Chapter 1: Leadership (LD)

LD.1	The facility is in compliance with all Saudi Arabian laws and health care regulating bodies including the Ministry of Health (MOH).
	Why we have this standard The senior manager or director is responsible for the organization\92s: \B7 Compliance with applicable law and regulation. \B7 Response to any reports from inspecting and regulatory agencies.
	How the standards will be identified ˜ Document Review License (MOH) , Saudi Council for health care institutions licenses, Civil defense bylaws, MOH -Medical and dental Practitioner Bylaws ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There is evidence that the hospital is not in compliance with Saudi Arabian laws and healthcare regulating bodies including the MOH
	Score 1 MM)	N/A
	Score 2 (PM)	N/A
	Score 3 (FM)	There is evidence that the hospital is in compliance with Saudi Arabian laws and healthcare regulating bodies including the MOH
	Teaching Tool(s)
	Sample Document(s) MOH MOH 1 MOH 2 MOH 3 MOH 4 MOH 5 MOH 6 MOH 7 MOH 8 MOH 9 MOH 10 MOH 11 MOH 12 MOH 13		MOH 14 MOH15 MOH 16 MOH 17 MOH 18 MOH 19 MOH 20 MOH 21 MOH 22 MOH 23 MOH 24
LD.2	The hospital has a defined and clear organizational structure that is known to all staff and includes the following: LD.2.1 There is an organizational chart which identifies the names and titles of the hospital leaders, and department heads. LD.2.2 The organizational chart is current. LD.2.3 The organizational chart is explained to all employees as part of his/her orientation.
	Why we have this standard 1. The hospital leaders make sure that staff understand the flow of responsibilities and authority lines and that there is a current list of name/s titles available with the organizational chart to support good communication between professionals. 2. Medical, nursing, and other clinical leaders have a special responsibility to patients and to the organization. 3. The leaders jointly plan and develop policies that guide the delivery of clinical service provide for the ethical practice of their professions; and 4. Oversee the quality of patient care. 5. The organizational structure(s) and the associated processes used to carry out these responsibilities can provide a single professional staff composed of physicians, nurses, and others or separate medical and nursing staff
	How the standards will be identified ˜ Document Review Organizational Chart with identified positions ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There is no organizational chart.
	Score 1 MM)	There is an organizational chart that is not current and/or is not posted.
	Score 2 (PM)	There is a current organizational chart. The staff members interviewed are not familiar with the positions or the organizational chart is not part of the general/departmental orientation and/or the organizational chart is not posted.
	Score 3 (FM)	There is a current organizational chart that is covered in the general/departmental orientation and the staff members interviewed are familiar with the positions.
	Teaching Tool(s) Organization Structure
	Sample Document(s) Organizational Chart Organizational Chart 3 Sample Organizational Chart
LD.3	Besides the hospital director, the following positions are identified by the organizational chart and hospital meetings as part of the leadership group: LD.3.1 Medical Director. LD.3.2 Administrative Director. LD.3.3 Nursing Director. LD.3.4 Quality Management Director /leader. LD.3.5 Department heads.
	Why we have this standard The structure chosen can be highly organized with bylaws and rules and regulations or can be informally organized. In general, the structure(s) chosen The organizational structure(s) and processes support oversight of the quality of clinical services: \B7 includes all the relevant clinical staff; \B7 is appropriate for the organization\92s complexity and size of the professional staff; and \B7 effective in carrying out the responsibilities listed above.
	How the standards will be identified ˜ Document Review Hospital meetings , Organizational Chart, Leadership formation order with terms of reference
	Coding Scoring Criteria
	Score 0 (NM)	Only the Hospital Director is identified and there is no leadership role for any other position.
	Score 1 MM)	Besides the Hospital Director, there is a Medical Director and Administrative Director.
	Score 2 (PM)	Besides the Hospital Director, there is a Medical Director, Administrative Director, and Nursing and Quality Director
	Score 3 (FM)	Besides the Hospital Director, all of the positions in LD.3.1 - LD.3.5 are included.
	Teaching Tool(s) Organization Structure
	Sample Document(s) Organizational Chart Organizational Chart 2 Sample Organizational Chart
LD.4	The leadership meets regularly (at least monthly) in a minuted formal meeting (like an executive committee) to discuss all aspects of medical care, and services provided to patients.
	Why we have this standard To ensure the decision making to meet and meet the needs of the complexity of patient care needs
	How the standards will be identified ˜ Document Review Formal meeting minutes of leadership + terms of reference ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There are no meeting minutes for the leadership or the minutes do not contain evidence of any discussion of aspects of medical care and services provided to patients.
	Score 1 MM)	The leadership meeting minutes contain evidence of discussion of aspects of medical care and services provided to patients but the meetings were less than 4 meetings per year.
	Score 2 (PM)	The leadership meeting minutes contain evidence of discussion of aspects of medical care and services provided to patients but the meetings were less than 7 meetings per year.
	Score 3 (FM)	The leadership meeting minutes contain evidence of discussion of aspects of medical are and services provided to patients and there were 9 or more meetings per year.
	Teaching Tool(s)
	Sample Document(s) Hospital Executive Leadership Meeting Charge
LD.5	There is evidence that all members of the leadership group are qualified by appropriate education and experience.
	Why we have this standard Good departmental or service performance requires clear leadership from a qualified individual.
	How the standards will be identified ˜ Document Review Job descriptions matched with personnel file ˜ Sampling Request 10% sample
	Coding Scoring Criteria
	Score 0 (NM)	Hospital Director has no degree in Hospital Administration. MD is a General Practitioner only. Nursing Director has no degree. Quality Director has no degree in Healthcare Administration or CPHQ certification. Clinical Heads have no Board Certification or equivalency according to Saudi Council.
	Score 1 MM)	Less than 50% of the leadership group have the appropriate qualifications.
	Score 2 (PM)	Greater than 50% and less than 80% of the leadership group have the appropriate qualifications.
