures and policies.
Guiding measures:
4.1. Qualification, training, education and experience of the anesthetic
and sedation services match the position description.
4.2. The roles and responsibilities of the anesthetic and sedation
COR services head are specific and documented.
4.3. The head supervises and enforces the implementation of policies
and procedures related to anesthesia and sedation.
4.4. The head ensures the implementation of standardized anesthesia
and sedation services throughout the hospital.

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 ASC 5. A uniform process guides procedural sedation (moderate and deep
sedation) administration.
Any sedation required for a procedure (endoscopy, imaging, Emergency
room, small surgery …) has to follow a specific documented policy
dictating all aspects of the anesthetic act. The policy should state who are
6
the personnel needed, allowed, their required qualifications and
expertise as well as the locations where such acts are permitted.
Equipment needed for sedation in relation to the procedure itself or in
case of an emergency and the patient should be set by protocol and
present at the allowed areas.
Guiding measures:
5.1. There is a uniform process for procedural sedation (moderate and
deep sedation) administration
5.2. Procedural sedation administration is guided by policies and
procedures that include:
5.2.1. Staff qualifications required to administer procedural
sedation, documented in personnel files.
5.2.2. Areas where procedural sedation can be administered
COR 5.2.3. The equipment and supplies needed for procedural sedation
administration.
5.2.4. Pre-anesthetic checkout procedure
5.3. Areas, where procedural sedation is administered, contain
equipment and supplies (appropriate for the age of the patient and
type of procedure) needed for emergency.
5.4. Availability of an individual with advanced life support training
(certified advanced resuscitation such as ALS, ACLS…) during
moderate and deep procedural sedation.
ASC 6. The scope and content of a pre-sedation assessment and sedation
monitoring form are delineated in hospital policies.
All steps related to the procedural sedation act are documented, kept in
the patient’s file and conducted by qualified, expert health care workers.
5
These steps include the pre-sedation assessment, intra-procedural
monitoring, and recovery period. A standardized documented checklist
and protocol with preset recovery criteria for discharge after procedure
exists.
Guiding measures:
6.1. A pre-sedation assessment on the patient is completed by a
qualified practitioner by education and training, that includes but
not limited to:
6.1.1. Airway problems that may influence sedation type
6.1.2. Risk of patient based on ( history of the patient, allergies,
age, weight, previous adverse response to anesthesia or
sedation, current medications, substance abuse, vital signs)
6.1.3. Type and level of the sedation that will be administered
6.2. The sedation monitoring form contains the following:
6.2.1. Vital signs
6.2.2. Ventilator status and Oxygen saturation

140
 6.2.3. Skin color
6.2.4. Level of consciousness and response to stimuli
6.2.5. ECG findings
6.3. Patients are monitored during recovery period and until patient
achieved baseline level of consciousness and normal hemodynamic
parameters.
6.4. The patient’s pre-sedation assessment and sedation monitoring
form are documented in the patient’s record.
6.5. The hospital has a recovery and discharge criteria for patients
undergoing procedural sedation.
ASC 7. Pre-anesthesia and pre-induction are guided by policies and procedures.
Pre-anesthesia assessment is divided into 2 parts, Pre-admission (hours
or days) prior to a surgery or procedure, and Pre-induction. Both parts
4 should be well governed by policies and protocols dictating the qualified
personnel and the checklists (for patient and equipment) needed for both
to ensure standardized delivery of care. These documentations should be
kept in the patient’s file.
Guiding measures:
7.1. The hospital has policies and procedures to guide pre-anesthesia
and pre-induction.
7.2. Pre-anesthesia (prior to admission or prior to procedure) and pre-
induction assessments (immediately before the induction of
anesthesia and focusing on physiological stability, readiness to for
anesthesia and ensuring machine safety) are conducted prior to
inpatient and outpatient surgery/procedure anesthesia
administration by qualified individuals (i.e. anesthetist).
7.3. Pre-anesthesia and pre-induction assessments are documented in
patient records.
ASC 8. The anesthesia care is documented.
A thorough documentation during anesthesia is obligatory and much
5 contain all relevant information related to the patient, procedure,
anesthesia, and the identity of all health care personnel involved in the
anesthetic procedure.
Guiding measures:
8.1. The anesthesia care is documented in the patient’s record, that
includes but not limited to the following:
8.1.1. Age, sex, weight
8.1.2. Medical history
8.1.3. Medication history
8.1.4. Vital signs (pre-operative)
8.1.5. The anesthesia agent
8.1.6. Method of administration
8.1.7. Anesthesia dose
8.1.8. Allergies
8.1.9. Medication administered
8.1.10. Other concerns

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 8.2. The anesthetist, nurse anesthetist and anesthesia assistants
participating in the administration and monitoring of anesthesia are
identified in the patient’s anesthesia record.
ASC 9. Patients undergoing sedation are informed of the risks, benefits and
alternative to anesthesia prior to a procedure.
A clear anesthetic consent is obligatory before any sedation and
anesthetic procedure. A documented consent protocol should be clear to
all health care workers, stating which health care personnel are qualified
4 to obtain such consent, when and who besides the patient is allowed to
sign on their behalf if they are unable. The medical officer should clearly
explain to the patients or, if not possible, to their legal guardians all the
risks and benefits of the anesthetic act, and if available any other
alternatives. All possible post-operative pain management protocols
should also be clearly explained and documented.
Guiding measures:
9.1. Documented evidence that a qualified individual informed the
patient and/or family members and/or guardian about the risks
benefits and alternative to anesthesia and documents it.
9.2. Documented evidence that a qualified individual informed the
patient and/or family members and/or guardian about
postoperative analgesia.
9.3. An informed consent is obtained prior to sedation.
ASC 10. The patient is monitored during and post-anesthesia.
Patients monitoring during the anesthetic procedure and after should be
guided by preset documentation and protocols ensuring all necessary
5 data are obtained and documented in the patient’s record. Post
anesthesia recovery monitoring is guided by procedures, protocols and
should be written down in the patient’s record on clear standardized
documents and checklists containing well defined discharge criteria.
Guiding measures:
10.1. There is a policy and procedure for monitoring the patient’s status
during and post-anesthesia.
10.2. There is a policy, procedure and criteria to discontinue monitoring
services and discharge the patients from the post-anesthesia unit.
10.3. The results of the patient monitoring are documented in the
patient’s record.
10.4. Time arrival to and discharge from the recovery room is
documented.
ASC 11. The hospital implements standardized processes to safeguard correct-
site, correct-procedure, and correct-patient surgery. [QMPS-15]
Wrong patient, procedure and site are never events and should not be
accepted. Therefore, a standardized documented procedure starting
6
from the patient’s room until induction should be mandatory, with
several safety steps. In the patient’s room, a member of the surgical
team who is familiar with the patient and surgery , should mark the limb
or site of surgery, confirming it with the patient or legal guardian,

142
 associated documents and using an approved and standardized marker
and method ( i.e. : check with clear initials ). Upon arrival to the
operating area and then entering the operating room until the induction
time, multiple steps and verifications checks should be implemented by
several members of nursing, surgical and anesthetic personnel. A Final
check before surgical start, “procedure time out” is obligatory. All these
steps are documented in the patient’s record.
This process must be evaluated regularly, and this can be done using
audits, observations, file reviews audits on the entire process must be
conducted and any non-compliance documented with improvement
projects and targets implemented and rechecked.
Guiding measures:
11.1. The hospital has a standardized process that is implemented before
induction of anesthesia in surgical procedures that consists of
preoperative verification, site marking and procedure time-out.
11.2. Preoperative verification is implemented using a checklist and
consists of:
11.2.1. Patient identification
11.2.2. Patient consent form
11.2.3. The procedure being performed
11.2.4. The site and side on which the surgery is being performed
11.2.5. Laboratory test and images
11.2.6. Disclosure of any implants or prosthesis
COR 11.2.7. Prophylactic antibiotic (if any)
11.2.8. Other concerns related to surgeon or anesthesiologist (i.e.
allergies, blood loss, difficult airway)
11.3. One of the individuals performing the procedure utilizes a
standardized mark, as per hospital policies and procedures, to
identify the surgical site to be operated.
11.4. Patients and/or family member and/or next of kin are involved
during site marking in the patient’s room.
11.5. Compliance rate to preoperative verification processes and timeout
procedure is regularly (within a year timeframe) measured and
documented.
11.6. Evidence of process evaluation and improvement implementation,
when needed.
ASC 12. Patients undergoing surgery have a medical assessment performed and
a surgical care plan completed for stays of more than 24 hours.
A preoperative assessment by the surgical team must be completed and
in the patient’s file prior to admission to surgery. Basic required
5
documentation includes (history, physical exam…) and a signed informed
surgical consent. A surgical care plan with type of surgery and post-
operative care plan should be documented in the records prior to
surgery and adjusted afterwards according to the patient’s status
Guiding measures:

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 12.1. Evidence of a complemented medical assessment by the
responsible physician in the patient’s medical record. That includes
the following:
12.1.1. History and physical examination.
12.1.2. Pre-operative diagnosis.
12.1.3. Diagnostic tests (laboratory, radiology, etc.) as ordered.
12.1.4. Signed informed consent.
12.1.5. Planned procedure
12.2. Evidence of a completed surgical care plan.
ASC 13. A procedure time out process is implemented before the initiation of the
surgery. [QMPS-16]
A “time out “procedure is the final step of the preoperative checklist
6
before starting surgery. A final check for correct patient-procedure-site
and implants. This step should be performed by all involved health care
personnel (circulating nurse, anesthetist and surgeon).
Guiding measures
13.1. Timeout is conducted in the location of the surgery, with the whole
surgery team present (i.e. surgeon, nurse and anesthetist),
immediately before starting the procedure and after the
administration of anesthesia.
13.2. The timeout is implemented to verify the patient and the surgery,
and consists of:
13.2.1. Verifying the correct patient identification
COR 13.2.2. Verifying the correct side and site of the procedure with site
marking
13.2.3. Verifying the correct patient position
13.2.4. Verifying the availability of the correct implants/devices
13.2.5. Verifying that the preoperative verification checklist has
been completed
13.3. The timeout procedure is documented.
13.4. Evidence of process evaluation and improvement implementation,
when needed.
ASC 14. A surgical report is included in the patients’ record.
All performed surgeries must have an operative report detailing all the
pertinent information in order to allow for complete transfer and
handover of patient information for continuing the care process . A basic
4
uniform operative report with different sections for all the necessary
information required for all surgeries. The report must be available in
the file prior to transfer to the floor with accessibility by necessary
health care workers.
Guiding measures:
14.1 A uniform operative report is completed which includes:
14.1.1. Pre-operative and Post-operative diagnosis
14.1.2. Name of the surgeon and assistant
14.1.3. Description of the surgery/procedure and findings
14.1.4. Prophylactic antibiotic treatment (if any)

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 14.1.5. Operative complications (if any)
14.1.6. Amount of blood loss and amount of transfused blood(if
any)
14.1.7. Labeled samples and surgical specimens sent for
examination
14.1.8. Final count of tools used during surgery ( i.e. needles,
surgical instruments and gauzes)
14.1.9. Registry number of all implantable devices
14.1.10. Date, time and signature of physician
14.2 The operative record is documented in the patient’s record by the
end of the surgery before transfer to floor.
ASC 15. Patients undergoing surgery have a post-surgical care plan completed by
the end of the surgery before transfer to floor.
4
The post-surgery handling of the patient follow a uniform plan which is
documented and updated following the patient’s needs.
Guiding measures:
15.1. There is a uniform post-surgical care plan.
15.2. The post-surgical care plan is included in the patient’s record.
15.3. The post-surgical care plan is updated based on the patient’s needs
(based on the reassessment of the patient) throughout their
hospital stay.
ASC 16. Anesthesia services specific indicators are collected and used as part of
the quality improvement for anesthesia services.
Anesthesia services must periodically choose one or more indicator to
assess quality of care. Data can be retrospectively or prospectively
4 collected and analyzed with results used towards determining current
status, planning improvement projects or assessing impact of previous
projects. Results and action plans are communicated to the
administration for study and assigning appropriate improvement plans
accordingly.
Guiding measures:
16.1. Indicator(s) is/are used to monitor progress for each quality
improvement objective.
16.2. Data is collected, analyzed, and interpreted to establish a baseline
for indicators.
16.3. Outcome indicators are evaluated to determine the effectiveness of
the quality improvement activities.
16.4. Results are properly communicated to the hospital executive
management.
ASC 17. Surgical care specific indicators are collected and used as part of the
quality improvement for surgical care.
Surgical care indicators either general across all specialties and surgeries
4 or targeted indicators determined after multidisciplinary discussions
(quality department, specific surgical specialty department, nursing …)
should be routinely assessed, analyzed and leading to quality
improvement projects which are later audited, at a preset time frame,

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 assessing their impact of those indicators. These quality indicators,
improvement projects and their benefit should be overseen by the
hospital management either directly or by a committee containing all
relevant medical and non-medical members.
Guiding measures:
17.1. Indicator(s) is/are used to monitor progress for each quality
improvement objective.
17.2. Data is collected, analyzed, and interpreted to establish a baseline
for indicators.
17.3. Outcome indicators are evaluated to determine the effectiveness of
the quality improvement activities.
17.4. Results are properly communicated to the hospital executive
management.

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Patient Services: Oncology Services (ONCO)
Introduction
The Oncology Services chapter is an integral part in patient services. It requires
specific and collaborative care including proper diagnosis, treatment and
appropriate care transition. The standards, aimed at providing safe and effective
patient care, target systemic therapy (hormonal, biological and cytotoxic) and
radiotherapy.
The Oncology Services chapter targets the following sections:
 Building a qualified and competent staff
 Establishing policies and procedures
 Providing safe and effective services
 Managing medication in a safe manner
 Involving family in patient’s care
 Monitoring quality indicators

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

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Standards
Risk
Standard and Guiding measures
Score
3 ONCO 1. Patient-centered care in the oncology services department is ensured
with adequate resources.
In order to deliver care to Oncology patients, a multidisciplinary team
as well as appropriate material resources, function as by
implemented guidelines and defined protocols and procedures in
order to ensure that the patient is at the center of their care, and all
required needs are being addressed.
Guiding measures:
1.1 The needed human and material resources are identified and
properly communicated to the hospital executive management.
1.2 Policies, procedures, guidelines and protocols related to oncology,
are in place with evidence of proper implementation.
1.3 A multidisciplinary assessment involving (such as physician, nurse,
dietitian and social worker wherever needed) assessment for all
cancer patients is followed and properly documented.
1.4 A process is in place for multidisciplinary consultation for all
“oncology” patients is in place and properly documented.
5 ONCO 2. Policies and procedures to maintain safe hospital radiotherapy
equipment are developed and implemented.
It is important that the processing, maintenance of radiotherapies
and disposal of radioactive wastes be done according to clearly
defined policies, taking into account the safety of staff, patients and
equipment.
Guiding measures:
2.1 Quality control reviews are performed at least annually and
properly documented.
2.2 A process for selecting and prioritizing equipment is in place.
2.3 Evidence of periodic radiotherapy equipment inspection,
maintenance, update and calibration of dosimetry is in place.
2.4 An equipment log is in place to record maintenance and downtime,
identify and document upgrades and repairs.
2.5 Protection of patients and staff in case of equipment failure or
damage is ensured at all times.
2.6 All safety requirements are ensured and documented when the
services are contracted from external providers.
2.7 Management of radioactive wastes is ensured via a specific process.
6 ONCO 3. The staff in the oncology department is competent and qualified.
As oncology is a highly specialized discipline with particularly higher
safety risks to staff, patients and the environment, oncology staff are
qualified and trained to handle all care processes and materials (Use
of devices, oncology medications palliative and end of life care.

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 Guiding measures:
3.1 A qualified physician specialized in the oncology/radiation oncology
field is responsible for managing the oncology department.
3.2 The nurse manager and the nursing staff are qualified by education,
training and experience in the field of oncology.
COR 3.3 Evidence of staff training on equipment and devices used in
oncology services including infusion pumps used in cancer therapy
medication administration and other equipment or devices.
3.4 Staff is trained and educated about how to manage palliative (pain
management) and end-of-life care.

5 ONCO 4. The staff working in radiotherapy is qualified and competent.

The Radiotherapy team is qualified and available, physicians and
safety officers.
Appropriate specialties and competencies are essential in the safe
running of the radiotherapy and access to qualified staff and user
manuals must be facilitated.
Guiding measures:
4.1 Qualified radiation oncologists and medical physicists are available
and accessible.
4.2 A qualified radiation safety officer is in place.
4.3 Evidence of staff training on radiotherapy equipment is in place.
4.4 The instructions and user guides of the radiotherapy equipment are
accessible at all times.
5 ONCO 5. Safe and accurate handling of cancer therapy medications is ensured
via a process.
Management of cancer therapy medications is highly sensitive due to
their cytotoxicity thus requires highly specialized resources.
Therefore, staffs who handle them should be trained and identified.
Areas of preparation and of storage in Oncology and Pharmacy
should be defined and separated as by national laws, regulations and
hospital policies. Spills should be properly managed and any incident
reported and undergo a corrective plan.
Guiding measures:
5.1 The staff responsible for acquiring, receiving, storing, preparing,
administering, transporting, and disposing of cancer therapy
medications and contaminated supplies is identified and well
trained.
5.2 Cancer therapy medications are stored away from preparation
areas, and abide by specific regulations and instructions for
preventing its adverse effects on the pharmaceutical staff (i.e.
pharmacists and unit staff).
5.3 Proper management of cancer therapy medication spills is ensured
at all times.
5.4 Incidents related to cancer medication therapy spills are
documented, analyzed and corrective actions are taken accordingly.