	Score 3 (FM)	Greater than 80% of the leadership group have the appropriate qualifications.
	Teaching Tool(s)
	Sample Document(s) Job Description Format Director Human Resources \96 Job Description Director Operating Room\96 Job Description Director TQM \96 Job Description Exec Director Academic Affairs\96 Job Description Exec Director Patient Affairs \96 Job Description Director Of Nursing \96 Job Description Hospital Director \96 Job Description
LD.6	Each member in the leadership group has a defined scope of responsibility as outlined in a current job description.
	Why we have this standard Qualified directors are knowledgeable about the required space, staffing and other resources that are necessary to provide effective services. 1. The responsibilities of each role are defined in writing. 2. To make sure persons who direct departments have the necessary education, experience and set of competencies required for job performance. 3. To make sure persons who direct departments have the authority and the accountability to adequately direct their departments. 4. Make sure policies and procedures describe the roles and responsibilities, and the authority allowed for each position.
	How the standards will be identified ˜ Document Review Job descriptions - leadership
	Coding Scoring Criteria
	Score 0 (NM)	Less than 20% of the sampled leadership have a job description and responsibility assigned.
	Score 1 MM)	At least 20% and less than 50% of the sampled leadership have a job description written and scope of responsibility described.
	Score 2 (PM)	At least 50% and less than 80% of the sampled leadership have a job description written and the scope of responsibility described.
	Score 3 (FM)	80% or more of the sampled leadership have a job description written with the scope of responsibility described
	Teaching Tool(s)
	Sample Document(s) Job Description Format Director Human Resources \96 Job Description Director Operating Room\96 Job Description Director TQM \96 Job Description Exec Director Academic Affairs\96 Job Description Exec Director Patient Affairs \96 Job Description Director Of Nursing \96 Job Description Hospital Director \96 Job Description
LD.7	The hospital has a mission, vision, and values statement that is clearly written known to all staff, and: LD.7.1 The mission, vision and, values statement is clearly written. LD.7.2 The mission, vision , values statement is publicly displayed to all staff and customers. LD.7.3 All staff employed by the hospital can state the mission statement. LD.7.4 The mission, vision and, values statement will be included in the orientation program
	Why we have this standard 1. Leadership\92s responsibility is to approve by the governing body for the mission statement, vision, values, strategic planning, budget and resources. 2. Mission statement describes the fundamental reason for the existence of the organization. It should describe all the essential components of the organization, such as identification of the system's customers; geographic service area; major services provided; economic goals; and organizational strengths. 3. The vision statement declares where the organization wants to be in the future and serves as a major focal point of strategic quality planning. 4. The values statement identifies the basic tenets and principles of how people will work together. The values statement covers issues of fairness, honesty, commitment, dependability and expectations. \B7 Mission: Purpose of the organization \B7 Vision: Desired future status \B7 Values: Beliefs and principles \B7 Goals: Proposed accomplishments
	How the standards will be identified ˜ Document Review Mission, Vision, Values ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There is no mission, vision and values statement.
	Score 1 MM)	There is a mission statement and no vision, vision, or values statement or there is a mission, vision, and values statement that is not clearly written. Or the staff interviewed cannot state the mission statement.
	Score 2 (PM)	There is a mission, vision, and values statement clearly written and not publicly posted or the staff interviewed cannot state it.
	Score 3 (FM)	There is a mission, vision and values statement clearly written, publicly posted, and the staff interviewed can state it.
	Teaching Tool(s) Mission, Vision Mission Statement IMC International Medical Center Mission, Vision King Faisal Specialist Hospital & Research Center Mission, Vision Johns Hopkins Medicine Mission
	Sample Document(s) Employee Relations Manual
LD.8	The hospital has a written scope of service for the provision of medical care and includes: LD.8.1 The range of service i.e., Pediatrics, Gynecology or a general hospital. LD.8.2 The age groups who receive care. LD.8.3 The number of patients seen annually. LD.8.4 The major diagnostics or therapeutic methods used. LD.8.5 The scope of services is signed by the Medical Director, the Administrator, or both.
	Why we have this standard The clinical leaders also determine the scope and intensity of the various services to be provided by the organization directly or indirectly. 1. To make sure the scope of service and aspects of care are written by every department and communicated throughout the hospital. 2. To make sure planning and policy development is done on a collaborative basis involving nursing, physicians, and other services such as infection control and others as needed. 3. To make sure each department policies and procedures are consistent with their scope of service and aspects of care. 4. To make sure each department staff competencies are consistent with their scope of service and aspects of care.
	How the standards will be identified ˜ Document Review Hospital scope of service
	Coding Scoring Criteria
	Score 0 (NM)	There is no hospital scope of service.
	Score 1 MM)	N/A
	Score 2 (PM)	There is a written hospital scope of service that does not contain all contains only 2 out of the elements of the documents. LD.8.1 \96 LD.8.5.
	Score 3 (FM)	There is written hospital scope of service that contains elements LD.8.1 \96 LD.8.5.
	Teaching Tool(s) Mission, Vision Departmental Scope of Care
	Sample Document(s) IPP - Scope of Service Worksheet for Defining Scope of Care Equipment & Technology and Consumable Scope of Services Worksheet (Clinical) Scope of Services Worksheet (Non-Medical)
LD.9	The leadership has a 3 year strategic plan for the hospital that is updated every year and has the following components: LD.9.1 Guided by the Mission, and Vision of the organization. LD.9.2 Based on the Strength, Weakness, Opportunity, Threat, (SWOT) analysis. LD.9.3 Summarized by at least 5 strategic Directions (customer, community, employee, education, continuous improvement, and financial). LD.9.4 Translated actions and timelines for implementation with identified staff responsibilities.
	Why we have this standard To assure that senior leadership and management leading by example to integrate quality improvement into the strategic planning process and throughout the entire organization and to promote quality values and QI techniques in work practices. The responsibilities are primarily at the approval level and include: a. Approving the organization\92s mission; approving the organization\92s various strategic and management plans and the policies and procedures needed to operate the organization on a daily basis; b. Based on the dimensions (customer, community, employee, education, continuous improvement, and financial).
	How the standards will be identified ˜ Document Review Strategic plan
	Coding Scoring Criteria
	Score 0 (NM)	There is no 3 year hospital strategic plan.
	Score 1 MM)	There is a written strategic plan but it is not current and/or not 3 years.
	Score 2 (PM)	There is a written strategic plan but it does not have all l the components
	Score 3 (FM)	There is a written hospital strategic plan (3 years) that is current and signed by the Hospital Director and has all the elements of LD.9.1 \96 LD.9.4
	Teaching Tool(s) Strategic Plan SWOT Plan Human Resource Strategic Plan
	Sample Document(s) Required Resources Guidelines Departmental Business Plan Mission, Vision, Values SWOT Analysis Format to Set Departmental Goals Strategic Plan
LD.10	The hospital has the following essential committees that provide oversight and management for: LD.10.1 Pharmacy & Therapeutics Committee. LD.10.2 Morbidity & Mortality Committee. LD.10.3 Infection Control Committee. LD.10.4 Cardio Pulmonary Resuscitation (CPR) Committee. LD.10.5 Credentialing and Privileging Committee. LD.10.6 Operating Room Committee. LD.10.7 Tissue Review Committee. LD.10.8 Blood Utilization Review Committee. LD.10.9 Safety Committee. LD.10.10 Quality Management Committee. LD.10.11 Medical Record Review Committee. LD.10.12 Patient Rights/Patient Advocacy/Patient Care Committee. LD.10.13 Utilization Review Committee *The above committees can be combined as needed according to the hospital\92s scope of service and resources.
	Why we have this standard 1. To establish the system for the formation and operation of appropriately authorized Hospital Committees, subcommittee teams and task forces. 2. Their role will be to assist the Hospital leadership for effective management of patient care and hospital operations through multidisciplinary teams. 3. To provide the guidelines and define the authority and reporting responsibility of all authorized committees in the Hospital.
	How the standards will be identified ˜ Document Review Committee formation orders ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There are no hospital committees.
	Score 1 MM)	At least 4 hospital committees are active and there are 7 documented minutes.
	Score 2 (PM)	At least 8 hospital committees are active and there are 10 documented minutes.
	Score 3 (FM)	All of the hospital committees are active and there are documented minutes.
	Teaching Tool(s) Minutes of Meeting Importance Teaching Tool Committee How to Run an Effective Meeting
	Sample Document(s) Pharmacy & Therapeutics Committee FO Morbidity & Mortality Committee FO CPR Committee FO Medical Credentialing Committee FO Operating Room Committee FO Tissue Review Committee FO Blood Transfusion Committee FO Hospital Safety Committee FO Medical Record Review Committee FO Patient Care Executive Committee FO Utilization Review Committee FO Committee Formation & Approval Process Agenda Template Minutes Template APP: Committee Structure Quarterly/Annual Committee Report Committees Safety Committee
LD.11	All of the Hospital-wide committees have terms of reference that: LD.11.1 Clearly outline the committee\92s functions. LD.11.2 List the members and their titles. LD.11.3 State the required percentage of attendance required to hold the meeting. LD.11.4 State how often the committee is expected to meet (e.g. monthly for functional committees / quarterly for boards and councils). LD.11.5 Outlines the distribution of the minutes to the Hospital Director, Medical Director, Quality Management Director/leader, and members.
	Why we have this standard To establish the system for the formation and operation of appropriately authorized Hospital Committees, subcommittee teams and task forces.
	How the standards will be identified ˜ Document Review Committee formation order
	Coding Scoring Criteria
	Score 0 (NM)	There are no terms of reference for the committees that have been formed.
	Score 1 MM)	There are terms of reference for the committees that have been formed and the terms of reference do not outline the committee\92s functions and/or the committee membership.
	Score 2 (PM)	There are terms of reference for the committees that have been formed and the terms of reference do outline the committees functions and the committee membership. The committee terms of reference do not outline the required percentage to hold the meeting or the distribution list for the committee minutes.
	Score 3 (FM)	All of the Hospital committees formed have terms of reference (LD.11.1 \96 LD.11.5).
	Teaching Tool(s) Committee Terms of Reference Template
	Sample Document(s)
LD.12	The hospital committees meet as outlined in the terms of reference (no less than quarterly).
	Why we have this standard Their role will be to assist the Hospital leadership for effective management of patient care and hospital operations through multidisciplinary teams.
	How the standards will be identified ˜ Document Review Hospital committee minutes
	Coding Scoring Criteria
	Score 0 (NM)	The hospital committees have not met and there are no written terms of reference.
	Score 1 MM)	At least 4 hospital committees meet as outlined in the terms of reference and there are seven (7) documented minutes.
	Score 2 (PM)	At least 8 hospital committees meet as outlined in the terms of reference and there are ten (10) documented minutes.
	Score 3 (FM)	All of the hospital committees meet as outlined in the terms of reference and there are documented minutes.
	Teaching Tool(s)
	Sample Document(s)
LD.13	There is a uniform method in a policy and procedure that addresses how the chairpersons of a committee receives and refers the committee recommendations for approval by the responsible decision makers.
	Why we have this standard To establish the system for the formation and operation of appropriately authorized Hospital Committees, subcommittee teams and task forces.
	How the standards will be identified ˜ Document Review Committee minutes (resolved items + Policy
	Coding Scoring Criteria
	Score 0 (NM)	There is no evidence that the Hospital Director and/or his designee approved the committee recommendations or acquired any resources as recommended by the committee (when feasible).
	Score 1 MM)	There is a mechanism for approval of recommendations but no evidence that resources were acquired by the Hospital Director and/or his designee as an action from committee recommendations.