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 5.5 Cancer therapy medication is properly disposed by the pharmacy
and oncology unit, as per national laws and regulations and hospital
policies.
5 ONCO 6. Cancer therapy medications are safely ordered.
As therapies are classified as high-alert drugs with considerable risk
of serious harm, additional safety barriers need to be placed to
avoid any risk of error. Ordering of any cancer therapy medications
should be Standardized and follow a pre-printed protocol. No verbal
order is allowed and any change in the order should be properly
managed and documented, use of dose calculator is ensured.
Guiding measures:
6.1 A complete order for all cancer therapy medications is in place.
6.2 Any changes in the order of cancer therapy medications is properly
managed and communicated.
6.3 There are no verbal or telephone orders for cancer therapy
medications as per specific policy.
6.4 Ordering of cancer therapy medications follows a standardized
format (pre-printed protocol), as per hospital policies and
procedure.
6.5 Proper dose calculation of cancer therapy medications is ensured,
and documented.
6 ONCO 7. Preparing and dispensing of cancer therapy medications follows
specific policies and procedures.
The pathway of cancer therapy medication is well defined in order to
ensure safety and security throughout. The process should include
medical order, verification of order, transcribing labeling, dispensing
and preparing (Hood, Laminar flow). The pharmacist holds a capital
role in this process namely for conducting regular verification on it.
Guiding measures:
7.1 Pharmacist verification of the medication order for completeness
and appropriate review is conducted regularly, as per hospital policy
prior to dispensing and transcribing medications on the medical
administration record.
7.2 Labeling and administering of cancer therapy medications follows a
COR
standardized format.
7.3 Separate preparation areas with a 100 percent externally-vented
biohazard (laminar airflow) hood using protective equipment are
ensured.
7.4 Safe dispensing of cancer therapy medications is ensured at all
times.
4 ONCO 8. The access to care in the oncology services is provided in a timely and
coordinated manner.
The access to Oncology department is possible at all times and is well
defined by criteria for admission and discharge. Access of any patient
to another department or facility should be possible in case the

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 patient needs cannot be met in a satisfactory manner is possible if
needed.
Guiding measures:
8.1 Admission and discharge criteria for the oncology department are
followed.
8.2 Timely response to oncological emergencies is ensured at all times,
as per policies and procedures.
8.3 Access to another facility is ensured in case the patient’s needs are
not met.
4 ONCO 9. Patients and family caregivers are involved in the care provided.
Involving the patient and his family in the plan of care should be
ensured and documented. It implies providing and explaining
information by qualified team members, obtaining a written
consent on planned medications and procedures, discussing
treatment options and respecting the choice of the patient and
families according to their rights and responsibilities.
Guiding measures:
9.1 Information are provided to patients and families in a timely
manner, documented and verified to ensure proper understanding.
9.2 The hospital has policies and procedures to assess the rights of
family and/or next of kin to provide informed consent.
9.3 Informed consent is signed before chemotherapy/each procedure
by patients or his/her family/next of kin, when necessary.
9.4 Patients and families are informed about their rights and
responsibilities, and how to report any breach in their rights.
9.5 Treatment options are discussed with patients and families and
their choice is respected at all times.
5 ONCO 10.Care plans are developed following patient assessment as hospital
policies and procedures.
Patients should be comprehensively assessed to be able to develop
a plan of care. This should be conducted via standardized tools as
per policies and procedures implemented by the hospital. The
assessment approach includes, along with medication
reconciliation, physical, psychological, potentially in-hospital risks,
pain management and palliative care.
Guiding measures:
10.1 A holistic approach is used during the assessment of the patients’
physical and psychosocial health via a standardized tool.
10.2 A medication reconciliation process is initiated at the time of
admission.
10.3 Patients are assessed for falls; proper measures are implemented
and evaluated for patients who are identified at risk for fall.
10.4 Patients who are at risk for pressure ulcer are assessed and
monitored.
10.5 Patients who are at risk for venous thromboembolism are assessed
and monitored.

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 10.6 Patients are assessed for pain and options for pain management are
provided.
10.7 Assessment for the patients’ palliative care and end-of –life issues is
performed when appropriate.
10.8 Reassessment of the patient or any change in the patient’s
condition is properly documented in the medical record.

5 ONCO 11. Care plans for cancer patients are properly implemented as hospital
policies and procedures.
The patient’s individualized care plan implies an accurate
identification, a documented medical report and an assessment of
oral care.
The hospital should ensure a round-the clock access to care/services
and respond to any need of the oncology patients and of their
families.
Guiding measures:
11.1 At least 2 patient identifiers are used at accurately identify patients
(patient’s triple name and medical number) excluding patient’s
room number or location.
11.2 The care plan is individualized and documented.
11.3 A process for sharing information (i.e. medical report) for patients
receiving cancer therapy at more than one hospital, when
requested.
11.4 Oral health for cancer patients is assessed and interventions are
implemented when needed.
11.5 Laboratory and diagnostic services are available twenty four hours a
day, seven days per week and results are reported in a timely
manner.
11.6 Urgent medications are accessed by authorized staff twenty four
hours a day, seven days per week.
11.7 Consultation services are available and provided in a timely
manner.
11.8 Access to services needed by the oncology patients is ensured.
11.9 Patient and family have access to psychological and support
services, when needed.
5 ONCO 12. The treatment plan for cancer patients should follow standard
protocol and guidelines.
Oncology Patients are assessed by standardized tools for diagnosis
and treatment, through defining their staging, history and evolution
and accordingly deciding on treatment protocols which are
consistently implemented to avoid variation in practices among
patients.
Guiding measures:
12.1 Patient’s stage of cancer is determined via a standardized process.
12.2 Prior to treatment, a plan of care which includes patient’s history is
developed and regularly updated.

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 12.3 Treatment protocols are consistently followed.
6 ONCO 13. Accurate and safe administration of medications and cancer
therapies are ensured.
Cancer therapy medications and radiation therapy should be
managed administered and provided according to hospital
guidelines and standards of practice. Accuracy and safety implies
also a proper communication of critical patient information and
parameters. Any side effects gone unnoticed can lead to serious
consequences, and thus must be closely assessed and managed.
Guiding measures:
13.1 The staff follows hospital’s guidelines for managing cytotoxic
medications spills.
13.2 Administration of cancer therapy medications and the provision of
radiation therapy services follow standards of practice.
COR 13.3 Critical patient information is identified and properly communicated
to the staff via a specific policy.
13.4 Height, weight and relevant clinical parameters of the patients are
properly documented.
13.5 Side effects of the cytotoxic medications are assessed, monitored
and managed properly.
ONCO 14. Accurate and safe delivering of radiotherapy is ensured, when
applicable.
Radiotherapy providing and treatment plan follow standards of
6
practice specified by policies and procedures to ensure safety and
accuracy. Also, there should be a periodic review of the plan of
treatment by a radiation oncologist.
Guiding measures:
14.1 Imaging, planning, and treatment of radiotherapy follow specific
policies and procedures.

14.2 Patients with implanted electronic device are identified and

monitored during radiotherapy.
14.3 Radiotherapy treatment prescription/orders are complete.
COR
14.4 Verification/change in the radiotherapy treatment plan is verified
based on hospital policies and procedures.
14.5 Radiotherapy treatment plan is peer reviewed by a radiation
oncologist, periodically.
ONCO 15. Accurate and safe administration of systemic therapies is ensured.
Before any administration of any systemic therapy, there should be
a clear and documented review and checking of parameters of the
6 patient, double checking medication dose and rate, and proper
management of devices for central venous injection.
This ensures safety and precision of high risk medication
administration.
COR Guiding measures:

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 15.1 Revision of patient’s height, weight and relevant clinical parameters
is performed before each cycle or when clinically indicated.
15.2 Administration of systemic therapies is properly documented.
15.3 Dose and rate of administration of systemic therapies are double
checked before administration via an infusion pump.
15.4 Management of central venous access device follows specific
guidelines.
ONCO 16. The transfer to another service or setting is appropriately planned.
The need to transfer any patient to another service should follow a
previously prepared plan according to clinical guidelines responding
6
to patient’s needs, but also taking into consideration the approval of
the patient. A review of the transfer plan should be continuously
performed and corrective measures should taken accordingly.
Guiding measures:
16.1 A transfer plan is in place and properly documented.
16.2 Transfer of care follows specific clinical guidelines.
16.3 Patients’ decision whether to end or limit services, transfer to
COR another service, or transition home is respected
16.4 Patient’s information is properly communicated during care
transition.
16.5 Transfer plan is evaluated and corrective actions are taken when
required.
4 ONCO 17. Oncology services specific indicators are collected and used as part
of the quality improvement in the oncology services department.
Oncology department holds several areas where organizational
performance and clinical quality can be subject to improvement,
and where adverse events can be prevented. Therefore, it is
important to define and prioritize the key improvement objectives
for this department, based on observations, audit surveys and
benchmarking.
Indicators should be easy to identify, comprehensive, set with
adapted targets, in order to monitor the progress of the quality
improvement plan. (Examples of such indicators include rate of
central catheter devices complications, survival rate at 5 years for a
number of preselected cancer types…)
Discussion of indicator results should be done at the leadership level
of the department and also at the hospital management level in
order to engage appropriate improvement actions, with a timely
feedback of results and action plans to the concerned teams.
Guiding measures:
17.1 Indicator(s) is used to monitor progress for each quality
improvement objective.
17.2 Data (e.g. waiting time, treatment-related toxicity outcomes,
disease control and survival outcomes, patient-reported outcomes,
peer review rates for radiotherapy treatment plans) is collected,
analyzed, and interpreted to establish a baseline for indicators.

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17.3 Outcome indicators are evaluated to determine the effectiveness of
the quality improvement activities.
17.4 Results are properly communicated to the hospital executive
management.

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Patient Services: Medical Imaging (MI)
Introduction
The Medical Imaging chapter covers investigations of patients that provide
imaging information for the diagnosis, prevention, and treatment of disease or
assessment of health. The chapter’s scope includes the arrangements for
requisition, patient identification, choice of appropriate techniques, patient
information, patient consent, patient preparation, performance of imaging
procedures, interpretation, reporting, and advice regarding the result, in
addition to the consideration of safety and ethics in diagnostic imaging services.

The standards have been developed to deal with all aspects of imaging services,
from control of services, facility and environment, imaging processes and
procedures, equipment, documentation of records and control of risk and
safety.
The Medical imaging chapter targets the following sections:
 Select, operation and maintenance of the medical imaging equipment
follow policies and procedures
 Staff qualification
 Results reporting
 Safe environment in the medical imaging department
 Medical imaging quality control program
Each standard was supported by a corresponding set of guiding measures that
further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

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Standards
Risk
Standard and Guiding measures
Score
MI 1. Medical imaging services cover the patient’s scope of service offered
by the institution and healthcare professionals.
As medical imaging is a key element for medical diagnosis, the scope of
services and their availability should cover the needs of clinical
departments, whether in-house or in collaboration with other imaging
5
centers. Accessibility to imaging exams, their timeliness (including
those requested urgently) and necessary patient preparation are key
components that need to be well defined and clearly shared with
clinical units in order to set correct expectations and prevent
unnecessary delays in the diagnostic process.
Guiding measures:
1.1 Policies and procedures related to medical imaging are developed
and implemented in the hospital.
1.2 Information related to medical imaging services about service
volumes, waiting times, client experience and medical professional
needs, are collected on an annual basis, results are analyzed and
improvements are made accordingly.
1.3 Medical imaging services are provided in coordination with other
centers or medical professionals performing this service, when
necessary.
1.4 Rules of functioning should be defined in agreement with clinical
units and other imaging units (including outsourced units), when
necessary.
1.5 Resources needed to deliver timely access to the medical imaging
services are identified.
1.6 The medical imaging department is run by qualified and registered
radiologists.
1.7 The roles and responsibilities of chief technicians are clearly
described in job description and as per hospital policies and
procedures.
MI 2. The hospital ensures a proper physical environment for the imaging
services providers.
Department’s infrastructure takes into consideration ease of patient
accessibility and safety, the efficient separation of spaces into waiting
5
areas, procedure areas and screening areas in order to ensure patient
confidentiality and adequate technical and environmental conditions
for the safe provision of imaging services for patients, staff and
equipment.
Guiding measures:
2.1 There is a separate space area for the patients to wait in and for the
providers to perform medical imaging procedures.

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 2.2 Confidentiality and security are ensured by providing a space area
for screening patients prior to medical imaging examinations.
2.3 Warning signs are put on the entrance of the medical rooms to
restrict access when it is in use.
2.4 The hospital ensures proper temperature, humidity, and ventilation
inside the department.
2.5 Wheelchairs, walkers and crutches are present and accessible to the
patients undergoing imaging procedures.
2.6 A backup electrical system for the medical imaging department is in
place and tested regularly.
MI 3. Specific policies and procedures are in place to properly select and
operate the medical imaging equipment.
Initial orientation of new employees on these procedures and efficient
5 communication to staff about procedure updates and new procedures
are key to ensure the standardized application of required standards of
care. These procedures should also be accessible for easy consultation
and for regular update as needed.
Guiding measures:
3.1 Staff has an up-to-date manual for operating medical imaging
equipment.
3.2 Evidence that staff is trained on the medical imaging equipment
before using it.
3.3 Evidence that new staff is oriented to the policy and procedure
manual of the medical imaging department.
3.4 Staff is informed about any updates in the policy and procedure
manual of the medical imaging.
3.5 Previous policies and procedures related to medical imaging are
retained according to the hospital policy of record retention.
MI 4. Qualified staff performs medical imaging examinations using
delineated policies and procedures.
These procedures delineate the management of the risks related to the
5 imaging examination and ensure standardized implementation: patient
and examination site identification, allergies, nephrotoxicity secondary
to contrast media administration, risks related to patient sedation and
radiopharmaceuticals, etc.
Guiding measures:
4.1 The staff properly identifies patients (two identifiers), nature of the
medical imaging examination, and the site (in case of interventional
procedure) before conducting it, and document appropriately.
4.2 A process is defined to manage patients who need an imaging
examination.
4.3 Policies and procedures for administering medications such as
contrast media, sedatives and radiopharmaceuticals are followed.
4.4 Qualified and trained staff (in advanced resuscitation) monitors
patients receiving contrast media, sedatives and
radiopharmaceuticals during and after the procedure.

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 4.5 Treating, documenting, and reporting adverse reactions follow
specific policies and procedures.
MI 5. Specific policies and procedures are in place to ensure maintenance of
the medical imaging equipment.
5 There should be documented evidence of adequately planned and
executed preventive maintenance plan and a detailed history of
maintenance actions for equipment.
Guiding measures:
5.1 Evidence of an annual program for preventive maintenance of
equipment.
5.2 Preventive maintenance records are retained for at least 2 years.
5.3 Evidence of an equipment corrective maintenance and actions log.
MI 6. Cleaning and reprocessing diagnostic devices and equipment are
performed according to specific policies and procedures.
The contamination risk of diagnostic machines, devices and accessories
(such as ultrasound machines, interventional radiology suite and
accessories, endoscopes, mobile x-ray machines, aprons and markers,
injectors, etc.) need to be well evaluated and managed according to its
6 criticality relative to its degree of invasiveness (Spaulding Classification
or its equivalent). Therefore clear instructions for cleaning, disinfection
and reprocessing of devices should be explained and trained to imaging
staff, following the hospital’s infection control procedures while
adhering to the manufacturer’s recommendations, to avoid any cross
contamination and machine damage risks.
Guiding measures:
6.1 In case of external medical imaging service provider, the hospital
ensures that a contract is in place to monitor the quality of the
services provided.
6.2 Containing and transporting contaminated devices and equipment
for reprocessing internally and externally, follows specific policies
and procedures.
6.3 The hospital ensures that staff is competent and properly trained on
COR
policies and procedures for reprocessing the diagnostic devices.
6.4 Selecting appropriate cleaning, disinfecting, and reprocessing
methods follows hospital’s policy and procedures for cleaning,
disinfecting and reprocessing diagnostic equipment.
6.5 The clean devices are stored separately according to manufacturer's
instructions.
6.6 The hospital maintains a record for reprocessed devices related to
the medical imaging department.
MI 7. Requests for medical imaging services are managed appropriately.
As the imaging services may not be familiar with the patient’s case,
status or needs, medical imaging requests (written or electronic) are
4
the standardized method of communicating complete and relevant
patient information to the medical imaging services, and should be
relayed prior to imaging the patient and interpreting the report. This is

159
 to avoid risks of errors such as identification, optimize quality of
interpretation, in addition to avoiding unnecessary exposure to
radiation. A list of available imaging exams should be available to
select from. Requests should be made according to the patient’s
clinical status and needs in addition to the medical level of urgency to
which the medical imaging department must respond accordingly in
due time. This clinical information needs to be well documented in the
request.
Guiding measures:
7.1 Resources for selecting appropriate medical imaging examinations
are provided to the medical team.
7.2 A complete signed and validated prescription or electronic request
that identifies the patient, appropriate medical team member, date
of the request, level of urgency, relevant clinical information, type of
procedure, and special instructions, is maintained.
7.3 In case of emergency, the staff collects information identified in the
request and ensures a written or electronic request is filled by the
medical team prior to interpreting the results of medical imaging
examination.
7.4 Staff in the medical imaging department respond to “STAT” orders
within the hospital’s specified timeframe.
MI 8. Screening patients is conducted before performing medical imaging
examinations.
It is critical that patients are screened for all possible clinical factors
that may increase the risk of harm if not appropriately addressed prior
6 to undergoing the medical imaging exam and being exposed to
radiation or contrast media. This can be done in a form of a
standardized screening checklist for each patient including relevant
criteria to check, in addition to required information to be provided to
the patient or family.
Guiding measures:
8.1 Screening patients for allergies, magnetic resonance imaging
contraindications, coagulation profile and medical conditions prior to
the administration of contrast media, implant devices and materials
inside the body is done before medical imaging examination.
COR
8.2 Information is given to patients and families before obtaining an
informed consent regarding the performing medical imaging
examination.
8.3 Staff asks female patients with childbearing age about any potential
pregnancy before procedures involving radiation.
MI 9. Results are reported to the appropriate medical team following
interpretation.
The hospital specifies through a policy or procedure the required
5
timeframe for reporting medical imaging exam results. It should
account for the level of urgency of the exam in addition to handling
any critical findings that should be reported immediately to the

160
 medical team, while meeting the needs of units, especially critical care
or emergency units. Also, medical images need to be collected in a way
facilitating comparison of previous to current findings, in order to
assess patient evolution. Data regarding the reported timeframes
should be collected and evaluated regularly compared to the set
hospital policy or procedure in order to put in place any necessary
corrective actions.
Guiding measures:
9.1 Results of the medical imaging examination are interpreted in a
timely manner and reported immediately to the referring medical
team in case of critical findings according to specific policies and
procedures.
9.2 Elements of the report include: patient identification, relevant
information about the procedure, identification of the ordering
physician, reporting date and time, identification of the reporting
radiologist.
9.3 Medical images and reports are stored appropriately.
9.4 Time frame of emitting results meet the needs of units with special
attention to emergencies and critical results.
9.5 Data is collected regarding the timeframe for interpreting results,
outcomes are analyzed and corrective actions are taken accordingly.

MI 10. The hospital ensures a safe environment in the medical imaging

department.
Ensuring a safe environment involves ensuring the safety of
equipment, staff and patients at all times and reporting any
sentinel/adverse events and near misses in a timely manner to ensure
appropriate improvement actions. Equipment must be periodically
inspected, maintained and calibrated, as per hospital and
manufacturer recommendations, and evidence of this should exist.
5
Regularly inspecting that staff is not exposed to unsafe levels of
radiation is done via adopting technical protocols that can minimize
emission of radiation, providing radiation protection, testing their
efficacy, and checking level of exposure using dosimeters. These tests
and results must be documented and evaluated for any necessary
corrective actions. The department must have the resources (human,
knowledge and equipment) to be able to respond to any medical
emergency with patients occurring in the department.
Guiding measures:
10.1 A safety plan is in place that indicates the periodic inspection,
maintenance, and calibration of all equipment, the provision and
regular testing of radiation protection aprons and thyroid and gonad
shields for staff and patients.
10.2 Monitoring of the staff radiation exposure is performed at least
quarterly using the radiation dosimeters; data are properly collected
and recorded.

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 10.3 Evidence of staff training on responding to medical emergencies (i.e.
patient arrest) at the medical imaging department.
10.4 Fall prevention and precautions measures are properly implemented
in the medical imaging department.
10.5 Sentinel events, near misses, and adverse events in the medical
imaging department are identified, reported to quality management
and patient safety committee and documented in a timely manner.
10.6 The results of the reports related to sentinel events, near misses,
and adverse events are analyzed, and corrective actions are taken
accordingly.
MI 11. A quality control program for medical imaging services is in place.
It is important that the equipment and report results are accurate
and reliable in order to provide optimal images for reading and
correct diagnosis. Thus the department has a procedure describing
the method and frequency of quality control done on imaging
4
equipment and quality control audits on a sample of reports to
ensure accuracy and reliability. Results of the quality control are
documented. Any internal bias or discrepancies should be accounted
for by external validation sources or a peer radiologist (latter) with
identified corrective actions taken accordingly.
Guiding measures:
11.1 Quality control procedures for testing the accuracy of the
equipment are conducted and recorded, problems are identified
and corrective actions are taken accordingly.
11.2 Quality control procedures including peer review for testing the
validity of a sample of the medical imaging reports by internal and
external sources are performed, results are compared and
corrective actions are taken when needed.
11.3 If the result is different / there are discrepancies in the results then
random sampling is conducted and another radiologist is consulted.
11.4 The hospital has the right to send reports to another external
institution in case of discrepancy.
11.5 Repeat/reject analysis is conducted and recorded, problems are
identified and corrective actions are taken accordingly as part of the
quality control program in the medical imaging department.
MI 12. Medical imaging specific indicators are collected and used as part of
the quality improvement in the medical imaging department.
Assessing the quality of services provided is an ongoing process in the
imaging department.
Department objectives relative to the quality of services must be
3 measurable, with a target and be benchmarked with reference data in
order to compare and assess progress, and evaluated regularly.
Performance indicators should include a list of outcome indicators
from various sources of information to help evaluate the quality of
services and any opportunities of improvement such as such as
turnaround times stratified by level of urgency, patient satisfaction

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 rate, utilization rate of machines, audits or quality control checks etc.)
Which could reflect department performance and are benchmarkable.
Discussion of indicator results should be done at leadership level of the
department and also at the hospital management level in order to
engage appropriate improvement actions, with timely feedback of
results and action plan to concerned teams.
Guiding measures:
12.1 Information and feedback from staff, service providers, and hospital
leaders about the quality of the medical imaging services are
collected to guide quality improvement initiatives and identify areas
of improvement.
12.2 A mechanism to ensure appropriate use of medical imaging services
is in place.
12.3 Measurable objectives for quality improvement initiatives and
timeframe in which they will be reached, are set.
12.4 Indicator(s) is used to monitor progress for each quality
improvement objective.
12.5 Data related to the appropriateness of examinations, the accuracy
of the interpretations, and the incidence of complications and
adverse events are collected, analyzed, and interpreted to establish
a baseline for indicators.
12.6 Indicator data is evaluated for to determine the effectiveness of the
quality improvement activities.
12.7 Results are properly communicated to the executive management.

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Patient Services: Emergency Services (ES)
Introduction
The Emergency Services chapter is characterized by the ability to deal with
emergency cases. The hospital must be equipped with competent staff and an
effective triage system to ensure safe and collaborative practices. The urgency
of the patients’ clinical condition mandates the timely assessment and provision
of the appropriate treatment.
The Emergency Services chapter targets the following section:
 Establishing appropriate ambulance services
 Building a qualified and competent team
 Establishing effective triage system
 Providing safe and effective services
 Monitoring quality indicators

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

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Standards
Risk
Standard and Guiding measures
Score
ES 1. The hospital-owned ambulance services, when available are properly
managed, to provide safe and effective care.
In order to make sure that the patients are safely transported
to/from the hospital, a series of hospital defined criteria should be
defined and met prior to transportation and during it. Those criteria
5
start from initial risk stratification, proper communication and
ensuring the required and qualified resources (personnel
qualifications, equipment, medications, safety protocols/policies
etc.) satisfying the patient’s currents needs and possible risks during
transport, ensuring a safe and secure arrival.
Guiding measures:
1.1 The patient needs are assessed prior to transport.
1.2 Proper communication channels are ensured between the hospital
and the ambulance services.
1.3 Safe measures are ensured by the ambulance services during
patient transportation including having a licensed driver and safety
belts.
1.4 Infection control guidelines are implemented while transferring
patients.
1.5 A qualified healthcare professional certified in advanced
resuscitation or critical care is always available when transporting
high-risk patients.
1.6 Criteria for identification of high-risk patient population such as
patients with myocardial infarction or patients having
cerebrovascular accidents, definition and knowledge of care
pathways are followed by the first encounters.
1.7 Transportation of high-risk patients to and from the hospital follows
a specific procedure.
ES 2. The hospital-owned ambulances, when available are properly
equipped and maintained.
The ambulances should always be ready to respond to any call for
5 adult or pediatric urgent cases timely and efficiently. The equipment
and supplies should be checked and maintained and this process
documented to avoid any failure that would endanger the patient’s
safety.
Guiding measures:
2.1 The ambulances have adequate equipment and supplies including
those for pediatric patients, and ready to transport patients twenty-
four hours per day, seven days per week.
2.2 Evidence of daily checking of the materials list.

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 2.3 Equipment in the ambulances is cleaned and disinfected after the
transfer of patients and properly documented.
2.4 Maintenance of the ambulances and their equipment is conducted
on regular basis and properly documented.
ES 3. Transfer of care of patients to a hospital is ensured via a specific
process.
To ensure safety and continuity of care, upon and after transfer,
communication with the receiving hospital should be done prior to
5 patient transfer, using a standardized communication tool, including
all the necessary patient needed to allow the receiving hospital team
to be prepared. Effective communication requires that the
information sent be complete and accurate, and that the receiving
hospital acknowledges receipt of information.
Guiding measures:
3.1 Standardized patient information is communicated effectively via a
communication tool and properly documented.
3.2 Communication with the receiving hospital is done to ensure the
availability of the resources needed.
3.3 Summary of the patient’s condition, treatments and interventions
done are provided by the transporting team to the receiving
hospital.

ES 4. Patient-centered care in the emergency department is ensured with

adequate resources.
The Emergency Department offers designated spaces and required
materials and medications to deal with all kinds of emergencies,
namely the need for isolation and resuscitation for adult and
6
pediatric care. As well, administrative and healthcare professional
ratio in the ER should be adjusted to properly handle any increase in
the flow of patients, in addition to considering patient acuity and
changes in required level of care that could happen suddenly and
rapidly at any time.
Guiding measures:
4.1 Registration of emergency patients is ensured by a registration
clerk.
4.2 Rooms are divided to ensure patient privacy and security.
4.3 Process related to proper and regular checking of medications and
supplies, and refilling them is in place.
COR 4.4 Emergency and advanced resuscitation equipment exist in areas
where sedation procedures are conducted.
4.5 Specific pediatric pathways are available.
4.6 Patient safety is considered when the workload is assigned to the
healthcare workers.
4.7 The workload of the healthcare workers is adjusted based on the
patients’ flow in the emergency department.
5 ES 5. The flow of patients is managed in the emergency department.

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 Emergency department should ensure a permanent access to care
24/7. Intra and inter hospital transfer and transport policies or
procedures exist to help standardize safe transfer of patients within
and between hospitals. These should clarify how and when patients
are moved from the ER to other departments, on what clinical
criteria, and with what resources, in order to ensure safe transfer
but also a continuous fluid access to ER care. Management flow,
transfer from with and from outside the hospital should be
coordinated by a defined process with an overlook from hospital
executive management.
Guiding measures:
5.1 The hospital executive management oversees and manages the
patients flow through the hospital.
5.2 Overcrowding, flow and transfer of patients inside the hospital are
managed according to established protocols/policies.
5.3 Access to the emergency department is provided twenty-four hours
per day and seven days per week.
5.4 Processes and procedures are followed to coordinate the transfer
of patients inside the hospital and between the hospitals.
ES 6. Healthcare workers of the emergency department are qualified and
competent.
The Emergency department should be run by healthcare specialists,
able to manage the flow of patients with any kind of emergency
6 regardless of age and emergency type of the disease, medical or
surgical, traumatic et.. Thus, physicians and nurses in each team
should hold recognized qualifications (ATLS, ACLS, PALS, ATNC,
TNCC, etc.) enabling them to meet all requirement of care for all
types of cases.
Guiding measures:
6.1 The head of the emergency department is an emergency medicine
specialist physician who is qualified by education, appropriate
training, and experience with valid certification in managing and
resuscitating emergency and trauma patients.
6.2 At least one physician in each team is certified by an accredited
training body in the Advanced Management of Trauma care
patients, such as Advanced Trauma Life Support (ATLS), and
Advanced Trauma Care (ATC).
COR
6.3 At least one nurse in each team is certified by an accredited training
body in the management of trauma care patients, such as Advanced
Trauma Care for registered Nurses (ATCN), Trauma Nursing Core
Course (TNCC), and Advanced Trauma Nursing Course (ATNC).
6.4 A qualified emergency physician covers the emergency department
twenty-four hours per day, seven days per week and needs to be
physically present on site.
6.5 The healthcare workers involved in patient care are certified with
advanced life support as appropriate to the age of patients

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 (Advanced Trauma Life Support, Pediatric Advanced Life Support,
Advanced Neonatal Life Support, Advanced Cardiovascular Life
Support …).
ES 7. Consultation services in the emergency department are provided via
a specific process.
A significant part of patient encounters in the emergency
department require consultancy of a specialized physician
(orthopedic, infectious diseases, urology, gynecology, etc.) in order
4 to identify the diagnosis and care plan. Therefore, the hospital
should define a policy for offering a permanent consultation service
in the emergency department. Procedures should define and
document this process which include the way of communication
with the consultant, how consultancy is delivered and documented
and the possibility of consulting doctors outside the hospital.
Guiding measures:
7.1 A policy and procedure for managing consultation services that is
originated from the emergency department is in place.
7.2 Consultations services and ways of communication are identified.
7.3 A process is in place when consulting physicians outside the hospital.
7.4 The consultation services are available twenty-four-hours a day,
seven days per week and overseen by an attending physician.
7.5 A process exists for documenting consultations is in place.
ES 8. Patients are prioritized in the emergency department via an effective
triage process based on specific policies and procedures.
All patients should be handled in the emergency department as soon
as they arrive. A standardized process of triage (for example based
on international triaging methods such as ESI, CTAS, CIMU, etc.)
6
should define the priorities and rapidly identify the needs of each
patient in order to deliver the proper care in a timely manner.
Documented surveillance and reassessment should be conducted by
the healthcare team to follow up on the patients’ condition, taking
into consideration their acuity and risk of deterioration.
Guiding measures:
8.1 Trained nurses in triage systems conduct and document triage
assessment in a timely manner via a standardized assessment tool.
8.2 A standardized tool for pediatric patients during the triage is in
place and properly documented.
8.3 Patients present in the waiting areas are provided with names of
the healthcare workers.
COR
8.4 Reassessment is done when there is a change in the patients’
condition.
8.5 There is a process that identifies patients’ needs and prioritizes
services accordingly.
8.6 Patients in the emergency department are monitored for any
deterioration in their medical condition and are reassessed
appropriately.

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 8.7 Healthcare workers assess the patients received, and document
their assessment in a timely manner.
ES 9. The emergency department has policies, procedures, clinical
guidelines and pathways that ensure patients’ care.
Patients in ER should be handled and treated according the evidence
based medicine recommendations and guidelines. There should be
5
specific protocols and procedures for the management of specific
medico legal conditions as per local legal requirements. Procedures
which define the patients’ flow in and out of the ER should also
exist, including criteria to admit and to discharge from ER.
Guiding measures:
9.1 Policies and procedures include, but not limited to, the following:
9.1.1 Management of medico-legal cases such as alcohol and
narcotic abuse and criminal acts.
9.1.2 Management of suspected victims of abuse, neglect, and
domestic violence.
9.1.3 Management of suicidal patients.
9.1.4 Care of trauma patients.
9.1.5 Patient transfer from emergency department to inpatient
areas or to another hospital.
9.1.6 Admission and discharge process.
ES 10. Care plan is developed following patient assessment.
A care plan for patients in emergency department should be
developed in a multidisciplinary way and based on the logic of
assessment and reassessment of all the patient’s clinical condition
and risks, which can help identify adapted interventions to
potentially improve the patient’s clinical status and/or prevent
unwanted outcomes.
Initial assessment should be performed upon admission of the
patient, same as reconciliation of medications.
The patient’s assessment gains to be performed using standardized
5 methods and tools (systematic clinical exam, vitals and physiological
parameters, screening of the risk of acquiring some hospital
conditions, such as developing pressure ulcers, in-hospital falls,
venous thrombo-embolism, delirium, etc.) In order to arrange for
any necessary preventive measures.
Based upon the assessment, adequate interventions are identified
and planned by the clinical staff, and both the assessment and the
interventions are documented in the patient’s care plan. When
patient prognosis is not favorable despite the clinical interventions
undertaken, an assessment for palliative care is conducted and
discussed with the patient’s family.
Guiding measures:
10.1 A comprehensive approach is used during the physical and
psychosocial assessment of patients via a standardized tool.
10.2 A medication reconciliation process is initiated at the time of
admission.

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 10.3 Patients are assessed for falls, proper measures are implemented
and evaluated for patients who are identified at risk for fall.
10.4 Patients who are at risk for suicide are assessed and monitored.
10.5 Patients who are at risk of developing pressure ulcer are assessed
and monitored
10.6 Patients who are at risk for developing venous thromboembolism are
assessed and monitored.
10.7 Patients’ are assessed for pain and options for pain management are
provided.
10.8 The assessment for the patients’ palliative care and end-of-life issues
is being performed when appropriate.
10.9 Patients are reassessed and results are documented in the medical
record if there is any change in the patient’s condition.
ES 11. Patients receive safe and effective care in the emergency
department.
Emergency department offers a permanent access to care for all kind
of patients, adults and babies and thus should ensure in a timely
manner the required logistics for care provision, such as medications,
laboratory services for diagnosis and therapeutic procedures for
urgent situations.
Standardization of practice is important to ensure conformity to
6 guidelines and reduce variation in care. This should be implemented
through the elaboration and diffusion to the ER team of protocols
and procedures relative to the most common pathologies
encountered in the ER.
Also, procedures should be elaborated to cover in particular a
number of critical themes, including: patient identification, clinical
assessment, vitals surveillance, isolation of infectious patients, pain
management and palliative care. The care plan should be
documented in the medical record.
Guiding measures:
11.1 The healthcare workers provide services to patients following an
individualized and documented plan of care and properly document
it in the medical record.
11.2 Proper patient identification using an armband is conducted before
providing any service or performing any procedure.
11.3 All patients receive same standards of care through consistent with
evidence-based treatment protocols.
COR
11.4 The healthcare workers working in the emergency department
identify, isolate and manage patients having or suspected to have
infectious diseases.
11.5 Laboratory and diagnostic services are available twenty-four hours
a day, seven days per week and results are reported in a timely
manner.
11.6 Urgent medications are accessed by authorized healthcare workers
twenty-four hours a day, seven days per week.

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 11.7 The healthcare workers monitor patients who received narcotics or
sedative agents.
11.8 Information related to pediatric medications is accessible at all
times, and healthcare workers ensure the proper and safe
administration of weight-based pediatric dosages.
11.9 Information related to patients and their care is effectively
communicated and documented during care transition.
ES 12. Emergency department specific indicators are collected and used as
part of the quality improvement in the Emergency services
department.
Emergency department processes hold several priority areas where
organizational performance and clinical quality can be subject to
improvement, and where adverse events can be prevented.
Therefore, it is important to define and prioritize the key
improvement objectives for this department, based on observations,
audit surveys and benchmarking.
5 Indicators should be set with adapted targets, in order to monitor
the progress of the quality improvement plan.
Such indicators should include a list of outcome indicators (such as
readmission rates to ER within 10 days, mean patient turnaround
time by triaging level, etc.) that could reflect clinical and
organizational performance and are benchmarkable.
Discussion of indicator results can be done at the leadership level of
the department and also at the hospital management level in order
to engage appropriate improvement actions, with a timely feedback
of results and action plans to the concerned teams.
Guiding measures:
12.1 Indicator(s) is used to monitor progress for each quality
improvement objective.

12.2 Data are collected, analyzed, and interpreted to establish a baseline

for indicators.
12.3 Indicator data is evaluated to determine the effectiveness of the
quality improvement activities.
12.4 Results are properly communicated to the hospital executive
management.

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Patient Services: Obstetrics and Child Health (OS)
Introduction
The Obstetrics and Child Health chapter is an integral part in patient services. It
tackles the process of pre-delivery until the baby and mother are provided care
at another setting. It requires specific and collaborative care from
multidisciplinary healthcare providers to ensure safe health care for the mother
and baby.
The Obstetrics and Child Health chapter targets the following sections:
 Obstetrics and nursery services staff qualification
 Patient care plan
 Pre-delivery preparation
 Post-delivery care
 Breastfeeding policy in line with the baby friendly hospital initiative
 Safe nursery services
 Quality improvement indicators
Each standard was supported by a corresponding set of guiding measures that
further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

172
Standards
Risk
Standard and Guiding measures
Score
OS 1. The hospital has qualified and competent staff in the obstetrics
department.
Pre-delivery care, delivery and post-delivery care is a highly
specialized, delicate process that needs to be safely ensured,
requiring the presence and availability of a competent and trained
4
multidisciplinary team: Specialized doctors, nurses and midwives. Due
to the unplanned nature of some deliveries, emergencies should be
covered by specialists of neonatology/pediatrics and anesthesiology
in a previewed, easily accessible set up for any need for urgent
caesarian section and eventual neonatology care.
Guiding measures:
1.1 The director, nurse manager, nurses and midwives of the obstetrics
services are qualified by education, training and experience.
1.2 A qualified obstetrician certified in advanced resuscitation is
physically present in the delivery room during all deliveries.
1.3 A pediatrician on call is always available in case of emergencies.
1.4 A qualified certified pediatrician/neonatologist attends all cesarean
section deliveries before 36 weeks, all high-risk pregnancies or if the
baby is diagnosed with a medical condition.
1.5 A qualified anesthetist is available in case a defined threshold of
birth is reached.
1.6 An operating room for cesarean sections close to the delivery rooms
is in place.
OS 2. Care plan is developed and documented using a comprehensive
manner.
Assessment of patient individual needs and identification of high-risk
deliveries should be conducted in a standardized manner and
5 reported to the staff members as well as the patient and family.
Standardization of assessment should be in the form of specific
documented tools or policies/procedures specifying how pre, per and
post-natal assessment is conducted and how and when results should
be communicated with the patient and the staff involved.
Guiding measures:
2.1 Patient’s physical and psychological health is assessed using a
holistic approach and a standardized assessment approach.
2.2 Accurate and complete medication information is communicated
during care transition and follows the medication reconciliation
policy.
2.3 Processes for identifying and management for women who are at
risk for intrapartum and postpartum bleed and pain are followed.