	Score 2 (PM)	There is and evidence that resources were acquired by the Hospital Director and/or his designee as an action from committee recommendations. But there is no a mechanism for approval of recommendations
	Score 3 (FM)	There is a mechanism for approval of recommendations and evidence that resources were acquired by the Hospital Director and/or his designee as an action from committee recommendations.
	Teaching Tool(s) Definitions of Policy and Procedures How To Write a Policy and Procedure Policy Guidelines Policy and Procedure Checklist Signature Sheet Policy and Procedure Approval
	Sample Document(s) IPP \96 Committee Recommendations APP Format IPP Format Policy on Policy & Procedures Policy Numbering System Signature Sheet for Policy and Procedure Approval Signature Sheet for Policy and Procedure
LD.14	There is an annual review of each committee\92s accomplishments written by the committee chairman and submitted to the committee\92s reporting authority and there is a policy to govern the process.
	Why we have this standard To establish the guidelines and define the authority and reporting responsibility of all authorized committees in the Hospital to the leadership.
	How the standards will be identified ˜ Document Review Annual committee accomplishments + policy
	Coding Scoring Criteria
	Score 0 (NM)	There is no policy or evidence of an annual review of any committee\92s accomplishments.
	Score 1 MM)	There is a policy to govern committee annual review process and there is evidence of a written annual review by the committee chairman for 7 committees.
	Score 2 (PM)	There is a policy to govern committee annual review process and there is evidence of a written annual review by the committee chairman for 10 committees.
	Score 3 (FM)	There is a policy to govern committee annual review process and there is evidence of a written annual review by the committee chairman for all committees.
	Teaching Tool(s)
	Sample Document(s) Committee Chairmen Annual Report Template
LD.15	The leadership recognizes and supports patient\92s rights by: LD.15.1 Educating the patient with the necessary information on his/her rights and responsibilities as part of the admission process. LD.15.2 Sponsoring ongoing educational sessions for staff on patients\92 rights.
	Why we have this standard 1. Patients and families need complete information on the care and services offered by the organization as well as how to access those services. Providing this information is essential to building open and trusting communication among patients, families, and the organization. 2. Health care organization educate patients and families so that they have the knowledge and skills to participate in the patient care processes and care decisions. Each organization builds education into care processes based upon its mission, services provided, and patient population. Education is planned to ensure that every patient is offered the education he or she requires.
	How the standards will be identified ˜ Document Review Patient rights/responsibilities, educational sessions ˜ Interview ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There is no patient rights/responsibility statement provided to patients as part of the admission process and there is no evidence of ongoing educational sessions for staff on patient rights.
	Score 1 MM)	There is a patient rights statement but is not publicized to patients and staff
	Score 2 (PM)	There is a patient rights/responsibility statement provided to patients as part of the admission process and there is no evidence of ongoing educational sessions for staff on patient rights.
	Score 3 (FM)	There is a patient rights/responsibility statement provided to patients as part of the admission process and there is evidence of ongoing educational sessions for staff on patient rights.
	Teaching Tool(s)
	Sample Document(s) APP Patient-Family Rights & Responsibilities PFR Statement
LD.16	The hospital has a generalized consent form that provides authorization for general treatment and a policy to govern its use and completion.
	Why we have this standard 1. One of the main ways that patients are involved in their care decisions is by granting informed consent. To consent, a patient must be informed of those factors related to the planned care required for an informed decision. Informed consent may be obtained at several points in the care process. For example, informed consent can be obtained as the patient enters the organization and before certain procedures or treatments for which the risk is high. The consent process is clearly defined by the organization in policies and procedures. Relevant laws and regulations are incorporated into the policies and procedures. 2. Patients and families are informed as to what tests, procedures, and treatments require consent and how they can give consent (for example, verbally, by signing a consent form or through some other means). Patients and families understand who may, in addition to the patient, give consent. Designated staff members are trained to inform patients and obtain and document patient consent.
	How the standards will be identified ˜ Document Review General consent form
	Coding Scoring Criteria
	Score 0 (NM)	There is no generalized consent form.
	Score 1 MM)	There is a generalized consent with the wrong scope There Is a generalized consent form with the proper scope and is not properly filled as per the related policy but is clearly filled
	Score 2 (PM)	There is a generalized consent with the proper scope and is properly filled but not clear as per the related policy
	Score 3 (FM)	There is a generalized consent with the proper scope and is properly and clearly filled as per the related policy
	Teaching Tool(s)
	Sample Document(s) Consent for General Treatment IPP Informed Consent
LD.17	The leadership supports and oversees the patient complaint process by: LD.17.1 Assigning responsibility for receiving, resolving and aggregating data related to patient complaints. LD.17.2 Taking quality improvement and strategic actions based on monthly, quarterly and annual trended report data.
	Why we have this standard \B7 Patients have a right to voice complaints about their care and to have those complaints reviewed and, when possible, resolved. Also, decisions regarding care sometimes present questions, conflicts, or other dilemmas for the organization and the patient, family, or other decision makers. \B7 These dilemmas may arise from issues of access, treatment, or discharge. They can be especially difficult to resolve when the issue involve, for example, withholding resuscitative services or forgoing or withdrawing life-sustaining treatment. \B7 The organization has established processes for seeking resolution of such dilemmas and complaints. The organization identifies in policies and procedures those who need to be involved in the processes and how the patient and family participate.
	How the standards will be identified ˜ Document Review
	Coding Scoring Criteria
	Score 0 (NM)	There is no Patient Complaint Committee or other effective process to handle patient complaints.
	Score 1 MM)	There is a process but not implemented
	Score 2 (PM)	There is a process that is implemented but no evidence of complaint resolution
	Score 3 (FM)	There is a process that is implemented and there is evidence of quality improvement actions based on complaints analysis
	Teaching Tool(s)
	Sample Document(s) Data Confidentiality Problem Resolution Procedure Patient Complaint/Comment/Compliment Form Patient Complaints Form Patient Complaints Form 1 IPP Patients and Family Complaints
LD.18	The leadership supports patient education by: LD.18.1 Providing funding for patient education materials. LD.18.2 Ensuring the creation and implementation of a patient educational plan.