173
 2.4 Reporting of and response to abnormal test results and reports are
done in a timely manner.
2.5 Results of the assessment are communicated to the patients and
the other staff.
2.6 Plan of care is developed and documented in a comprehensive and
individualized manner.
OS 3. The patient is prepared for Cesarean section (C-section) or vaginal
birth.
Choice and justification of type of labor is standardized and deployed
4
in a multidisciplinary collaborative and thoroughly documented
manner. The care plan should be deployed and individualized to each
patient.
Guiding measures:
3.1 Policies and procedures for women at labor are developed and
implemented in a collaborative manner including obstetricians,
pediatricians, anesthesiologists, delivery room nurses and midwives,
and other staff as needed.
3.2 Justification criteria for C-section are delineated.
3.3 The hospital has a process for immediate C-section
3.4 A partogram and care plan is developed and documented for each
patient that includes fetal health assessments, plans of action, and
clinical actions taken during the stages of labor that follows a
structured approach.
OS 4. Safe and accurate management of medications including oxytocin,
prostaglandin, epidurals, and general anesthetic, is ensured at all
times.
The medications that administered in the process of delivery are of a
delicate use and might have side-effects on the patient and on the
6
fetus. Thus they should be safely prepared and administered
according to standard operating procedures and their potential
effects closely monitored. Epidural anesthetics must be carefully
administered by a by a qualified professional in order to minimize
complications.
Guiding measures:
4.1 Policies and procedures are available for safe oxytocin and
prostaglandin administration.
COR 4.2 The fetal heart rate is monitored and documented during oxytocin
and prostaglandin administration.
4.3 A qualified team member administers the epidural anesthesia
following anesthesia policies and procedures.
OS 5. Care for the mother and the baby is ensured following labor and birth.
Specific testing and care are performed by qualified staff to the baby
and mother starting immediately after delivery until criteria of
6
discharge from post-partum unit are met. They are meant to make
sure that the newborn is well in shape and does not require specific
advanced care. As well post C-section women can develop post-

174
 operative complications, thus should be observed and monitored
before being cleared. This is why defined criteria should be applied to
decide upon the discharge. Education and information should be
given to the mother regarding the possible events or complications
that are noted in the post-delivery phase.
Guiding measures:
5.1 APGAR test performed on the baby at 1 and 5 mins after childbirth,
before transfer to recovery room.
5.2 The mother who underwent C-section is observed by staff during
her transfer from the operating room to the recovery room.
5.3 The baby is transferred from the operating room, after delivery, to
the nursery department accompanied by a qualified staff.
5.4 A documented postpartum monitoring for the mother and
newborn assessment are to be performed after delivery
5.5 Skin-to-skin contact is supported.
COR
5.6 Patient is provided with education about the following but not
limited to; uterus involution, lochia, episiotomy, breastfeeding,
baby care, pain, baby blues.
5.7 Criteria are applied when determining whether the mother and
baby are fit for discharge from the postpartum unit.
OS 6. A written breastfeeding policy is in place and properly implemented,
as per applicable laws and regulations.
The hospital should develop and apply a breastfeeding friendly policy
aiming at encouraging and educating lactating women about
6
breastfeeding. In addition the hospital should ensure that the staff is
trained and adheres to it for the best benefit of the newborn. This
should be performed via documented audits, observations,
knowledge and competency testing.
Guiding measures:
6.1 The hospital has a breastfeeding policy.
6.2 Evidence of staff training and education about the breastfeeding
policy.
6.3 Regular monitoring and reassessment of staff adherence to the
breastfeeding policy is ensured.
6.4 Pregnant women are informed about the benefits and the
management of breastfeeding.
COR
6.5 No artificial teats or pacifiers are given to breastfeeding infants.
6.6 The hospital encourages breastfeeding on demand.
6.7 The hospital implements rooming-in policy (mothers and infants
are allowed to remain together 24 hours a day).
6.8 Evidence of mother training on proper breastfeeding and
maintenance of lactation.
6.9 No drink or food other than breast milk is given to newborns unless
medically indicated and documented in medical record.

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 OS 7. Obstetrics services specific indicators are collected and used as part of
the quality improvement in the Obstetrics services department.
Obstetrics hold several priority areas where organizational
performance and clinical quality can be subject to improvement, and
where adverse events and suboptimal results are generally observed
but can be largely prevented.
Therefore, it is important to define and prioritize the key improvement
objectives for this process, based on observation, audit and
benchmark.
Once improvement objectives are identified, indicators should be set
4
with adapted targets, in order to monitor the progress of the quality
improvement plan.
Such indicators should include a list of outcome indicators (such as first
C-section, rate of artificial inductions for births before 39 weeks, rate
of APGAR 4 and 5 births at 5 min, etc.) that could reflect clinical
performance and are benchmarkable.
Discussion of indicator results should be done at leadership level of the
department and also at the hospital management level in order to
engage appropriate improvement actions, with timely feedback of
results and action plan to concerned teams.
Guiding measures:
7.1 Indicator(s) is used to monitor progress for each quality
improvement objective.
7.2 Data is collected, analyzed, and interpreted to establish a baseline
for indicators
7.3 Outcome indicators are evaluated to determine the effectiveness of
the quality improvement activities.
7.4 Results are properly communicated to the hospital executive
management.
OS 8. The nursery department follows specific measures to ensure the safety
of the newborns.
The security and safety of newborns in the nursery department
6 require a trained staff regarding resuscitation and newborn care as
well as standardized policies and procedures concerning infection
control and newborn identification and fall prevention. The Area
should limited to authorized staff as per the hospital’s policies.
Guiding measures:
8.1 Evidence of policies and procedures to guide the nursery
department
8.2 Evidence of policies and procedures on infection control principles
for the nursery department.
COR
8.3 A registered/qualified nurse and/or midwife is always present in the
nursery department.
8.4 The access to the nursery department is limited to authorized
persons only for the security of newborns which is delineated in
policies and procedures.

176
8.5 There is documented and implemented fall risk assessment and
prevention program for newborns.
8.6 Documented evidence that staff providing newborn care received
training and are certified from an accredited body in Neonatal
resuscitation such Neonatal Resuscitation Program, and Neonatal
Advanced Life Support.

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Patient Services: Critical Care (CC)
Introduction
Critical care is a multidisciplinary care that involves critically ill patients suffering
from one or more organ failure. The care provided is not limited to adult,
neonatal and pediatric intensive care units or post anesthesia care unit (PACU);
it goes further to include services that target the entire hospital such as rapid
response teams and code teams. The standards are aimed at providing safe and
effective patient care; taking into consideration the specialized settings present
in these units such as the mechanical ventilation and the cardiac monitor.
The Critical Care chapter targets the following sections:
 Building a qualified and competent team
 Safeguarding equipment and supplies
 Providing safe and effective services
 Involving the family in patient care
 Monitoring of quality indicators

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

178
Standards
Risk
Standard and Guiding measures
Score
CC 1. The hospital ensures the availability of resources (human, financial,
structural, informational, or technological) to provide safe and high-
quality patient-centered care services.
Availability of critical care services is vital for the management of
patients with a high risk of deterioration. Such services require
resources in adequate quantity and skill set to be able to ensure
provision of highly specialized and safe care. Therefore, human
resources need to always be available according to a safe ratio, with
the appropriate qualifications and competencies, and the size of the
critical care unit should correlate with the hospital needs and
capacity. Equipment needed for patient surveillance/monitoring and
care should also be in adequate number and functionality relative to
the capacity and specific population of patients.
Critical patients need to be managed in a holistic multidisciplinary
and patient-centered approach given their complex needs and the
5
risks entailed by their stay in critical care. Such risks include the loss
of mobility, malnutrition, delirium, and compromised respiratory
function, potential adverse effects occurring from the administration
of high alert medications and combination of medications, as well as
any potential social and psychological impacts on the patient.
Respecting the patient’s rights and dignity is essential in all care
services, especially in critical care settings, since critical patients may
have a compromised ability to communicate their concerns and
interact with their surroundings. Structure of the critical units should
be designed to take into account patient privacy, effective
monitoring, safety, ergonomic factors and infection risks.
Communication with the patient’s family regarding the patient
status, care plan, including palliative care and end-of-life options
should be consistently provided, and their concerns discussed with
the medical staff.
Guiding measures:
1.1 The hospital executive management identifies the required
resources.
1.2 Medical staff of the critical care units is physically available 24
hours per day, 7 days per week to manage critically ill patients.
1.3 Care of patients is provided equally to all critical care patients
using a multidisciplinary approach (includes but is not limited to:
an intensivist or physician trained in critical care areas, nurse,
clinical pharmacist, respiratory therapist, dietitian, social worker,
physiotherapist, and the consultant of the primary service under

179
 which the patient was first admitted) and documented in the
medical record.
1.4 Confidentiality, privacy and safety are taken into consideration in
designing the units.
1.5 Access to information related to palliative care and end-of-life
care is ensured at all times.
CC 2. The hospital has qualified and competent staff in its critical care
units.
Staff in critical care services should have adequate skillsets to be
able to ensure the provision of highly specialized and safe care.
These skillsets are acquired by education, training and experience.
Moreover, competencies regarding the basic critical care procedures
should be regularly tested and documented to ensure the required
level of care is met at all times, by all hospital caregivers, with
5 eventual corrective actions being implemented accordingly.
An ongoing continuous education program should be in place in the
critical units in order to constantly update the staff on clinical
knowledge, recommendations of best practice and evidence based
care. These trainings should be validated by knowledge tests to
ensure transmission of information.
Advanced resuscitation certifications from recognized accreditation
bodies aid in the provision of standardized best-practice care for
critical patients, aiming to ensure high quality and safety of care.
Guiding measures:
2.1 The chief of department and the nurse manager of each critical
unit are qualified by education, training and experience.
2.2 The critical unit's staff are qualified by education and training.
2.3 There is an ongoing and documented competency assessment to
ensure the effectiveness of the training and education given to
nursing staff on the following clinical needs:
2.3.1 Fundamental critical care support.
2.3.2 Identification of symptoms and signs of patient
deterioration and escalation of care
2.3.3 Infection control principles.
2.3.4 Blood transfusion.
2.3.5 Use of the defibrillator.
2.3.6 Care of patients with tracheostomies.
2.3.7 IV therapy.
2.3.8 Pressure ulcer prevention and care.
2.3.9 Knowledge of dosage range, side effects and
complications of commonly used high alert medications in
critical care including vasopressors, narcotics and
controlled medications.
2.3.10 Recognizing critical ECG changes including arrhythmias.
2.3.11 Using pulse oximetry.
2.3.12 Assisting physician in placing central lines or arterial lines.
2.3.13 Assessing Glasgow Coma Scale (GCS).

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 2.3.14 Care of patients on ventilators.
2.3.15 Reading central venous pressure (CVP) and swan Ganz
monitoring.
2.3.16 Care of Endo-Tracheal Tubes.
2.3.17 Sedation and delirium management.
2.3.18 Central venous catheters.
2.3.19 Ventriculostomy
2.3.20 Enteral and parenteral feeding
2.3.21 Infusion pumps.
2.4 Training and education are given on :
2.4.1 Working respectfully and effectively with patients and
families with diverse cultural backgrounds, religious
beliefs, and care needs.
2.4.2 The organization's ethical decision-making framework.
2.4.3 The hospital information system and other technology
used in delivering care, if present
2.4.4 Pain management.
2.4.5 Care of the dying patients.
2.4.6 End of life decisions.
2.4.7 Communicating bad news.
2.5 The effectiveness of the training and education is evaluated by
competency testing, outcomes are analyzed and corrective
actions are taken accordingly.
2.6 Staff in the critical care areas has appropriate training
certification from accredited body in advanced resuscitation
depending on age such as (ALS, ACLS, APLS, PALS, NRC, NRP,
NELS)
CC 3. Equipment and supplies are available in the critical care units to
ensure patient safety.
Availability of specific equipment and supplies is important to
ensure life-saving interventions for critical patients. These include
equipment for continuous monitoring, mechanical ventilation
(invasive and non-invasive), continuous infusion pumps, portable
ventilators and monitors for patient transfer, as well as medications
commonly used in critical settings. The equipment and supplies
should be readily available at all times, in order to respond to urgent
clinical needs, and therefore should be checked for availability and
6
correct functionality at least on a daily basis and as needed.
Care of such equipment and their accessories by staff should be in
line with manufacturer’s requirements in order to prevent
malfunction, while adhering to infection control procedures and
policies, in order to prevent cross contamination between patients.
Such policies include disinfection of equipment or accessories,
replacement of single use items and reprocessing of multiple use
items.
Given the elevated level of risk of patients residing in the critical
care units, it is important that there is a round-the clock access to

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 diagnostic tests, and that they are performed in a prompt and timely
manner. This includes the possibility of performing some of these
diagnostic tests at the patient’s bedside in the critical care unit.
Examples include bedside imaging exams (portable x-ray machines,
ultrasound machines etc.) and laboratory point of care tests, such as
blood gas machines.
Guiding measures:
3.1 Isolation rooms are in place with at least one negative pressure
room.
3.2 The equipment related to the critical care units are present, and
not limited to the following:
3.2.1 Ventilators.
3.2.2 Suction apparatus.
3.2.3 Airway sets.
3.2.4 Crash cart that includes a defibrillator and all emergency
supplies and medications.
COR 3.2.5 ECG monitor, pulse oximetry and vital signs monitoring
devices.
3.2.6 Automated blood pressure monitoring machine.
3.2.7 Intravenous infusion and blood transfusion pumps.
3.2.8 Portable monitoring equipment for patient transfer.
3.3 Daily checking of the availability and the functionality of the
equipment is ensured.
3.4 The disinfection and cleaning of the equipment are performed on
daily basis and as needed.
3.5 The availability of the laboratory and imaging services is ensured
in the critical care units.
CC 4. Outreach services within the hospital are provided by the critical
care units and managed properly.
Hospitalized patients in regular clinical wards may experience an
acute deterioration or cardio-respiratory arrest at any moment,
therefore the hospital must be able to provide access to critical care
services and resources (human, structural, equipment) in a timely
and standardized manner, 24 hours a day, 7 days a week.
In order to respond efficiently to such medical emergencies, it is
important to have a designated medical emergency team (rapid
5 response or code blue teams) with clearly defined roles and
responsibilities, who are called upon based on a set of standardized
criteria. Such criteria should be evidence-based and appropriately
communicated throughout the hospital.
The rapid response team and code blue teams must be comprised of
qualified, competent individuals with the appropriate education,
training and experience in managing critical care patients and
meeting the needs of the medical emergency, in a timely, multi-
disciplinary manner. The roles of these individuals as well as the
rapid response process should be clearly defined in a dedicated

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 procedure, and its implementation regularly evaluated to ensure the
required level of response is given.
Guiding measures:
4.1 A clear role of the code team is defined and properly
communicated in the hospital.
4.2 Offering outreach services, such as a rapid response, medical
emergency team or other organizational teams are provided with
the standardized criteria to determine whether critical care
services are required.
CC 5. The access to service for current and potential patients and referring
hospitals is ensured in a timely manner.
It is of paramount importance that patients who are in need of
critical care services are provided timely and efficient access to care.
That being said, critical care units are highly specialized in terms of
skill set, set up, equipment and staff resources; thus a set of
standardized criteria to admit patients to such units must be in place
in order to ensure all patients are being provided the appropriate
level of care, safely, and ensure efficient resource utilization.
5 Furthermore, standardized discharge criteria must also be in place to
reduce the risk of discharging patients from the critical care unit pre-
maturely, which can increase the risk of deterioration on regular
wards; in addition, reducing the need to keep patients in a higher
level of care unnecessarily.
In case any of the patient’s needs could not be met, the hospital
should be able to facilitate the access to other facilities which can
provide the required level of care, in a timely fashion. To ensure safe
continuity of care in cases of admission, discharge or transfer to
other facilities, a handover system must be in place.
Guiding measures:
5.1 Standardized criteria for admitting and discharging patients to
and from the critical care units are in place.
5.2 Access to referring hospitals is facilitated in case where potential
patients’ needs are not met.
CC 6. The admission and discharge criteria in the critical care units are in
place and properly coordinated.
The standardized admission and discharge criteria for critical care
units are documented and communicated to the medical and
nursing staff. The decision to admit or discharge a patient from such
6 units is made in accordance with the critical care physician.
As the stay in critical care units can be potentially complex and
prolonged, when patients are discharged to a lower equity ward, a
documented summary of the patients’ stay is made available for the
medical and nursing staff of the lower equity ward. This is important
for the safe continuity of care in the receiving wards.
COR Guiding measures:

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 6.1 The decision to admit or discharge patients from the critical care
units is determined by the critical care physician.
6.2 A documented summary of all the critical care stay is available at
the time of discharge to a lower equity level.
CC 7. There is an effective way of communicating information related to
patient care in the critical care unit and with the regular floors.
When transferring care of any patient, especially a critical care
patient, from one shift to another, or between critical units and the
regular wards, the transfer of patient medical information also must
occur. This is in order for receiving teams to be aware of the
patient’s status, plan of care and needs, thus ensuring safe
continuity of care and the safety of the patient.
This transfer of information and care, or handover, between units or
wards must occur in a standardized, documented manner, in order
to ensure that all the required information is being relayed in a
6 consistent and traceable approach, every time. A hospital policy
exists for the documented handover between staff from shift to
shift, for each category of personnel, and between the critical care
unit and the regular ward staff.
Handover should include but is not limited to: patient clinical
diagnosis, evolution during hospital stay, performed procedures,
current clinical status, specific needs and risks, current care plan, any
pending matters and any special issues to pay attention to.
It is important that handover is done effectively with every transfer
of care instance. Therefore, the effectiveness of this process should
be assessed (audits, observations etc.) where the outcome of the
evaluation be analyzed and any corrective actions put in place.
Guiding measures:
7.1 At the end of each shift, a document evidence of handover
process between the critical care physicians of the same floor is
in place as per hospital’s policy
7.2 At the end of each shift, a document evidence of handover
process between the critical care nurses of the same floor is in
place as per hospital’s policy.
7.3 At the end of each shift, a document evidence of handover
process between the critical care nurses and the unit nurses at
COR
the time of transfer as per hospital’s policy.

7.4 There is a documented evidence of handover process between

the critical care physician and the unit physician at the time of
transfer to a regular floor that includes documented plan of care,
medications and other special care requirements as per hospital’s
policy.
7.5 Evaluation of the handover processes is conducted and corrective
actions are taken accordingly.
3 CC 8. Patients and family caregivers are involved in the care provided.

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 In the delivery of patient-centered care, patients and their family
caregivers must be involved in the care and decision making process.
Both have the right to ask or be provided with information in a
timely manner, including the clinical risks relative to the patient’s
case and the potential medical options and relative consequences
and risks. Additionally, it is important that the patient and family
have understood the information that was provided and that this
process is documented for traceability and educational purposes.
Part of involving patients and their family caregivers in the care
provided includes informing them of their rights and responsibilities,
and the institution should inform them how to report any breach in
their rights.
The hospital/institution must have guidelines or a policy in place for
the informed consent of patients and/or their family
caregivers/decision makers. The guideline/policy should address
who is qualified to provide informed consent, when should it be
acquired and address any exceptional cases.
Furthermore, any ethical aspects related to the patient’s care must
be addressed proactively by the healthcare team, in concurrence
with the patient and/or family caregivers/decision makers. A policy
addressing this issue must be in place. For example, such issues may
be referred to an ethical committee or qualified parties to address
these issues thoroughly.
Guiding measures:
8.1 Information is provided to patients and families in a timely
manner, documented and verified to ensure proper
understanding.
8.2 The ability of the patients to provide informed consent is
assessed based on institutional guidelines.
8.3 Informed consent is signed before each surgery, anesthetics,
blood and blood products, procedures by patients or his/her
substitute decision-maker when necessary, as per the hospital’s
policy.
8.4 A policy exists for proactively identifying, managing and
addressing ethics-related issues.
8.5 Patients and families are informed about their rights and
responsibilities, and how to report any breach is their rights.
CC 9. A care plan is developed and documented using a comprehensive
manner.
The care plan for critical patients should be multidisciplinary
(medical, nursing, dietetic, physiotherapy, etc.) and is based on the
5
logic of assessment and reassessment of all the patient’s clinical
condition and risks, which can help identify adapted interventions to
potentially improve the patient’s clinical status and/or prevent
unwanted outcomes.

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 The patient’s assessment gains to be performed using standardized
methods and tools (for example incorporating a systematic clinical
exam, vitals and physiological parameters, as well as a screening of
the risk of acquiring some hospital conditions, such as developing
pressure ulcers, in-hospital falls, venous thromboembolism,
delirium, etc.)
It is recommended that the patient’s assessment would be regularly
performed in a multidisciplinary approach. For example, a daily
round with the concerned healthcare team members, such as the
physician/intensivist, nurse in charge, pharmacist, inhalation
therapist, in addition to other allied health professionals such as
nutritionist, physiotherapist, if available and possible.
Initial assessment is performed upon admission of the patient to
critical care, and reassessment is daily (per shift for certain criteria)
and according to patient needs.
Based upon the assessment, adequate interventions are identified
and planned by the clinical staff, and both the assessment and the
interventions are documented in the patient’s care plan. When
patient prognosis is not favorable despite the clinical interventions
undertaken, an assessment for palliative care is conducted and
discussed with the patient’s family.
Guiding measures:
9.1 All the healthcare providers involved in the patient’s care follow
policies and procedures for assessment and reassessment of
patients including the time frame required for completing the
initial assessment and the frequency of reassessments.
9.2 Patient’s physical and psychological health is assessed using a
holistic approach and a standardized assessment tool.
9.3 Accurate and complete medication information is communicated
during care transition and follows the medication reconciliation
policy.
9.4 A process is in place to reduce the risk of harm resulting from
falls.
9.5 Patient at risk of developing pressure ulcers are assessed and
intervention to reduce the pressures ulcers are implemented.
9.6 Patients at risk for developing venous thromboembolism (Deep
Vein Thrombosis and pulmonary embolism) are identified and
managed.
9.7 An assessment regarding palliative care and end-of-life care
issues is conducted when appropriate in collaboration with the
family.

9.8 Results of the assessment are communicated with the patients

and the other staff and properly documented in the medical
record.

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 CC 10. Staff ensures the proper and appropriate implementation of the
care plan.
The care plan for critical patients should be multidisciplinary
(medical, nursing, dietetic, physiotherapy, etc.) and is based on the
logic of assessment and reassessment of all the patient’s clinical
condition and risks, which can help identify adapted interventions to
potentially improve the patient’s clinical status and/or prevent
unwanted outcomes.
The patient’s assessment gains to be performed using standardized
methods and tools (for example incorporating a systematic clinical
exam, vitals and physiological parameters, as well as a screening of
the risk of acquiring some hospital conditions, such as developing
pressure ulcers, in-hospital falls, venous thromboembolism,
delirium, etc.)
5 It is recommended that the patient’s assessment would be regularly
performed in a multidisciplinary approach. For example, a daily
round with the concerned healthcare team members, such as the
physician/intensivist, nurse in charge, pharmacist, inhalation
therapist, in addition to other allied health professionals such as
nutritionist, physiotherapist, if available and possible.
Initial assessment is performed upon admission of the patient to
critical care, and reassessment is daily (per shift for certain criteria)
and according to patient needs.
Based upon the assessment, adequate interventions are identified
and planned by the clinical staff, and both the assessment and the
interventions are documented in the patient’s care plan. When
patient prognosis is not favorable despite the clinical interventions
undertaken, an assessment for palliative care is conducted and
discussed with the patient’s family.
Guiding measures:
10.1 The care plan is individualized and documented.
10.2 The rounds are conducted on daily basis by a collaborative team.
10.3 At least 2 patient identifiers are used to accurately identify
patients (patient’s triple name and medical number) excluding
patient’s room number or location.
10.4 Any change in the patient’s health condition is properly
documented.
10.5 The patient and family caregivers access to psychological and
support services are continuously insured.
CC 11. Standardized care is ensured to all patients in all settings by
following evidence-based guidelines, best practices and treatment
protocols to improve the quality of care.
5
Clinical practice is subject to regular updates stemming from
evidence based knowledge and recommendations of new clinical
guidelines. Therefore, it is important that the critical care team be

187
 familiar with the process of reviewing practice guidelines in order to
update its practice in every aspect of clinical care.
Furthermore, standardization of practice is important to ensure
conformity to guidelines and reduce variation in care. This can be
implemented through the elaboration of protocols and procedures,
their diffusion via thorough training sessions and evaluation of the
effectiveness of trainings using knowledge and competency testing
for concerned staff. These protocols and procedures should include
but are not limited to the following themes: respiratory care
management, cardiovascular stabilization, care of sedated patients,
patient clinical assessment, vitals surveillance, pain management
and palliative care.
When designing standardized tools for patient evaluation,
planification and provision of care, the hospital can incorporate
relevant recommendations from clinical guidelines within these
standardized tools. This approach could render them decision
support tools for the user, and help implement these guidelines in
practice in a standardized manner.
Finally, critical patients are at risk for hospital acquired infections
(HAIs) such as ventilator associated pneumonia (VAP), central line
associated bloodstream infections (CLABSI) and catheter associated
urinary tract infections (CAUTI). Strict application of hand hygiene, in
addition to evidence based bundles of care for the prevention of
HAIs may help reduce this additional burden to the patients and
potentially improve their clinical outcomes.
Guiding measures:
11.1 There is a process for selection and review of evidence-based
guidelines.

11.2 Protocols and procedures are in place to reduce the unnecessary

variation in the services provided.
11.3 The patient circulation, respiration and oxygenation follow
specific policies and procedures.
11.4 Evidence-based criteria for intubation, weaning off ventilator and
extubation are in place.
11.5 Standardized tools are used to assess regularly and manage the
patient’s level of pain.
11.6 Patient’s sedation follows a standardized protocol where
spontaneous awakening trials are implemented.
11.7 There is a standardized protocol for managing
hyper/hypoglycemia in critical care settings.
11.8 The need to use restraints is assessed on daily basis.
11.9 Ventilator-associated pneumonia, central line infection, and
catheter-associated urinary tract infection care bundles are
implemented, when required.
11.10 Infection control standards are strictly applied in the critical care
units.

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 11.11 A process for palliative and end-of-life care is followed when
required.
CC 12. The transfer to another service or setting is appropriately planned.
Transition to another level of care or to another hospital setting is
performed to meet the needs of the patient as per the clinical
assessment. In cases where the patient willingly refuses to continue
the treatment plan or demands to be transferred to another
hospital, the medical team should inform the patient and/or family
about the possible risks that could occur from this decision. If the
patient/family still refuses, the medical team must obtain a
documented acceptance from the patient to act against medical
advice, before proceeding.
5 Any transition involves risks related to suboptimal continuity of care
and to physical intra or inter-hospital transport. Therefore proper
handover between sending and receiving teams is of utmost
importance and should be performed in a standardized,
comprehensive and documented manner. Also, the intra and inter-
hospital transport procedure should be well defined, including the
identification of the adequate human and material resources that
should be available to ensure a safe transfer. Regular evaluation of
the transfer procedure is important to ensure its correct application,
and any incident / adverse event related to it gains to be thoroughly
investigated.
Guiding measures:
12.1 A transition plan is in place and properly documented.
12.2 Transfer of care follows specific clinical guidelines.
12.3 The patient’s decision whether to end or limit services, transfer to
another service or home is respected.
12.4 Patient’s information is properly communicated during care
transition.
12.5 The transition plan is evaluated and corrective actions are taken
when required.
CC 13. Critical care specific indicators are collected and used as part of the
quality improvement in the critical care areas.
Critical care processes hold several priority areas where
organizational performance and clinical quality can be subject to
improvement, and where adverse events and suboptimal results are
generally observed, but can be largely prevented. Therefore, it is
important to define and prioritize the key improvement objectives
4
for a critical department, based on observations, audit surveys and
benchmarking.
Once improvement objectives are identified, indicators should be
set with adapted targets, in order to monitor the progress of the
quality improvement plan. Such indicators should include a list of
outcome indicators (such as standardized mortality rate, acquired
infection rates such as VAP, CLABSI, CAUTI, acquired pressure ulcers

189
 rate, etc.) that could reflect clinical performance and are bench
markable.
Discussion of indicator results ought to be done at the leadership
level of the department and also at the hospital management level
in order to engage appropriate improvement actions, with a timely
feedback of results and action plans to the concerned teams.
Guiding measures:
13.1 There is a quality improvement plan that addresses priority areas
and set indicators accordingly.
13.2 Indicator(s) is used to monitor progress for each quality
improvement objective.
13.3 Data is collected, analyzed, and interpreted to establish a
baseline for indicators.
13.4 Outcome indicators are evaluated to determine the effectiveness
of the quality improvement activities.
13.5 Results are properly communicated to the hospital executive
management and staff.

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Patient Services: Laboratory Services (LAB)
Introduction
The Laboratory Services chapter emphasizes the need to provide and maintain
high quality of care and safe laboratory services from the time of specimen
collection to the time of result reporting. Quality control process, data and
results reporting are also reflected as part of these chapter requirements as well
as in relation to medical staff functions.
The Laboratory Services chapter targets the following sections:

 Laboratory services meet the needs of patients

 Staff qualifications
 Staff training and education
 Infection control plan
 Environmental conditions and equipment in the laboratory department
 Samples collection and transportation
 Results reporting
 Records management and maintenance
 Safety and quality control program

Each standard was supported by a corresponding set of guiding measures that

further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

191
Standards
Risk
Standard and Guiding measures
Score
LAB 1. The laboratory services are available to meet the needs of the
patients.
The laboratory is responsible to ensure that patient needs are met,
5
in terms of availability of required tests and access to services
24/7, even if this requires an agreement with external services to
provide any lacking tests.
Guiding measures:
1.1 Laboratory services (e.g., hematology and biochemistry) are
available twenty-four hours per day, seven days per week.
1.2 A clear organizational structure with clear responsibilities of
laboratory services is in place.
1.3 The laboratory department establishes an agreement with external
laboratory organizations with clear requirements and
responsibilities, when necessary.
LAB 2. The laboratory services are provided by qualified staff.
As in all specialized units, all staff should have the necessary work
relevant qualifications, achieved through education and
experience. Staff should have routine laboratory training for new
5 policies, equipment and technical procedures to maintain staff
competencies. The Laboratory director is responsible to ensure
that the appropriate skills and competencies are available to
provide optimal services and that this is evaluated regularly to
satisfy current and any changing needs.
Guiding measures:
2.1 Staff is qualified by training, education and experience providing
laboratory services.
2.2 The head of the laboratory department shall be a full-time physician
or pharmacist specialized in laboratory medicine.
2.3 The laboratory director oversees the activities carried in and outside
the laboratory department.
2.4 The laboratory director provides leadership, management and
administrative coordination of functions and evaluation of staff
requirement and adjusts them accordingly.
2.5 Conditions to maintain staff competencies are defined.
LAB 3. The staff complies with the hospital designated standards of
practice.
Standards of practice are meant to guide the professional practice
5 of staff, including technical and non-technical aspects, quality
assurance and education, in addition, serve as a standard against
which staff performance will be compared to for safe, effective
and reliable services. Compliance to such standards can be ensured

192
 through audits, observations and competency testing. The hospital
develops laboratory standards of practice based on local and
international requirements and recommendations, legal
regulations, and must be revised in response to any updates. These
should be easily accessible for the staff, either via electronic or
paper form.
Guiding measures:
3.1 The laboratory has a licensure certificate as per applicable laws
and regulations.
3.2 The staff is informed about any changes or updates to the
applicable laws, regulations, and standards of practice.
3.3 A process exists on how to develop and to approve the standards
of practice related to the laboratory services.
3.4 Standards of practice related to the laboratory services are
updated at least every 3 years.
3.5 The staff has access to the on-force standards of practice and
instructions on how to implement them.
3.6 Compliance with applicable laws, regulations, and standards of
practice is monitored and improvements through instructions or
training activities are made accordingly.

LAB 4. The staff receives proper training and education on the hospital’s
laboratory services.
All laboratory staff should be familiar with the policies, procedures
and services offered by the laboratory. This first begins upon the
initial recruitment during orientation session, and then
5 subsequently through regular training sessions targeting the
required standards of practice. To ensure training effectiveness,
the goals and outcomes must be clearly defined prior, and that
post-training evaluations are carried out. This can include onsite
observations of staff practices, evaluating performance indicators,
conducting competency and knowledge tests and audits.
Guiding measures:
4.1 Orientation to the laboratory services is given to the new staff.
4.2 Evidence of staff training on new equipment and already existing
equipment.
4.3 Staff is trained and educated about how to work with patients and
families by respecting their cultural backgrounds, religious beliefs,
and care needs.
4.4 Competencies of the staff are assessed on regular basis, gaps in
training or competencies are identified, assessed and additional
training is received accordingly.
4.5 Training efficiency is checked.
4.6 Staff performance is assessed on a regular basis
LAB 5. The design of the laboratory department respects safety, privacy
4
and confidentiality.

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 Laboratory design should take into consideration the safety and
privacy of patients, staff and specimens in the regular workflow.
The pre-analytical, analytical and post-analytical steps of services
must comprise of sufficient space for tasks and storage, privacy in
specimen collection, and include appropriate safe storage
conditions for reagents, samples and records, as per local
regulations and international recommendations.
Guiding measures:
5.1 Access to the laboratory department is limited to the authorized
staff.
5.2 Patients with visual, hearing or mobility disabilities can safely access
the laboratory services.
5.3 There is a sufficient space to carry out the laboratory services
according to laws and regulations.
5.4 There is proper, safe, and adequate storage space for reagents,
supplies, consumables samples and records.
5.5 The laboratory’s sample collection areas are separated from the
reception and waiting areas.
LAB 6. The laboratory department has an infection control plan as part of
the hospital’s infection prevention and control plan.
The hospital’s infection control should include hospital wide
policies, in addition to taking into consideration specialized
departments as the laboratory. The laboratory’s infection control
procedures and policies take into account basic principles (such as
standard precautions, hand washing, prevention of specimen
5 contamination, cleaning…) Recommendations, application of
personal protective equipment when necessary, in addition to
ensuring the safety of specimens and staff during sample
processing, disposal and storage. Regular trainings and audits
should be conducted and communicated to the laboratory staff.
Evidence of corrective actions should exist. In addition, there
should be evidence of the qualification and assessment of waste
elimination suppliers.
Guiding measures:
6.1 The laboratory department implements policies and procedures
related to the infection control and safety plan in compliance with
hospital’s infection control plan.
6.2 Evidence of staff training about proper hand washing is in place.
6.3 Audits are conducted on regular basis, outcomes are analyzed and
corrective actions are taken accordingly.
6.4 Results of the audits are properly communicated to the relevant
departments.
6.5 The staff ensures the proper collection, containment and disposal of
wastes
6.6 Suppliers of waste elimination are qualified and assessed on regular
basis.

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 LAB 7. The environmental conditions in the laboratory department are
appropriately maintained
It is important that the laboratory environment is maintained to
ensure the safety and functionality of equipment and specimens at
all times. Temperatures of storage areas/units (for example
refrigerators) should be measured and recorded daily using a
temperature control chart. Any deviation from set temperature
5 ranges should be detected via an alert system (alarms) in order for
staff to take appropriate actions promptly with regards to the
viability of stored items. To ensure the continuity of laboratory
services and safety of specimens/ reagents, vital equipment must
be connected to a power supply 24/7 (such as storage units, critical
test machines), in addition to having emergency backup
equipment, at least for essential tests. Such back-ups should be
tested regularly and tests recorded.
Guiding measures:
7.1 Staff regularly monitor and record the storage temperature in the
laboratory department.
7.2 The critical equipment is continuously attached to an uninterrupted
power supply.
7.3 An alert system about changes in the refrigerator(s) temperature or
malfunction is in place and regularly tested.
7.4 The laboratory director/supervisor ensures that emergency backup
equipment is present and regularly tested
7.5 Equipment is used according to manufacturers’ recommendation.
LAB 8. The equipment in the laboratory department is maintained and
inspected.
The continuity of laboratory services depends on the reliable
functionality of its equipment. Thus, selection, assessment,
maintenance and inspection of appropriate, qualified equipment
should follow a specific process or policy, taking into consideration
6
manufacturers’ recommendations. This process is done by
qualified disciplines (for e.g. laboratory with biomedical
engineering). Therefore, any issue or malfunction that arises must
be addressed promptly as to not disrupt the laboratory activity.
Damaged equipment should be clearly indicated and separated
from functional ones.
Guiding measures:
8.1 A process for selecting appropriate laboratory equipment is in
place.
8.2 Qualification of the equipment is assessed before being used.
8.3 Maintenance and inspection of equipment follow the
manufacturers’ recommendations and the current standards of
COR practice specific to the laboratory services.
8.4 Problems in the equipment are identified, investigated and fixed in
a timely manner.

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 8.5 Damaged equipment is labeled as “out of order”, isolated and a
statement about the problem is in place.
LAB 9. The reagent and the supplies of the laboratory services are
appropriately purchased, labeled and used.
The appropriate quantity and quality of reagents and supplies are
essential for laboratory services. Inventories for all reagents and
supplies exist and checked regularly to avoid shortages and
5
prevent expiry before use. Upon reception of supplies and
reagents, the specifications, quantity, physical condition, storage
conditions and expiry should be verified, clearly indicated and
controlled before storage/use. Pre-defined conditions exist for the
use of expired reagents that must be tested prior to use.
Guiding measures:
9.1 Inventory control system is present to maintain a sufficient number
of reagents and supplies.
9.2 Reception control protocol for reagent and supplies of the
laboratory services is implemented.
9.3 Reagents and solutions are labeled with content,
concentration/titer preparation/reconstitution date, expiration date
and storage requirements.
9.4 The use of expired reagents is restricted to exceptional conditions
that require testing their suitability for use.
LAB 10. The staff in the laboratory department follows the standards of
practices in preparing reagents and supplies and reprocessing
glassware and non-disposable plastic ware.
Laboratory standards of practice specify how reagents and
supplies are prepared and that staff are familiar with their
respective material safety data sheet: where to locate it and how
5
to implement it. This aspect should be included in the staff
training. The laboratory’s water supply is important to ensure that
equipment run properly and reagents (thus tests) are processed
correctly. Thus the quality of the water supply is verified and
monitored according to manufacturer’s recommendations, where
evidence of this monitoring exists.
Guiding measures:
10.1 The staff prepares reagents and supplies under sterile conditions
and use high purity water (ultrapure water) during the preparation.
10.2 Staff is educated about how to implement the Material Safety Data
Sheet in the laboratory department.
10.3 Monitoring of the water supply is done to ensure compliance with
the manufacturers’ recommendation.