	Why we have this standard 1. The organization chooses how it organizes its educational resources in an efficient and effective manner. Thus, organizations may choose to appoint an education coordinator or an education committee, create an education service, or 2. Simply work with all staff to provide education in a coordinated manner.
	How the standards will be identified ˜ Document Review Patient education materials, patient education form (tracking) ˜ Interview ˜ Observation
	Coding Scoring Criteria
	Score 0 (NM)	There is no evidence of a patient education program (e.g. patient education materials or educational activities).
	Score 1 MM)	There are minimal patient educational materials and no evidence of staff education.
	Score 2 (PM)	There are some patient educational materials on greater than 50% of the units. There is some evidence of educational sessions for staff on aspects of patient education.
	Score 3 (FM)	There is evidence of a patient education program. There are patient education materials appropriate to the populations cared for available on nursing units and clinics. There are educational sessions for staff on aspects of patient education. There is documentation in the medical record that patient education occurs.
	Teaching Tool(s) How to Write an Education Plan Template Patient Education Patient Education Continuum Patient Education Continuum 2 Patient Teaching Plan
	Sample Document(s) Education Plan
LD.19	The leadership develops a professional code of conduct for all employees which describes the hospital\92s expectations of the staff regarding their behavior and communication with each other and with their patients.
	Why we have this standard The Code of Conduct is supplementary to the hospital's values. To ensure commitment to the, Saudi rules and regulations and cultural obligations and responsible conduct of its employees. The code of conduct provides guidance to ensure that hospital's business is conducted in an ethical and legal manner, and to stress the hospital's ethical responsibility to the patients and community it serves.
	How the standards will be identified ˜ Document Review Professional code of conduct
	Coding Scoring Criteria
	Score 0 (NM)	There is no written professional code of conduct for all employees.
	Score 1 MM)	There is a written professional code of conduct for all employees but only 2 out of 10 (20%) interviewed employees are aware of it
	Score 2 (PM)	There is a written professional code of conduct for all employees but only 4 out of 10 (40%) interviewed employees are aware of it
	Score 3 (FM)	There is a written professional code of conduct for all employees and employees are aware of it
	Teaching Tool(s)
	Sample Document(s) IPP \96 Code of Conduct IPP - Employee Conduct Resolution of Employee Disputes
LD.20	Facility general policies include policies that address methods of resolution for conflict between staff.
	Why we have this standard To provide for a systematic approach to resolve conflicts that may arise in the care of a patient in order to ensure optimum care to patients.
	How the standards will be identified ˜ Document Review ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There are no policies that address LD.20.
	Score 1 MM)	There is at least one policy that addresses LD.20.
	Score 2 (PM)	There are policies which address LD.20; however, there is no full implementation.
	Score 3 (FM)	There are policies which address LD.20 and there is full implementation.
	Teaching Tool(s)
	Sample Document(s) Resolution of Employee Disputes
LD.21	The leadership supports the Infection Control program by implementing recommendations made by the Infection Control committee and the Infection Control Director.
	Why we have this standard For an infection prevention and control program to be effective, it must be comprehensive, encompassing both patient care and employee health. The program addresses the infection issues that are epidemiologically important to the organization. In addition, the program is appropriate to the organization\92s size and geographic location, services, and patients.
	How the standards will be identified ˜ Document Review Infection control minutes l Recommendations
	Coding Scoring Criteria
	Score 0 (NM)	There is no evidence that the leadership implemented any recommendations made by the Infection control minutes.
	Score 1 MM)	N/A
	Score 2 (PM)	N/A
	Score 3 (FM)	There is evidence that the leadership implemented recommendations made by the Infection control committee.
	Teaching Tool(s)
	Sample Document(s)
LD.22	The leadership ensures that Staff Health Clinic implements the following processes to avoid the transmission of infection by: LD.22.1 Performing the necessary investigations following needle stick or sharps injury and this data is collected for trending and reported at the Safety committee and Infection control committee. LD.22.2 Conducting pre-employment physicals on every staff member as required by the Ministry of Health (e.g., Hepatitis screen & etc.). LD.22.3 Ensuring that all staff can have an appropriate immunization and protection in the various work areas. LD.22.4 Maintaining a current file on each hospital employee with the required immunization record.
	Why we have this standard 1. Employee health is also included to ensure that employees are screened and do not pose a safety risk caring for patients. 2. Some of the forms an infection control program can take care: committee structure, or designated staff with defined roles, responsibilities and a centralized reporting method with leadership support.
	How the standards will be identified ˜ Document Review Policy investigations following needle stick/sharps injury, pre-employment physical form (MOH), document recommended immunization/protection ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There is no evidence of Staff Health\92s compliance with LD.22.1 \96 LD.22.4.
	Score 1 MM)	There is evidence of Staff Health\92s compliance with 2 out of 4 of the LD.22.1 \96 LD.22.4.
	Score 2 (PM)	There is evidence of Staff Health\92s compliance with 3 out of LD.22.1 \96 LD.22.4.
	Score 3 (FM)	There is evidence of Staff Health\92s compliance with LD.22.1 \96 LD.22.4.
	Teaching Tool(s) How To Conduct Root Cause Analysis
	Sample Document(s)
LD.23	The hospital has a Finance Director who is qualified by experience and education (A Bachelor\92s degree in Finance with (2) years experience is preferred).
	Why we have this standard To ensure the qualification of the leadership taking the responsibility of the budgeting planning and financial management process in the hospital
	How the standards will be identified ˜ Document Review Job descriptions matched with personnel file
	Coding Scoring Criteria
	Score 0 (NM)	There is no Finance Director.
	Score 1 MM)	There is a Finance Director who may not have a Bachelor\92s degree in finance or accounting but has at least 3-5 years experience in the field of accounting or other equivalent education.