LAB 11. Requests for the laboratory services are managed appropriately.
5 Ensuring sufficient traceability in the laboratory requests process
contributes to enabling controls and accountability regarding this

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 process, including turnaround time of normal and urgent requests
by type of exam and according to clinical department (for example,
critical care units versus regular floors). It can also contribute to
preventing a number of unwanted events such as the loss of
specimens, omission or delay in executing the exam, errors in
understanding the type of exam requested, and errors or delays in
communication of results.
Guiding measures:
11.1 Standardized request forms comply with the standards of practice
and complete with information related to the patient, the treating
and requesting physician, sample(s) (date and time collected), the
required test(s) and the staff involved in collecting samples, are in
place.
11.2 There is a policy for handling urgent requests.
11.3 Verbal requests follow specific policy.
11.4 Any deviation from initial request is reviewed.
11.5 Turnaround times are established in agreement with the relevant
clinical departments.
11.6 Turnaround times are communicated, implemented and monitored
by samples.
11.7 Turnaround times are improved regarding fixed targets.
LAB 12. Samples are appropriately collected.
Incorrect sample collection and identification are among the most
dangerous and hard to detect errors that can affect the clinical care
process and potentially impact the patient’s safety and the care
5
outcomes.
Therefore strict procedures should be in place to ensure the
prevention of such errors and to handle samples where there is
missing or unclear information.
Guiding measures:
12.1 The staff uses at least two identifiers, as per hospital policies,
before performing the procedure.
12.2 The staff prepares the patient, identify the sample needed, collect
the sample, safely dispose of the materials used to collect the
sample and maintain the patient’s confidentiality throughout the
process.
12.3 The staff ensures that samples are traceable to the patients.
12.4 Actions are defined in case of non-conforming results.
LAB 13. Samples are transported in a safe and timely manner.
Transport of biological samples holds a number of risks that need
to be addressed in order to ensure sample integrity and
exploitability, including the risk of specimen spill and cross-
5
contamination.
Upon arrival to the laboratory, specimens need to be checked for
conformity before being accepted and processed or rejected. Such
criteria should be well defined and communicated to staff.

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 Traceability upon reception is paramount in order to track the
samples in the analytical chain, and specimens need to be stored in
correct conditions and for a required minimal amount of time,
should any additional testing or control be required.
Guiding measures:
13.1 Policies and procedure are in place for safe and confidential
transport of samples to and from the laboratory department.
13.2 Recording the samples received, their date and time and the
individual responsible for receiving them follow a specific process.
13.3 The samples are accepted or rejected according to established
criteria.
13.4 Each sample has a unique identification number.
13.5 Handling leaking samples follows specific policy.
13.6 Samples are stored appropriately based on the sample type and
examination requirements.
13.7 The retention of samples follows a specific policy.
13.8 The temperature of handling and storing samples is controlled.
LAB 14. The quality of the examination is evaluated, and results are
reported in an accurate and timely manner.
Lack of quality control of laboratory machines and processes can
impact large series of results and thus potentially many patients.
Some of these controls precede any processing of a series of
samples, and other controls should be done after the sample result
6
is obtained, and before release. Finally, regular external quality
control for some frequent exams should ensure the lab results are
reliable and conform to international standards. Deviations should
be assessed and identified problems corrected and recorded, and
communicated to staff in order to accommodate sample
processing.
Guiding measures:
14.1 Quality control procedures for testing the validity of the laboratory
tests by external sources are performed, results are compared and
corrective actions are taken when needed.
COR 14.2 Internal and external quality control programs are developed and
implemented.
14.3 Quality control results are recorded, with the identified problems
and the actions taken for solving the problem.
14.4 Laboratory staff is informed about the results.
14.5 A standardized format for reporting results exists.
14.6 The policy regarding the correction of the reports is implemented.
14.7 Releasing the results follows a specific policy.
14.8 A policy exists for reporting critical results.
14.9 The reported results mention the use of suboptimal specimen.
14.10 Results are interpreted appropriately by the laboratory director,
when applicable.

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 LAB 15. The laboratory department has a system for Point-of-Care-Testing
where applicable.
While the main advantage of point-of-care (POC) testing (for
example, ABGs or POC CBC) is the shorter time it takes to obtain a
result, it can also be performed by people who have not had
formal laboratory training. This includes nurses, doctors,
paramedics and testing by patients themselves. Also, POC testing
5
environment is generally less controlled than laboratory conditions
and the results can be at higher risk of external interference than
laboratory processes, which can lead to inaccuracies. Hence, POC
testing should follow specific policies and procedures in matter of
sample extraction, processing and in matter of equipment
maintenance and quality control in order to ensure results
reliability.
Guiding measures:
15.1. Policies and procedures are in place to specify the process of
having Point-Of-Care-Testing devices/methods.
15.2. Proper staff training and competency testing follow specific
policies and procedures.
15.3. The maintenance and quality management of the devices/methods
is addressed via policies and procedures.
15.4. A Point-Of-Care-Testing coordinator is in place.
LAB 16. Maintenance, protection and accessibility of records and
information are ensured through a laboratory information system.
The Laboratory Information System (LIS) is the foundation of the
laboratory’s operations and quality improvement process. It
ensures the implementation of the laboratory workflow while
permitting to enforce the application of quality control
5 procedures. Therefore, regular maintenance and testing of the LIS
should be undertaken to guarantee information continuity and
integrity. As the LIS is an integral part of the laboratory services
workflow, and includes confidential patient information, results
and records must be protected and in case of loss/damage. The
laboratory should ensure an alternative method of recording
results or retrieving records in case of system interruption.
Guiding measures:
16.1. An accurate and complete policy and procedure manual is
available to all the staff working in the laboratory department
which is regularly reviewed and approved at defined intervals by
the laboratory director or a person designated for this task, as per
hospital policies and procedures.
16.2. Accurate and complete data entry on the laboratory information
system is ensured at all times.
16.3. Regular testing and preventive maintenance are performed on
regular basis.

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 16.4. The laboratory information system is protected from loss,
destruction or tampering of information, and unauthorized access.
16.5. The continuity of information is ensured in case of system
interruption.
LAB 17. Accurate, up-to-date and secure records are maintained all times.
Patient records are important confidential documents
5 compromising a segment of the patient file that should be easily
retrieved if needed, but also stored in a secure location away from
any unauthorized access, and safe storage conditions.
Guiding measures:
17.1 A comprehensive record for each patient is in place.
17.2 Conditions of archiving records are specified.
17.3 Records are easily retrieved.
17.4 Security and confidentiality of the records are maintained at all
times.
17.5 Disposal of archived records follows a specific policy.

LAB 18. The laboratory department has a safety program in place.

The laboratory safety program is an extension of the hospital
safety plan and infection control program/plan. The program
5 includes policies, procedures, trainings, audits, competency testing
etc. addressing personnel safety, specimen handling safety,
equipment and environmental safety. Such practices should be
evaluated regularly and corrective actions taken and recorded.
Guiding measures:
18.1 The laboratory safety program is developed, monitored and
maintained by the safety officer.
18.2 The program includes training, education, monitoring and
evaluation.
18.3 Accessibility to the safety manual is ensured at all times.
18.4 Compliance with the safety program is monitored and actions are
taken accordingly.
18.5 The staff wears the appropriate personal protective equipment
according to the hospital policies and procedures.
18.6 Safety practices are ensured while exposing, handling, examining, or
disposing of biological and chemical materials.
18.7 Adverse and sentinels events are identified reported, recorded in a
timely manner and actions are taken accordingly to reduce the risk
of those incidents.
LAB 19. Laboratory-specific indicators are collected and used as part of the
quality improvement in the laboratory services department.
Laboratory processes hold several priority areas where
4 organizational performance and quality can be subject to
improvement, and where adverse events and suboptimal results
are generally observed but can be largely prevented. Therefore, it is
important to define and prioritize the key performance indicators

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 and improvement objectives for such a department, based on
observation, audits and benchmarking.
Once improvement objectives are identified, indicators should be
set with adapted targets, in order to monitor the progress of the
quality improvement plan.
Such indicators should include a list of outcome indicators along
the different steps of the laboratory process (pre-analytical,
analytical and post-analytical) such as the turn-around time for
certain common exams in normal and urgent priority levels, the
specimen rejection rate by type and by requesting department, as
well as the conformity to the critical results reporting procedure
criteria.
Discussion of indicator results should be done at leadership level of
the department and also at the hospital management level in order
to engage appropriate improvement actions, with timely feedback
of results and action plan to concerned teams.
Guiding measures:
19.1 Measurable objectives for quality improvement initiatives and the
time frame, in which they will be reached, are set.
19.2 Data related to tracks wait times and average response times for
elective, urgent, and emergent requests for laboratory services are
collected, analyzed, and interpreted to establish a baseline for
indicators.
19.3 Indicator data is evaluated to determine the effectiveness of the
quality improvement activities.
19.4 Results are properly communicated to the hospital executive
management.
19.5 Measurable objectives for quality improvement initiatives and
timeframe in which they will be reached, are regularly updated.

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Patient Services: Blood Bank and Transfusion
Services (BB)
Introduction
The Blood Bank and Transfusion Services strive to improve the quality and
safety of collecting, processing, testing, transfusion and distribution of blood
and blood products.
The standards address the entire transfusion chain from donor to recipient,
encompassing the selection of blood donors, safe blood collection, testing of
donated blood for transfusion and blood group serology, preparation, storage,
issue and transportation of blood components for appropriate clinical use and
lastly safe administration of blood to the recipients.
For hospitals that do not have a transfusion service and do not carry all the steps
of the transfusion chain, they should at a minimum be compliant to the
standards of storage and distribution activities; they should also establish a
cooperation (memorandum of understanding) with a transfusion center with a
blood bank license from the MOPH that performs all the transfusion-related
activities and supplies the hospital with blood components.

Standards that are Not Applicable for hospitals that only have blood storage
and distribution activities are standards 8, 9, 11, 17 and 20.

The Blood Bank and Transfusion Services chapter targets the following sections:
 Access to transfusion services
 Staff training and education
 Standard operating procedures
 Physical environment
 Blood and blood components storage equipment
 Blood Collection
 Receiving and sending blood and blood products
 Blood components and blood products transfusion
 Sentinel, adverse, and near miss events management

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Each standard was supported by a corresponding set of guiding measures that
further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

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Standards
Risk
Standard and Guiding measures
score
BB 1. Access to transfusion services is provided in a timely manner.
Transfusion services ranging from collecting, processing, testing and
transfusing are critical, lifesaving services which are required to be
available whenever needed, and that the response is performed
5 promptly, according to defined hospital policy and current
laws/regulations. It is important that the hospital ensures the
required human and material resources to allow the blood bank to
ensure continuity of service in a consistent manner, and be able to
manage urgent blood requests.
Guiding measures:
1.1 The response time for elective, urgent and emergent transfusion
services are set and tracked based on hospital’s policies and
applicable laws and regulations.
1.2 Resources (human capital, machinery and location) to provide
timely access to transfusion services (i.e. distribution of blood
components) are identified.
1.3 A policy is in place for distributing uncross matched tests in
emergency situations.
1.4 When the blood bank is closed, an emergency procedure is in place
in case of urgent need for blood products.
BB 2. The staff receives proper training, education on the hospital’s
transfusion services.
Given the risks inherent to the blood bank processes and their
potential impact on the patients, it is of paramount importance that
all blood bank staff should be qualified and familiar with the policies,
procedures and services offered by the blood bank, in addition to
hospital wide policies such as infection control, hygiene, quality
improvement and safety. This first begins on initial recruitment,
5 during, and then subsequently through regular training and
educational sessions targeting the required standards of practice,
equipment, handling patients and adverse events. To ensure training
effectiveness, the goals and outcomes should be clearly defined
priory, and post-training evaluations be carried out. This can include
onsite observations of staff practices, evaluating performance
indicators, conducting competency and knowledge tests in addition to
regular audits.

Guiding measures:
2.1 Evidence that orientation to transfusion services is given to the new
staff regarding standard operating procedures, ethics issues,
information systems and confidentiality, sanitation, workplace
health and safety, infection control and hygiene, and quality

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 improvement and safety activities, including preventing sentinel
events, adverse events, and near misses.
2.2 The head of the Blood Transfusion services department shall be a
full-time physician specialized in laboratory medicine or
hematologist with a permit from the Ministry of Public Health.
In a hospital with only storage and distribution activities, laboratory
director is responsible for these activities.
2.3 Evidence of staff training on new equipment and already existing
equipment.
2.4 Staff is trained and educated about how to work with patients and
families respecting their cultural backgrounds, religious beliefs, and
care needs.
2.5 Access to ongoing professional development, training and
educational activities is ensured.
2.6 Competencies of the staff are assessed and maintained on regular
basis.
2.7 Gaps in training or competencies are identified, assessed and
additional training is received accordingly.
2.8 A current and complete record on qualifications, trainings, and
competencies, is in place.
BB 3. Standard operating procedures are developed and implemented.
Standard operating procedures (SOPs) are important documents
which ensure consistency in any activity, by providing clear
instructions on how to carry out specific activities or procedures,
mandatory by all blood bank staff. Critical services such as storage,
5
distribution, collection, preparation, testing, prescription and
transfusion should be performed in a standardized manner, guided by
the SOPs, which are easily accessible to staff. Compliance to such
standards should be ensured through audits, observations and
competency testing.
Guiding measures:
3.1 Standard operating procedures for storage, distribution and blood
collection, blood components’ preparation, testing (where
applicable) are available

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 3.2 Standard operating procedures related to storage, distribution and
blood collection, blood components’ preparation, testing (where
applicable) are updated every two years or more often, if required.
Policies and procedures should at least include but not limited to
the following:
3.2.1 Blood and blood products are provided according to
physician’s orders
3.2.2 Screening for communicable diseases (if applicable)
3.2.3 Safe collection of blood from blood donors (if applicable)
3.2.4 Safe storage of blood and blood products
3.2.5 Acceptable cross-matching procedures
3.2.6 Unit label which includes: recipient identity, unit number
and compatibility status
3.2.7 Identification and follow up of recipients with antibodies,
this should include at a minimum consultation with the
blood transfusion services director or laboratory director
when only blood storage and distribution services are
available
3.3 The staff has access to the standard operating procedures and the
instructions on how to implement them.
3.4 The staff is informed about any changes or updates in the standard
operating procedures.
3.5 Compliance with standard operating procedures is monitored and
improvements related to the instructions or training activities are
made accordingly.
BB 4. The physical environment ensures safe, effective and efficient
transfusion services according to applicable laws and regulations.
The physical environment should be designed to ensure that the
blood bank staff, its equipment, and patients operate in a safe and
5 effective manner, as applicable by laws and hospital policies. The
safety of the blood components should be ensured by restricting
access to authorized staff, and having adequate space to process and
store, while complying with the hospital’s infection control and waste
management policies in addition to the Blood Bank’s SOPs.
Guiding measures:
4.1 There is a sufficient space to carry out the storage, distribution and
blood collection, blood components’ preparation, testing (where
applicable) according to applicable laws and regulations.
4.2 Access to the blood component storage area is limited to the
authorized staff.
4.3 Clean work areas are maintained at all times.
4.4 Handling, examining and disposing of biological materials follows
biologic safety procedures.

4.5 Safety of patients and staff is ensured by following hospital’s

policies and procedures on infection prevention and control.

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 4.6 Access to hand washing facilities is ensured and evidence of staff
training on hand washing procedure is in place.
4.7 Disposing of the waste materials complies with applicable laws and
regulations.
BB 5. Equipment is properly maintained and inspected.
The continuity of blood bank services and the safety of blood
products depend on the reliable functionality of its equipment (e.g
centrifuges). Thus, selection, assessment, maintenance and
inspection of appropriate, qualified equipment should follow a
specific process or policy, taking into consideration manufacturers’
5
recommendations and is documented. Therefore, the daily and
regular quality control checks in addition to any issue or
malfunction (e.g equipment alarm, calibration problems in
measurement equipment, etc.) that may arise should be addressed
promptly as to not disrupt services or compromise the safety of
the process.
Guiding measures:
5.1 Preventive maintenance schedule for existing equipment is properly
followed.
5.2 The staff maintains, inspect, validate, and calibrate the equipment
according to the standards operating procedures that comply with
manufacturer’s recommendation and properly document it.
5.3 Information on the day-to-day operation of equipment, according
to the manufacturer’s instructions including the quality control
results and the criteria for acceptable ranges is maintained via a
record.
5.4 Problems with the equipment are identified, investigated and
corrective actions are taken accordingly.
BB 6. Blood and blood components storage devices are properly used and
maintained.
Correct and safe storage conditions are one of the critical blood bank
services as there are various storage conditions for the different
blood components. In addition, some components could be stored for
a period of time before being transfused. Thus to ensure no adverse
4 effects related to sub-optimal storage conditions occur with patients,
storage facilities/equipment must have a continuous power supply,
continuous daily monitoring of temperature (refrigerator circular
chart recorders, digital thermometers attached to the fridge/freezer)
with a connected alarm system to alert the staff of any deviation, so
as prompt action is taken to not compromise the integrity of the
blood and blood components.
Guiding measures:
6.1 Preventive maintenance schedule for blood and blood components
storage equipment is properly followed.
6.2 There is a continuous temperature monitoring system attached to
the equipment used for storing blood and blood components.

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 6.3 Staff regularly monitor and record the conditions for blood and
blood components storage equipment.
6.4 The equipment is continuously attached to an uninterrupted power
supply.
6.5 Alert system, to alert the staff about changes in the temperature or
malfunctions in storage compartments, is in place and regularly
tested.
BB 7. Blood components and blood products are properly stored under
appropriate environmental conditions.
Various blood components require different storage conditions as per
standards of practice and guidelines. Each component (red blood
5
cells, platelets and plasma) should have the required storage
temperature indicated on it in order to avoid errors. Additionally the
source of component and various types of components should be
clearly labeled and stored separately.
Guiding measures:
7.1 Each type of blood component and blood product is stored at a
specific temperature and accordingly labeled.
7.2 Evidence that storage temperature for each blood component is
properly documented.
7.3 Red Blood Cells are stored at 1-6 degrees Celsius unless there are
specific requirements for freezing are identified.
7.4 The standard operating procedures are followed regarding storing
freezing and thawing plasma
7.5 Platelets and pooled platelets and apheresis platelets are stored at
20-24 degrees Celsius with gentle agitation up to 5 days.
7.6 Separation of blood components from donor samples, recipient
samples, tissues for transplantation, and reagents is ensured at all
times.
BB 8. The hospital manages blood donation via a specific process (if
applicable).
There should be a well-defined policy with regards to blood donation
which specifies how donors are identified, what information is given
5
to them about the process, questionnaire screening as per MOPH
regulations, reporting and communication with the donor of
significant findings and training requirements for staff to handle any
complications during the blood withdrawal.
Guiding measures:
8.1 The donors are identified and educated about the donation process
and the possible complications.
8.2 Screening process for donation is based on the nationally
standardized questionnaire as per the list of donor selection criteria
approved by MOPH and available online
8.3 The staff ensures that the national questionnaire is properly filled
and signed by the donor before blood collection.