	Score 2 (PM)	There is a Finance Director who may not have a Bachelor\92s degree with experience in the field of accounting or other equivalent education.
	Score 3 (FM)	There is a Finance Director who has a Bachelor\92s degree and experience in accounting equivalent education.
	Teaching Tool(s)
	Sample Document(s) JD - Director Finance & Accounting Services
LD.24	The hospital has documents that provide evidence of a capital and operating budget process that addresses the manpower plan, consumable and capital assets resources and assigns resources to all patient care units based on the scope of care and complexity of patient needs.
	Why we have this standard 1. To institute uniform procedures in the management and control of funds made available; 2. To the Hospital Corporation, by providing specific; 3. Guidelines and procedures for the proper handling, recording, accounting and monitoring of the funds; and 4. Shows the overview of the overall accounting system of the Hospital which includes the flow and accumulation of financial data, the conversion of the data into financial information, the source documents as well as its summarizing reports and the books of original and final entries including the subsidiary ledgers.
	How the standards will be identified ˜ Document Review Capital operating budget
	Coding Scoring Criteria
	Score 0 (NM)	There are no documents for capital or operating budget of the hospital.
	Score 1 MM)	There is a budget process that but is not consistent with the scope of service but not linked to the strategic plan
	Score 2 (PM)	There is a budget process that is consistent with the scope of service but not linked to the strategic plan
	Score 3 (FM)	There is evidence of a capital and operating budget process that linked to scope of service and strategic plan
	Teaching Tool(s) Capital and Operating Budget
	Sample Document(s) Signing Authority Policy Signature Authority: Major Capital Purchases Capital Equipment Questionnaire
LD.25	Members of the leadership group work collaboratively to provide quality care by: LD.25.1 Problem solving, planning together and documenting these meetings. LD.25.2 Collaborating with each other to develop policies. LD.25.3 Collaborating with each other to develop budgets.
	Why we have this standard Because they are responsible for governance approve the policies and plans to operate the organization.
	How the standards will be identified ˜ Document Review Leadership minutes, signatures on polices by leadership, signatures on budgets or meeting minutes ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There are no documented meetings by the leadership for compliance to LD.25.1, LD.25.2, LD.25.3.
	Score 1 MM)	There is some written evidence of compliance with documented meetings to LD.25.1 - LD.25.3 but no minutes.
	Score 2 (PM)	There are infrequent documented meeting minutes by the leadership every 3-4 four months for LD.25.1, LD.25.2, LD.25.3.
	Score 3 (FM)	There are documented meeting minutes, memos, etc. by the leadership that occur on a regular basis (every 2 months for one of the aspects of LD.25.1, LD.25.2, LD.25.3).
	Teaching Tool(s)
	Sample Document(s)
LD.26	All department heads have a comprehensive departmental manual that is available to staff and includes the following: LD.26.1 A mission, vision, values, and scope of service consistent with the hospital\92s mission. LD.26.2 An organizational chart. LD.26.3 Policies and procedures for staff members to implement that are current and clearly written.
	Why we have this standard To define the scope of department and delineate the areas of service provided.
	How the standards will be identified ˜ Document Review Departmental manuals, how to write IPPs with format ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	Less than 20% of the sampled units have departmental manuals.
	Score 1 MM)	At least 20% and less than 50% of the units have comprehensive departmental manuals LD.26.1- LD.26.3.
	Score 2 (PM)	At least 50% and less than 80% of the units sampled have comprehensive departmental manuals LD.26.1- LD.26.3.
	Score 3 (FM)	80% or more of the units sampled have comprehensive departmental manuals LD.26.1- LD.26.3.
	Teaching Tool(s) Mission Statement Mission, Vision, Values Statement Scope of Service
	Sample Document(s)
LD.27	All departmental manuals are reviewed every (2) years and revised as needed.
	Why we have this standard To ensure the consistency of improvement through the department.
	How the standards will be identified ˜ Document Review ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	Less than 20% of departmental manuals sampled are revised at least every 2 years (as appropriate).
	Score 1 MM)	At least 20% and less than 50% of the departmental manuals sampled are revised at least every two (2) years.
	Score 2 (PM)	At least 50% and less than 80% of the departmental manuals sampled are revised at least every two (2) years.
	Score 3 (FM)	80% or more of the departmental manuals sampled are revised at least every two (2) years (as appropriate).
	Teaching Tool(s)
	Sample Document(s)
LD.28	A policy on how policies are created, approved, revised, composed, and terminated is available.
	Why we have this standard To provide definitions of working documents used in delivery and support of care. To set guidelines for developing the Hospital policies and procedures, approval, distribution, review, revision, and to provide the formats or frameworks used in administrative and patient care policies and procedures.
	How the standards will be identified ˜ Document Review Policy ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There is no policy.
	Score 1 MM)	There is a policy but only less than 25% of staff interviewed responded correctly.
	Score 2 (PM)	There is a policy but only less than 50% of staff interviewed responded correctly.
	Score 3 (FM)	There is a policy and more than 80% of staff interviewed responded correctly.
	Teaching Tool(s) Signature Sheet for Policy & Procedure Approval
	Sample Document(s) IPP \96 Policy & Procedure Format
LD.29	The leadership supports the Hospital wide Safety plan by providing the necessary resources as identified by the Safety officer and the Safety committee in order to minimize risk to patients and staff.
	Why we have this standard A facility management and safety program, in a large or small organization, requires the assignment of one or more individuals to provide leadership and oversight. Whatever the assignment, all aspects of the program must be managed effectively and in a consistent and continuous manner. Program oversight includes: \B7 planning all aspects of the program; \B7 implementing the program; \B7 educating staff; \B7 testing and monitoring the program; and \B7 periodically reviewing and revising the program.
	How the standards will be identified ˜ Document ReviewSafety committee minutes ˜ Observation
	Coding Scoring Criteria
	Score 0 (NM)	There is no evidence that the leadership provided the necessary resources identified by the Safety officer and the Safety committee.