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 8.4 The donor is notified of the significant findings that are detected by
screening and laboratory tests.
8.5 Evidence that staff is trained and competent to deal with adverse
events related to blood withdrawal.
BB 9. The standard operating procedures for autologous donation are
followed when collecting blood (if applicable).
Autologous donation holds a number of advantages for the patient,
but must follow specific, strict well-defined criteria and protocols set
4
by the SOP. When such forms of donation are permissible, associated
risks, exclusion and inclusion criteria explained, education and an
informed consent should be obtained by the patient or family/next of
kin.
Guiding measures:
9.1. The standards operating procedures for autologous donations are
set and updated by the medical director of the blood bank.
9.2. Requesting, collecting, and using autologous blood follow the
standard operating procedures.
9.3. Exclusion and inclusion criteria for autologous donation are in place.
9.4. Prescription from the attending physician of the donor-recipient
patients and the approval of the appropriately designated person
are ensured before collecting the autologous blood.
9.5. An informed consent is obtained from patient and/or family and/or
next of kin after patients are educated about the benefits and the
risks of autologous blood donation.
BB 10. The blood components are uniquely identified via a proper labeling
system.
Identification errors in blood transfusion can lead to serious and even
fatal outcomes for the patient. Therefore, it is crucial that blood
6 component identification information is clearly indicated on the outer
packaging that cannot be damaged upon storage nor handling. The
labeled requirements are used for the proper identification, storage
and traceability of the component at every step and no component can
be stored nor used if it is not labeled.
Guiding measures:
10.1. The staff labels the blood bags using an appropriate labeling
system.
10.2. After the staff performed all the required tests, labeling is done
taking into consideration the following requirements: identification
COR of the collecting facility, product name, unit number, ABO/Rh,
expiration date and time.
10.3. New label is created in case of any changes, modifications or
transformations of the blood components.
10.4. An expiration date for each blood components is set.
BB 11. Preparing blood components and blood products follow the standard
5 operating procedures.

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 The following blood bank activities should follow the SOPs set by the
hospital, according to the national laws/regulations and guidelines
provided by the MOPH. This is to ensure that practices are
standardized and avoid any variation in practices that could cause
errors, risks and blood wastage.
Guiding measures:
11.1 Preparation of blood components follows national laws/regulations
and guidelines.(List of blood components and good transfusion
practice guidelines published on the website of the MOPH)
11.2 Sterility and integrity of the blood components and blood products
are maintained following standards operating procedures
BB 12. A system for receiving or sending blood and blood products to and
from outside facilities is properly implemented
In order to ensure safety of products, and avoid the misuse of
blood/blood components between facilities, blood bank facilities
5
should have a clearly defined procedure/policy specifying when and
how units should be released, conditions of acceptance/rejection and
those subsequent appropriate actions are taken in case any unit is
rejected. Evidence of each transaction (to or from) must be available
Guiding measures:
12.1 Preset criteria for accepting or rejecting the blood components
received from outside facilities are in place
12.2 A procedure for requesting or releasing blood, via a prescription,
from or to outside facilities is in place and properly documented.
12.3 The staff verifies upon each reception of blood component from an
outside facility the acceptance criteria (expiration date, integrity of
the bag)
12.4 Actions are defined and taken in case the acceptance criteria are
not met.
BB 13. Blood components and blood products are safely packed and
transported within the facility.
Transportation is a key step for any transfer of specimens or blood
components, before its use. Thus a thorough check of the bags must
5 be done according to set criteria and documented each time, prior to
transfer. Set conditions of transfer should also defined (container
specifications, temperature required, personnel) including identity of
the transporter, type and quantity of products delivered and timing
of the transfer.
Guiding measures:
13.1 The staff visually inspects each blood bag before delivery, check the
integrity of the bag (leakage, abnormalities), checks expiration date
and documents the inspection
13.2 Transporting blood and blood components within the facility
follows standard operating procedures that guarantee the safety of
the personnel and the integrity and quality of the bag.

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 BB 14. Requests for blood components and blood products are carried out in
a timely manner.
As the first step of the blood transfusion process, it is important that
requests are collected in a standardized manner/ tool, requiring the
correct identification of the recipient using two accepted identifiers
5
(e.g. full name, medical file number) every time. This request should
be cross checked with the identity of the recipient samples sent;
where in order to ensure correct match of request with samples,
independent recipient samples withdrawn by independent personnel
are labeled with correct patient label to be sent to the blood bank.
Guiding measures:
14.1 There are standard operating procedures for:
14.1.1 Handling requests for blood components and blood products
14.1.2 Proper identification of the recipients before blood
collection using two identifiers
14.1.3 Proper collection and labeling of recipient samples
BB 15. Blood components and blood products are distributed in a safe
manner.
One of the most critical aspects in safe transfusion services is
ensuring the correct identification and match of the recipient, and
donor, respectively. This should be performed at every step in the
5 transfusion services workflow. Cross checks between requests,
patient labels and the blood/blood component bags identification
should be performed with evidence of verification. Moreover, to
avoid mistaking a rejected bag for release, such units must be
segregated from the rest, well labeled, identified in a designated area
for units to be discarded.
Guiding measures:
15.1 A process is in place for distributing blood and blood products to
ensure:
15.1.1 Identification of the recipient.
15.1.2 Identification of the donor unit.
15.1.3 Confirmation that the donor’s ABO/Rhesus is identical or
compatible.
15.2 The staff safely stores the blood components that don’t meet the
releasing criteria, in an isolated and identified location until they are
distributed for appropriate disposal.
BB 16. Selection and distribution of blood components and blood products
for transfusion follow specific process.
After requesting, the appropriate selection of the blood components
must follow the facility’s SOP consistently. Testing recipient samples,
6 cross matching with donors’, selecting the donor unit should all be
documented standardized steps. SOP should also specify conditions
of selection of units in case of pediatric, infant and neonate recipients
with regards to compatibility and component specifications for the
infant and mother (if possible). Transfusions’ ultimate goal is to

211
 improve patient outcomes, and thus SOP should specify in which
restricted cases some routine screening steps could be overlooked in
case of life-threatening cases.
Guiding measures:
16.1 The staff takes a blood sample within 72 hours after transfusion in
case where
16.1.1 The recipient is pregnant within the last three months,
16.1.2 The recipient’s history is uncertain or not available, or
16.1.3 The recipient has evidence of transfusing red cells or any
component containing red cells within the last three months.
16.2 Testing recipient's blood is performed according to standard
operating procedures.
COR
16.3 Cross-matching the donor's and recipient's blood is done before
distribution of red blood cells components according to standard
operating procedures.
16.4 Standard operating procedures for selecting and handling
component for infants are followed.
16.5 Specific standard operating procedures for releasing blood
components without testing it for infectious diseases or
compatibility are followed in case where delaying transfusion can
be life-threatening to the recipient.
BB 17. Diseases transmitted through blood /platelets transfusion are
prevented by proper testing the donor blood sample (if applicable).
Every donor sample should be screened for a specific set of
6 transmissible blood/platelet diseases as applied by the local
laws/regulations, and evidence of this screening is available, and that
all test negative prior to releasing the unit (except in certain life
threatening cases defined in the SOP).
Guiding measures:
17.1 Policies and procedures for testing and screening the blood samples
are implemented as per applicable laws and regulations against the
following but not limited to:
COR 17.1.1 HBsAg
17.1.2 Anti-HBc
17.1.3 Anti-HCV
17.1.4 Anti-HIV-1/2 P24Ag
17.1.5 Syphilis Testing (VDRL/RPR)

BB 18. Transfusing blood components and blood products follows standard

operating procedures.
Upon the release of the blood component and safe transfer to the
recipient’s location, pre-transfusion identification verification must be
5
thoroughly performed between prescription, blood unit bag, blood
request form and the recipient’s identity (using at least two
identifiers). These steps should be performed with two personnel
double checking the information. Upon transfusion, no other

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 medication should be administered, staff must verify patient identity
immediately before start of transfusion, and duration of transfusion
should be as per SOP and blood component guidelines (for e.g.
maximum of 4 hrs. for red blood cells, maximum of 1 hr. for platelets
etc.).
The staff must monitor the progression of the transfusion at set time
intervals at minimum, and note and report any adverse event related
to the transfusion in order to facilitate prompt corrective actions.
Guiding measures:
18.1 Administering blood components and blood products follow
standard operating procedures.
18.2 Proper patient identification using two identifiers is ensured before
transfusing blood components and blood products.
18.3 The staff ensures and documents that:
18.3.1 Blood components or blood products matches the
compatibility label/tag.
18.3.2 Blood components or blood products matches the
identifying information of the recipient.
18.4 Transfusion of blood components and blood products is done using
a sterile, pyrogen-free administration set.
18.5 The staff ensures that no drugs or medications are added to blood
components and blood products during transfusion.
18.6 The transfusion of red blood cells components is completed within
4 hours maximum.
18.7 The staff monitors the recipients for complication during and after
the transfusion.
18.8 Any sign or symptom that is associated with a transfusion-related
adverse event is reported, investigated and corrective actions are
taken and documented.
BB 19. A current, accessible record of each transfusion is maintained.
Every transfusion act should be completely documented with the
details of the act including recipient information, blood type,
component type, date and time, who transfused the patient and if
5 any complications or adverse events occurred and what was the
corrective/immediate action taken. This can be located in a specific
standardized transfusion data collection form/tool to be archived in
the medical record. The hospital should specify conditions of
retaining medical records, duration and contents.
Guiding measures:
19.1 The medical record is updated to include the type of blood
component and/or blood product transfused, the date and time of
transfusion, the identity of the team member who provided the
transfusion, and all transfusion-related adverse reactions.
19.2 Retaining medical records follows specific policies.
BB 20. Blood transfusion specific indicators are collected and used as part of
4
the quality control program.

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 Blood transfusion services have several areas where organizational
performance and clinical quality can be subject to improvement, and
where adverse events can be prevented. Therefore, it is important to
define and prioritize the key improvement objectives for this
department, based on observations, audit surveys and benchmarking,
as part of the hospital-wide quality improvement program.
Indicators should be set with adapted targets, in order to monitor the
quality and safety of services and the progress of the quality
improvement plan and target the various phases of transfusion
services. (Examples include turn- around time for urgent vs. elective
transfusion requests, percentage of blood component wastage, cross-
match/transfusion ratio etc...).
Discussion of indicator results are done at the leadership level of the
department and also at the hospital management level in order to
engage appropriate improvement actions, with a timely feedback of
results and action plans to the concerned teams.
Guiding measures:
20.1 Measurable objectives for quality improvement initiatives and the
timeframe in which they will be reached, are set.
20.2 Indicator(s) is used to monitor progress for each quality
improvement objective.
20.3 Data related to waiting times and average response times for
elective, urgent, and emergent requests for laboratory services are
collected, analyzed, and interpreted to establish a baseline for
indicators.
20.4 Indicator data is evaluated to determine the effectiveness of the
quality improvement activities.
20.5 Results are properly communicated to the hospital executive
management.
20.6 Quality control, assurance and safety standard operating
developed, implemented and documented.
BB 21. There is a system for managing all sentinel events, adverse events,
and near misses.
With any occurrence of a sentinel event, adverse event or near miss,
the hospital must have a defined system and process for the
detection, reporting, analyzing and feedback of this event. It should
be clear who can report, to whom, how and what events can be
5
reported. Such events must be investigated to determine the root
causes, and set appropriate corrective/improvement actions. Such
feedbacks and reporting of such events are documented and
discussed in concerned departments (such as the Blood bank and
Quality and Patient Safety Departments), and committees such as the
Transfusion committee or Quality and Safety Committee.
Guiding measures:
21.1 Sentinel events, adverse events, and near misses are identified,
evaluated, followed-up, and reported to blood transfusion

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 committees or any committee based on hospital policies,
procedures, laws and regulations.
21.2 Access to the information that identifies transfusion-related
adverse events is ensured at all times.

21.3 Reporting all sentinel events, adverse events, and near misses
related to blood or blood products is done immediately.
21.4 The cause of the sentinel event, adverse event, or near miss is
determined following proper investigations and corrective actions
to prevent recurrence are taken and documented.
21.5 A copy of the investigation report and recommendations for future
transfusions are retained in specific records based on hospital’s
policies and procedures.
BB 22. There is evidence of a hospital committee with defined terms of
reference, reporting lines and minutes of meetings to review
hemovigilance data
Transfusion services performance and hemovigilance should be
monitored and evaluated by a Transfusion/Hemovigilance Committee
with defined members, objectives and scope. Quality indicator data
and adverse events related to the donor, recipient and facility
4
operations are to be reported and discussed in this committee, where
final improvement actions/projects or corrective actions are set.
Every meeting is documented using minutes of meetings which
ensure the traceability of matters addressed, activities and
improvement actions agreed upon. This record is used to evaluate the
performance and effectiveness of the committee in improving
transfusion services.
Guiding measures:
22.1 There is evidence that the committee meets at least quarterly
22.2 Data collected regarding recipient and donor adverse reactions is
collated, analyzed and reported to the blood transfusion committee
22.3 Annual activity report and hemovigilance data shall be reported to
be the MOPH using the national hemovigilance questionnaire LCBT-
HV-008 on the website of the ministry

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Patient Services: Other Services (OTHER)
Introduction
The Other Services chapter is an integral part in patient services. It tackles burn
care, dietary services, social care, physiotherapy and mental health services. It
requires specific and collaborative care from multidisciplinary healthcare
providers to ensure safe health care for patients.
The Other Services chapter targets the following sections:
 Burn care
• Burn care policies and procedures
• Burn care assessment
• Pain assessment
• Quality improvement indicators
 Dietary Services
• Dietary services staff qualifications
• Dietary services policies and procedures
• Nutritional status assessment
• Food safety
• Quality improvement indicators
 Social Care
• Social services policies and procedures
• Psychosocial assessment
 Physiotherapy
• Physiotherapy staff qualification
• Physiotherapy assessment
 Mental Health
• Mental outpatient department
• Safe physical environment in the mental health department
• Mental health staff qualification
• Inpatient care plan
• Violence prevention
• Quality improvement indicators

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Each standard was supported by a corresponding set of guiding measures that
further clarify the standard. The guiding measures aim to facilitate the
implementation of the standards and to guide the hospitals in fulfilling the
objective of the standard.

217
Standards
Risk
Standard and Guiding measures
Score
Burn Care
OTHER 1. Burn care is guided by policies and procedures and provided by
qualified staff.
Similar to all specialized units, the burn care center should be
staffed with qualified medical and nursing personnel trained in the
assessment, management of burns and the general care of critical
patients. With such critical patients, standardized care based on
4 documented and regularly taught policies and procedures (burn
assessment, complications of burns, fluid resuscitations, burn
dressing, and infection control) is critical to achieve the best quality
of care.
Comparable to the training of all critical care unit personnel, burn
care center should must receive regular training sessions on all
aspects of critical care patients’ management, and audited regularly
or when the need arises.
Guiding measures
1.1. Staff providing burn care is qualified by documented education and
training in wound and burn care and advanced resuscitation (i.e.
ALS, ACLS).
1.2. Evidence of policies and procedures to guide patient burn care.
1.3. In case burn care is not provided, clear policies and procedures are
available to transfer patients to other organization
1.4. Evidence of policies and procedures for infection control for
patients with burns.
1.5. Evidence that staff received training and education on the following
but not limited to:
1.5.1. Measuring vital signs
1.5.2. Use of pulse oximeter.
1.5.3. Principles of infection control.
1.5.4. Use of the defibrillator.
1.5.5. Knowledge of the dosage, side effects, and complications of
commonly used high -alert medications.
OTHER 2. The hospital provides burn care tailored to the patient’s needs.
The process of receiving, assessing, establishing a care plan and
management strategies should involve a predetermined
5 multidisciplinary team (medical team, critical care and plastics,
specialized nursing staff, physiotherapy) and documented in the
patient’s records.
Based on the patient’s initial status (degree and severity of burns,
overall status, age, co morbidities …), the managing team

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 establishes and documents an initial care plan, which is updated and
tailored according to the patient’s needs throughout the stay.
Critical patients must be in a high level care unit (ICU, intermediate
care unit...) with high level monitoring documents in the patients’
electronic and physical records.
Guiding measures
2.1. Patients undergo an initial documented burn assessment upon
admission by a qualified medical staff member (i.e. registered
nurse).
2.2. Burn care plan is developed and documented in patient’s medical
record.
2.3. Interventions are documented and revised based on the patient’s
condition.
2.4. The hospital provides burn care tailored to the patient’s needs.
2.5. Evidence that the patient is continuously monitored.
OTHER 3. Pain is assessed and interventions are implemented accordingly.
Burn patients suffer significant pain from the burns and from the
management therapies and surgeries. By procedure the hospital’s
3 pain team or assigned qualified professionals should be consulted
for initial pain assessment, and reassessment after set timeframes,
interventions or when necessary. Pain assessment and the response
to treatments should be documented in the patient’s record.
Guiding measures:
3.1. The hospital has a policy and/or procedure to assess pain.
3.2. The assessment is performed and documented by qualified
individuals.
3.3. Targeted interventions are implemented and documented.
3.4. Pain is reassessed and documented after intervention(s) are
implemented.
OTHER 4. Burn care specific indicators are collected and used as part of the
quality improvement plan.
The burn care center must choose quality indicators that specifically
reflect clinical care, quality and safety of burn care provided”.
Certain outcome indicator examples include skin and neuromuscular
4 function, sensory and pain, satisfaction etc.
Data collection, analysis and results are compared to preset targets
in order to assess the efficiency and needed improvements of
current practices. Results, proposed changes or improvements to
current management strategies are relayed to the hospital’s
executive administration.
Guiding measures:
4.1. Indicator(s) is used to monitor progress for each quality
improvement objective.
4.2. Data is collected, analyzed, and interpreted to establish a baseline
for indicators

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 4.3. Outcome indicators are evaluated to determine the effectiveness of
the quality improvement activities.
4.4. Results are properly communicated to the hospital executive
management.
Dietary services
OTHER 5. The hospital has qualified and competent staff dietary department.
4 Staff that holds the Dietary department staff should be qualified
and trained is part of the Infection prevention and control
committee.
Guiding measures:
5.1. The director, nutritionist and dietician, are qualified by education,
training and experience.
5.2. The person responsible for the dietary services is on the infection
prevention and control committee
OTHER 6. Hospital provides adequate dietary services.
Dietary services policies and procedures should encompass the
whole process of food management, from reception to delivery,
5 considering isolation, hygiene and employees safety.
Nutritional status assessment should identify patient’s needs,
initially and throughout the stay according to customized dietary
plan, documented in the medical record.
Guiding measures:
6.1. Evidence of policies and procedures to guide dietary services,
including but not limited to:
6.1.1. Receiving or purchase of food
6.1.2. Preparation and handling of raw/processed food
6.1.3. Storage of prepared food and leftovers
6.1.4. Distribution of food
6.1.5. Patient snacks and late trays
6.1.6. Preparation of enteral feedings
6.1.7. Employee safety
6.1.8. Employee health and hygiene
6.1.9. Infection Control
6.1.10. Preparation of isolation trays
6.1.11. Cleaning of the department (if not provided by a centralized
housekeeping department)
6.1.12. Sanitation of chopping boards.
6.2. Evidence of criteria to identify patients at nutritional risk during an
initial nutritional assessment.
6.3. Patients undergo an initial documented nutritional assessment
upon admission by a qualified medical staff member (i.e. registered
nurse).
6.4. Patient plan of care is documented in the medical record
6.5. Evidence of comprehensive nutritional assessment by a licensed
dietitian for patients at nutritional risk.
6.6. Patient dietary plan is documented in patient’s medical record.

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 6.7. Evidence of dietary plan reassessment and revision (if needed) at
regular intervals by a dietitian during the patient’s stay at the
hospital.
6.8. Patient’s food order is based on the patient’s nutritional status and
needs.
OTHER 7. The hospital abides by food safety standards to reduce the risk of
food-borne diseases. [IPC-21]
Due to highly susceptible and frail populations among hospitalized
patients, such as the elderly, outbreaks of nosocomial food-borne
infections can add to the morbidity of these patients. Food-borne
bacteria can multiply rapidly if food is not maintained at certain
appropriate temperatures for refrigeration and hot holding, and if
there are delays between food preparation and distribution. Also,
dishwashers need to reach thermal disinfection temperatures to
sufficiently reduce the pathogens.
Most nosocomial food-borne pathogens are spread by the fecal-oral
route. The primary source of outbreaks may be contaminated
5 food/water, and infected/colonized patients, visitors, staff, or food
handler. Therefore, food handlers must be aware of high standards
of personal hygiene and perform hand hygiene and sanitation
appropriately and in the right indicated moments.
These and other potential hazards need to be addressed in a
systematic way by the hospital in order to prevent and control such
risks related to food-borne infections. Hazard Analysis Critical
Control Point (HACCP) is recognized as an effective food safety
assurance system and can be used to attain standards specific to
food safety such as Food Code (US food standards by FDA) and
Codex Alimentarius (International Food Standards by FAO/WHO).
Regular inspections and audits by the IPC team should be performed
to monitor the implementation of this program.
Guiding measures:
7.1. The hospital abides by Hazard Analysis and Critical Control points
(HACCP) to ensure clean and appropriate environment for safe food
handling.
7.2. Preparation of food is done using proper sanitation measures and
under appropriate room temperatures, and audits are conducted to
test the compliance.
7.3. Sanitation measures are implemented in the kitchen.
OTHER 8. Dietary services specific indicators are collected and used as part of
the quality improvement plan.
Dietary services hold several priority areas where organizational
performance and quality can be subject to improvement, and where
4 adverse events and suboptimal results are generally observed but
can be largely prevented. Therefore, it is important to define and
prioritize the key performance indicators and improvement
objectives for such a department, based on observation, audits and
benchmarking.

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 Once improvement objectives are identified, indicators should be
set with adapted targets, in order to monitor the progress of the
quality improvement plan.
Discussion of indicator results should be done at leadership level of
the department and also at the hospital management level in order
to engage appropriate improvement actions, with timely feedback
of results and action plan to concerned teams.
Guiding measures:
8.1. Indicator(s) is used to monitor progress for each quality
improvement objective.
8.2. Data is collected, analyzed, and interpreted to establish a baseline
for indicators
8.3. Outcome indicators are evaluated to determine the effectiveness of
the quality improvement activities.
8.4. Results are properly communicated to the hospital executive
management.
Social Care
OTHER 9. The hospital provides social care services
In case the hospital offers Social services, those services should be
guided by policies and procedures. Otherwise there should be a
3 policy of referral Social care and should be provided by a qualified,
educated and trained team.
Psychosocial assessment as well as a plan of care should also be
performed according to identified criteria and be kept in the
patient’s record.
Guiding measures:
9.1. Evidence of policies and procedures to guide social care services.
9.2. The hospital social care services are provided by qualified social
care worker/professional.
9.3. In case the hospital does not have social care services, there is a
delineated policy to refer patients.
9.4. Staff providing social care services are qualified by education and
training in social care.
9.5. Evidence of criteria to identify patients at psychosocial risk during
an initial psychosocial assessment.
9.6. Patients undergo an initial documented psychosocial assessment
upon admission by a qualified medical staff member (i.e. registered
nurse).
9.7. Evidence of comprehensive psychosocial assessment by social
worker for patients at psychosocial risk based on the initial
psychosocial assessment.
9.8. Psychosocial assessment and plan of care are documented in
patient’s medical record.

Physiotherapy

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 OTHER 10. The hospital provides physiotherapy services.
The hospital’s physiotherapy department is an essential
paramedical division for both surgical and medical patients
especially critical ones. The staff and senior physiotherapist should
have the necessary qualifications and experience delineated in the
documented job descriptions, procedures and policies.
4 Every patient should have an initial functional assessment upon
admission (mobility requirements and deficiencies, respiratory,
swallowing difficulties…) by the clinical staff (nursing, medical...)
and when needed a more detailed assessment by the physiotherapy
staff. A physiotherapy care plan should be initiated, regularly
updated, documented and modified when needed. Upon discharge
the home discharge plan must include the needed home
physiotherapy care.
Guiding measures
10.1. The physiotherapy department is guided by a qualified
physiotherapist.
10.2. Staff providing physiotherapy services are qualified by education
and training.
10.3. Evidence of policies and procedures to guide physiotherapy
services.
10.4. Patients undergo an initial documented functional assessment upon
admission by a qualified medical staff member (i.e. registered
nurse)
10.5. Evidence of comprehensive functional assessment by
physiotherapist for patients at functional risk.
10.6. Functional assessment and physiotherapy plan of care are
documented in the patient record.
10.7. Patient’s response to treatment therapy is recorded in the patient’s
medical record.

Mental Health

OTHER 11. The mental health outpatient department uses an integrated and
recovery approach for the care of each person with mental
conditions.
5 Mental health outpatient department should develop a strategy to
raise awareness about the stigma of mental health issues, manage
mental conditions, ranging from promotion of available mental
services to assessment, counseling, education and follow-up.

Guiding measures:

11.1. The mental health outpatient department has a strategy to

promote available mental health services, and reduce the stigma of
mental conditions

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 11.2. The mental health outpatient department explains confidentiality
and its limits to the persons with mental conditions and/or
caregivers at the first assessment
11.3. The mental health outpatient department helps the persons with
mental conditions and/or caregivers make informed choices
11.4. The mental health outpatient department has processes to follow
up with high-risk persons with mental conditions and/or caregivers
who do not appear for scheduled appointments or who were
referred to psychiatric admissions
11.5. The mental health outpatient department provides psycho-
education to persons with mental conditions and caregivers and
facilitates the access to self-help and family support group or
program, where available

OTHER 12. The mental health outpatient department acts as a referral mental
center
The department should have an active role in mental health
4 programs on a national level in coordination with healthcare
organizations and authorities to promote awareness and prevention
for mental health disease as well as providing training and
supervision to non-specialized staff and clinics.
Guiding measures:

12.1. The mental health outpatient department provides specialized

mental prevention programs in coordination with the general
hospitals, the mental health program at the ministry of public
health, the community and schools, to support health promotion
and disease prevention.
12.2. The mental health outpatient department provides outreach
mental health services
12.3. The mental health outpatient department has processes to act as a
referral center for the general hospitals, outpatient departments
not specialized in mental health and for clinics with integrated
mental health services
12.4. The mental health outpatient department provides training to non-
specialized staff on the World Health Organization mental health
gap action program
12.5. The mental health outpatient department provides support and
supervision to clinics with integrated mental health services
OTHER 13. A safe and secure physical environment for patients, families, staff
5 and visitors is ensured at all times in the mental health
department.

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 The mental health departement should be a secure area, only accessed
by staff upon authorization and continuously surveilled by security and
alarm systems.
Guiding measure:
13.1. Access to the mental health department is limited to the authorized
staff based on hospital policies.
13.2. Security staff is available 24/7 at the mental health department
13.3. A security alarm bell system linked to a central point is available.
OTHER 14. The staff in the mental health department are competent and
qualified.
Management of patients in the mental health department require
adequate resources with specialized skill set and to be able to
ensure the provision of highly specialized and safe care 24h/day 7
days/week
Moreover, it is important that these skills are acquired by
education, training and experience which should encompass
6 procedures addressing issues such as seclusion, isolation,
restraints, electroconvulsive therapy etc.…) with evidence of
competency training and documentation to ensure the required
level of care is met at all times, with eventual corrective actions
being implemented accordingly.
These resources and services must be headed by a qualified
professional able to integrate and guide the mental health care
services within the institution.

Guiding measures:
14.1. A full-time psychiatrist qualified by training and education in
psychiatry is in charge of the clinical aspects of the psychiatry
department/services
14.2. A registered nurse qualified by education and training in psychiatric
nursing and a minimum of five years of experience manages the
psychiatry department, when applicable.
14.3. The unit has its own dedicated head of psychiatry department who
can provide expert input into key matters of inpatient service
delivery, staff support and decision making, and overall acute care
COR service coordination.
14.4. There is at least one qualified practitioner, by education, training
and experience, on duty during therapeutic program.
14.5. There is at least one full-time psychotherapist in the department.
14.6. There is a registered nurse within the department on duty 24h
hours per day /7 days per week
14.7. Evidence of annually staff training on:
14.7.1. Seclusion and/or isolation room procedures
14.7.2. Physical and chemical restraint
14.7.3. Electroconvulsive therapy
14.7.4. Self-harm and suicide awareness and prevention techniques

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 14.7.5. Violent behavior de-escalation techniques
14.7.6. Basic psychology and psychosocial intervention.
14.7.7. Addiction
OTHER 15. Seclusion and restraint are used in a safe manner. [PFR-8]
Such behavioral management interventions should be used as a last
resort to control a behavioral emergency. Indications for
5 seclusion/restraint must be clearly defined in hospital policy/procedure,
diffused appropriately and documented in the file when occurring. Such
interventions should not be sustained longer than they should, and thus
must be reassessed daily.
Guiding measures:
15.1. The hospital has a policy and procedure for the use of seclusion and
restraints.
15.2. The use of seclusion and restraints are justified and documented in
patient records.
15.3. The need for seclusion and restraints is valid for a predefined
limited time and its need is reassessed every 24 hours.
OTHER 16. A care plan is developed and documented for each inpatient.
The care plan for mental health patients should be based on the
logic of assessment and reassessment of all the patient’s clinical
condition and risks, which can help identify adapted interventions
to potentially improve the patient’s clinical status and/or prevent
unwanted outcomes.
5 Initial assessment is performed upon admission, and reassessment
is according to patient needs to monitor and identify signs of
improvement and relapse
Based upon the assessment, adequate interventions are identified
and planned by the clinical staff, and both the assessment and the
interventions and the discharge/at home care plan are
documented in the patient’s care plan and discussed with the
patient and/or family.
Guiding measures:
16.1. Qualified medical and nursing staff follows policies and procedures
for assessment and reassessment of patients including the time
frame required for completing the initial assessment and the
frequency of reassessments.
16.2. The mental health department collaborates with the patient and/or
family member and/or next of kin to develop and document an
integrated and comprehensive care plan.
16.3. The patient’s care plan includes but is not limited to the following;
16.3.1 Patient’s treatment and outcomes
16.3.2 Timeframes to achieve the outcomes
16.3.3 Strategies to manage symptoms, including identification of
early warning signs of relapse and appropriate action.
16.3.4 An exit and aftercare plan

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 OTHER 17. Violence prevention plan is implemented, evaluated and
integrated into the occupational health and safety program. [HC-
15]
In case of occurrence of violence, the hospital should have policies
and procedures to support the process of reporting and
management of workplace violence including the availability of
resources to aid staff that were affected by violence.
5
Violent acts include physical assaults and threats directed toward
persons at work or on duty. A comprehensive zero-tolerance
violence prevention plan based on proactive risk assessment
approaches should include: Management commitment and
employee participation, worksite analysis and violence hazard
identification, workplace violence hazard prevention and control,
violence safety and training and record keeping and program
evaluation.
Guiding measures:
17.1. The hospital develops implements and documents a violence
prevention plan.
17.2. Evidence of proactive assessment of areas with possible workplace
violence and develops plans accordingly.
17.3. The hospital implements a zero-tolerance policy for forms of
violence or aggressive behavior whether verbal, physical, or sexual.
17.4. Support resources are available for staff enduring work violence.
OTHER 18. Staff is regularly educated and trained on techniques to prevent
and respond to violent and/or aggressive patient and family acts.
[HC-16]
Violence could lead to physical and mental repercussions,
5
therefore there is need to specifically educate and train staff to
prevent and respond to violence, resolve conflict and maintain
hazard awareness.
All aggressive/violent behaviors of patients/family need to be
documented
Guiding measures:
18.1. There is a policy and process to report violent and/or aggressive
patient and family acts.
18.2. Staff is regularly educated and trained on techniques to prevent and
manage violent and/or aggressive patient and family acts.
18.3. Violent and/or aggressive patient and family acts are documented.
OTHER 19. Mental health specific indicators are collected and used as part of
the quality improvement plan.
4 Mental Health services have several areas where performance can
be subject to improvement. Therefore, it is important to define
and prioritize the key improvement objectives for this
department, based on evidence-based indicators results, audit

227
 surveys and benchmarking, as part of the hospital-wide quality
improvement program.
Indicators could refer to international innovations in quality
measurement including “WHO’s assessment instrument for
mental health systems”, or the “International initiative for mental
health leadership” but should be set with adapted applicable
targets, in order to monitor the quality and safety of services and
the progress of the quality improvement plan. (Examples could
include seclusion and restraint minimization, reduction of suicide
attempts, adherence to psychotherapy and treatment, etc.…)
Discussion of indicator results are done at the leadership level of
the department and also at the hospital management level in
order to engage appropriate improvement actions, with a timely
feedback of results and action plans to the concerned teams.
Guiding measures:
19.1. Indicator(s) is used to monitor progress for each quality
improvement objective.
19.2. Data is collected, analyzed, and interpreted to establish a baseline
for indicators
19.3. Outcome indicators are evaluated to determine the effectiveness of
the quality improvement activities.
19.4. Results are properly communicated to the hospital executive
management.

228
SECTION III

Appendix

229
Launch of the Accreditation process on September 8th 2016 at
ESA, Beirut

Expert Subgroup Meetings

230
231
Glossary

SECTION IV

Glossary

Glossary
 Access to health care: "The timely use of personal health services to achieve the b

232
Glossary
 Access to health care: "The timely use of personal health services to achieve the best
health outcomes".

 Accreditation: The action or process of officially recognizing an institution as having a

particular status or being qualified to perform a particular activity

 Adverse drug event: An injury resulting from medical intervention related to a drug.

 Allied health professional: A broad field of healthcare professions made up of

specially trained individuals (such as physical therapists, dental hygienists,
audiologists, and dietitians) who are typically licensed or certified but are not
physicians, dentists, or nurses.

 APGAR test: A test performed twice at 1 minute and 5 minutes after birth, to assess
the newborn’s color, heart rate, stimulus response, muscle tone, and respirations.

 Benchmarking: A technique used by the organization to evaluate a result based on a

previously obtained result.

 Care plan: “A plan that identifies the patient's care needs, lists the strategy to meet
those needs, documents treatment goals and objectives, outlines the criteria for
ending interventions, and documents the individual's progress in meeting specified
goals and objectives. It is based on data gathered during patient assessment. The plan
of care may include prevention, care, treatment, facilitation, and rehabilitation”.

 Clinical guidelines: Statements based on rigorous systematic review of evidence that

help healthcare providers to optimize patient care, by providing recommendations to
care.

 Chemotherapy cycle: An oncology treatment course that is repetitive on a regular

intervals with periods of rest in between.

 Critical patient: Patients with unstable a vital signs and vital signs that are not within
normal limits.

 Disaster: As Defined by International Federation of Red Cross and Red Crescent

Societies, “A disaster is a sudden, calamitous event that seriously disrupts the
functioning of a community or society and causes human, material, and economic or

233
 environmental losses that exceed the community’s or society’s ability to cope using
its own resources. Though often caused by nature, disasters can have human origins”.

 Emergency situations: The situation where the hospital’s normal capacity does not
meet the influx of large number of patients in a specific time period.

 Family: A group of individuals that share ties of blood, marriage or adoption.

 Functional limitation: A restriction in the performance of essential physical and/or

mental daily life activities.

 Fundamental critical care: A course attended by clinicians to prioritize assessment

needs for the critically ill patient, select appropriate diagnostic tests, identify and
respond to significant changes in the unstable patient, recognize and initiate
management of acute life-threatening conditions.

 Guiding measures: a statement that aims to facilitate the implementation of the

standards and to guide the hospitals in fulfilling the objective of the standard.

 Healthcare-Associated Infections Outbreaks: An increase in the number of hospital-

acquired or healthcare facility-acquired cases of disease among patients or staff over
and above the expected number of cases in a hospital.

 Health Information system: It is a system that deal with capturing, storing, managing
or transmitting information related to the individual’s health or the activities of the
organizations.

 High-alert medications: Include medications that are involved in a high percentage

of errors and/or sentinel events and medications whose names, packaging and
labeling, or clinical use, look alike and/or sound alike.

 High-risk patients: Children and the elderly, patients who do not have the capacity to
understand the care process and cannot participate in decisions regarding their care.

 High-risk persons with mental conditions: A patient who may expose himself/herself
and/or the community to danger.

 Indicators: Established measures to determine the effectiveness of the organization

in meeting its customers’ needs and other operational and financial performance
expectations.

234
 Institutional review board (IRB): A formal committee that approves monitors and
reviews human based research.

 Medical record: A sequential written document of the patient’s examination and

treatment.

 Near misses: An act of commission or omission that could have harmed the patient
but did not cause harm as a result of chance, prevention, or mitigation.

 Next of kin: The patient’s closest living blood relative (i.e. the spouse, adult children,
parents, adult siblings, and other relatives).

 Outbreak: “A disease outbreak is the occurrence of cases of disease in excess of what

would normally be expected in a defined community, geographical area or season”.

 Partogram: A graphical representation during labor of time and dilation with alert
lines.

 Point-of-care testing: Medical diagnostic testing performed outside the clinical

laboratory in close proximity to where the patient is receiving care

 Policy: An overarching plan adopted by an organization to achieve its goals.

 Potable water: Potable water is water of a quality suitable for drinking, cooking and
personal bathing.

 Post-anesthesia: The period following the administration of anesthesia.

 Procedure: Documented steps in a process showing the way on how these steps are
to be performed.

 Process: A set of interrelated actions characterized by a group of specific inputs and

value-added tasks that make up a procedure for a set of specific outputs.

 Psychosocial: involving mental health, social status and functional capacity within a
community/society.

 Radioactive waste: any waste generated by nuclear medication, radiation, oncology

and PET, this includes all contaminated material.

 Reprocessing: The steps done to prepare used medical equipment/devices for use
(e.g., cleaning, disinfection, and sterilization).

235
 Screening: A preliminary assessment to detect a probability of a disease, sensation
and/or need.

 Sentinel event: Unexpected events that results in death or serious physical or

psychological injury.

 Special needs: Several physical, emotional, behavioral, or learning disabilities or

impairments that necessitate additional specialized services.

 Standard: a statement defining the outcome that should be in place to provide high
quality service

 Sterilization: A process that destroys or eliminates all forms of microbial life physically
or chemically in healthcare facilities.

 Systemic therapy: Treatment using substances that travel through the bloodstream,
reaching and affecting cells all over the body.

 Transition: transition from one setting to another, or transfer from one physician to
another or from a specific type of care to another.

 Triage: A process to assign order of interventions based on patient acuity.

 Verbal and telephone order: Orders that are spoken aloud rather than written.

236
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SECTION V
References of Glossary

237
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