	Score 1 MM)	N/A
	Score 2 (PM)	N/A
	Score 3 (FM)	On the facility tour and review of the committee minutes, there is evidence that the leadership provided the necessary resources identified by the Safety Officer and the Safety committee.
	Teaching Tool(s) Hospital Safety Committee FO
	Sample Document(s)
LD.30	The Hospital Director and/or his designee implements the \93No Smoking\94 policy by: LD.30.1 Monitoring all areas within the hospital for compliance to the no-smoking rule. LD.30.2 Disciplining staff who do not adhere to the policy.
	Why we have this standard To set forth the policy mandating Hospital a \93Smoke Free\94 Facility. Through establishment the concept that the smoking is a fire hazard and environmental contaminant. And to make all precautions to have a free smoking environment.
	How the standards will be identified ˜ Document Review No smoking policy ˜ Observation
	Coding Scoring Criteria
	Score 0 (NM)	There is no hospital policy that addresses No Smoking.
	Score 1 MM)	There is a hospital policy that addresses No Smoking but there is no evidence of any monitoring of the policy for compliance by staff.
	Score 2 (PM)	There is a hospital policy that addresses No Smoking and there is evidence of monitoring; however, there is evidence that staff still smoke in areas of the hospital from the facility tour.
	Score 3 (FM)	There is a hospital policy that addresses No Smoking and there is evidence of monitoring the policy and no evidence of staff smoking in any area of the hospital.
	Teaching Tool(s)
	Sample Document(s) IPP \96 No Smoking
LD.31	The hospital has a Hospital-wide disaster plan that includes: LD.31.1 Response to both internal and external disaster. LD.31.2 A description of the roles of every employee in the organization.
	Why we have this standard Community emergencies, epidemics, and disasters may directly involve the organization, such as damage to patient care areas as a result of an earthquake, or flu that keeps staff from coming to work. To respond effectively, the organization develops a plan and tests it. The plan provides processes for \B7 alternate care sites if needed; and \B7 alternate sources of medical supplies, communications equipment, and other materials.
	How the standards will be identified ˜ Document Review Disaster plan (Internal + External)
	Coding Scoring Criteria
	Score 0 (NM)	There is no Hospital wide disaster plan.
	Score 1 MM)	There is a hospital wide disaster plan but only addresses external disaster.
	Score 2 (PM)	There is a hospital wide disaster plan which addresses both internal and external disaster but it does not include the role of the employees
	Score 3 (FM)	There is a hospital wide disaster plan that addresses both internal and external disaster and the role of the employees.
	Teaching Tool(s) Development of Models for Emergency Preparedness Hospital Emergency Incident Command System
	Sample Document(s) Disaster Plan Forms Hospital Emergency Management Plan Emergency Disaster Preparedness Plan
LD.32	The leadership supports the implementation of the disaster plan by: LD.32.1 Planning, implementing evaluating disaster drills. (no less than annually) LD.32.2 Making improvements in disaster readiness based on results of disaster drills.
	Why we have this standard The organization plans its response to likely community emergencies, epidemics, and natural or other disasters. 1. The organization participates in community-wide disaster planning. 2. The organization tests its plan once a year when designated as a receiving site. 3. The organization has the supplies to carry out its plan
	How the standards will be identified ˜ Document Review Disaster drills (forms + results)
	Coding Scoring Criteria
	Score 0 (NM)	There are no documented disaster drills.
	Score 1 MM)	There is a disaster drill with poor documentation and/or occurring greater than on an annual basis.
	Score 2 (PM)	There is an annual disaster drill but there is no evidence of implementation of recommendations for improvement.
	Score 3 (FM)	There is an annual disaster drill and the results are documented with an action plan that is implemented for improvement.
	Teaching Tool(s)
	Sample Document(s) Disaster Evaluation Forms 1 Disaster Evaluation Forms 2
LD.33	The hospital has the following effective communication systems for contacting essential personnel in emergencies: LD.33.1 An overall paging system that is fully functional and is used for calling for help in case of emergencies. LD.33.2 Bleeps for all physicians and other staff as necessary. LD.33.3 Mobile telephones on the ambulances.
	Why we have this standard The leadership support the effective communication systems by support (buying, approve, attend)
	How the standards will be identified ˜ Observation
	Coding Scoring Criteria
	Score 0 (NM)	There are no essential communication systems (overhead paging system, bleeps, or mobile phones for the ambulances.
	Score 1 MM)	There is an overhead paging system but there are no bleeps for physicians and/or no mobile phones for the ambulances.
	Score 2 (PM)	There is an overhead paging system, bleeps for some physicians, and no mobile phones for the ambulances.
	Score 3 (FM)	There is an overhead paging system, bleeps for physicians, and mobile phones for all ambulances.
	Teaching Tool(s)
	Sample Document(s)
LD.34	The hospital has essential signs in the hospital that are clearly marked and in appropriate designated places. LD.34.1 Handicap access signs. LD.34.2 All fire exits (at least (1) one emergency exit sign is visible from any point in the facility). LD.34.3 Fire hydrants/fire extinguisher locations. LD.34.4 No entry signs where needed. LD.34.5 Hazardous material areas. LD.34.6 Directional signs to assist customers and staff find designated locations.
	Why we have this standard To facilitate the patient care and safety process.
	How the standards will be identified ˜ Observation ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There are no essential signs in the hospital.
	Score 1 MM)	There are 2 of the essential signs in the hospital (LD.34.1 \96 LD.34.6) and there is a written plan to obtain more as outlined in LD.34.1- LD.34.6.
	Score 2 (PM)	There are 4 of the essential signs in the hospital (LD.34.1 \96 LD.34.6) and there is a written plan to obtain more as outlined in LD.34.1- LD.34.6.
	Score 3 (FM)	The hospital has all of the essential signs (LD.34.1- LD.34.6).
	Teaching Tool(s)
	Sample Document(s)
LD.35	The leadership supports the hospital-wide Quality Management & Patient Safety plan by: LD.35.1 Providing the necessary resources for the Quality Management department. LD.35.2 Actively participating in Quality Improvement projects. LD.35.3 Implementing the recommendations made by the QI committee (when feasible).
	Why we have this standard This plan exists to build organizational excellence in patient care, education, and research. The focus is on patients, customers and involvement of staff. The Quality Management Plan is a system wide initiative pertinent to Hospital. The plan defines the aspects for identifying and managing all types of occurrences ranging from Near Misses to Sentinel Events. The plan will support analysis of the events and current trends in the literature, including Sentinel Event system to proactively assess risk in current processes and with consideration given to Safety on all new services and process design/redesign.
	How the standards will be identified ˜ Document Review QI committee minutes, QPS plan, QI team\92s membership for leadership involvement ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There is no QI department and the leadership does not participate in QI projects.
	Score 1 MM)	There is a QI department but the department lacks the necessary resources to accomplish its mission.
	Score 2 (PM)	There is a QI department and the department has the necessary resources; however, the leadership either does not participate in QI projects or does not implement the recommendations from the QI committee.
	Score 3 (FM)	There is a QI department, the department has enough resources to support its mission, the leadership participates in QI projects by either being a member or by assigning staff to participate and the leadership does implement recommendations made by the QI committee as evidenced by committee minutes and interview.
	Teaching Tool(s) The PDCA Improvement Process Patient Safety Plan Sample Plan: Patient Safety Culture Survey
	Sample Document(s) Patient Safety Plan Indicator and PDCA Worksheet Organizational QI Plan PDCA Application Form Quality Management Plan Safety Assessment Code (SAC)
LD.36	The leadership has basic knowledge of Quality Management concepts and this includes: LD.36.1 How to analyze data. LD.36.2 How to use an improvement cycle (PDCA) or other method to make improvements. LD.36.3 How to work in teams. LD.36.4 How to perform root cause analysis.
	Why we have this standard To accomplished the philosophy of Total Quality Management, Patient safety and the application of quality improvement processes, tools, and methodology (FOCUS PDCA). Allows us to meet the organization\92s mission, vision, values, and goals. The QMPS plan outlined in this document provides further delineation of activities.
	How the standards will be identified ˜ Document Review Educational sessions for leadership, PDCA, analyzing data, RCA, teams information ˜ Interview ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	The leadership has no knowledge of LD.36.1 \96 LD.36.4.
	Score 1 MM)	Less than 50% of the sampled leadership has led teams but lacks QI knowledge LD.36.1 \96 LD.36.4.
	Score 2 (PM)	More than 50% of the leadership has some QI knowledge (e.g. how to work in a team, PDCA cycle, RCA and/or analysis of data but the knowledge is weak in one or more of the areas.
	Score 3 (FM)	Most of the leadership sampled has some knowledge of QI (e.g. how to work in a team, PDCA cycle, RCA, and analysis of data and is actively seeking more knowledge (plan to attend workshops, read, etc).
	Teaching Tool(s) RCA Workbook
	Sample Document(s) Team Building in Medical Practice Setting Root Cause Analysis Outline IPP: Conducting Root Cause Analysis
LD.37	The leadership supports the Hospital-wide information plan by: LD.37.1 Participating in defining the terminology related to management of information including data, information, aggregated data, correlated data, confidentiality, integrity and security. LD.37.2 Approving the Hospital wide Management of Information (MOI) plan. LD.37.3 Providing the necessary resources to implement the hospital wide information plan.
	Why we have this standard \B7 There must be a strategic plan for the management of information based on the information needs related to the mission, scope of service, and internal and external customer. \B7 Information is generated and used during patient care and for managing a safe and effective organization. The ability to capture and provide information requires effective planning. Planning incorporates input from a variety of sources. o The care providers; o The organization\92s managers and leaders; and o Those outside the organization who need or require data or information about the organization\92s operation and care processes. \B7 The priority information needs of these sources influence the organization\92s information management strategies and ability to implement those strategies. The strategies are appropriate for the organization\92s size, complexity of services, availability of trained staff and other human and technical resources. The plan is comprehensive and includes all the departments and services of the organization.
	How the standards will be identified ˜ Document Review Information plan
	Coding Scoring Criteria
	Score 0 (NM)	There is no information plan for the hospital. and no proof of elements LD 37.1-37.3
	Score 1 MM)	There is a hospital information plan and proof of elements LD 37.1-37.3
	Score 2 (PM)	There is a hospital information plan and proof of only 2 of elements LD 37.1-37.3
	Score 3 (FM)	There is a hospital information plan There is proof of elements LD 37.1-37.3
	Teaching Tool(s)
	Sample Document(s) Management of Information Plan
LD.38	The hospital has an effective process for handling professional communication (vertical and horizontal) among hospital staff and that supports professional communication by: LD.38.1 Documented staff meetings. LD.38.2 Policy and procedure development. LD.38.3 Hospital newsletters.
	Why we have this standard To coordinate and integrate patient care, the leaders develop a culture that emphasizes cooperation and communication. The leaders develop formal (for example, standing committees, joint teams) and informal (for example, newsletters, posters) methods for promoting communication among services, and individual staff members. Coordination of clinical services comes from an understanding of each department\92s mission and services of each department and collaboration in developing common policies and procedures.
	How the standards will be identified ˜ Document Review Staff meeting minutes ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There are no documented department meetings with staff.
	Score 1 MM)	Less than 50% of the sampled departments hold regular meetings with their staff that are documented.
	Score 2 (PM)	At least 50% and less than 80% of the sampled department hold regular meetings with their staff that are documented.
	Score 3 (FM)	80% or more of the sampled department hold regular meetings with their staff that are documented.
	Teaching Tool(s) Communications Plan
	Sample Document(s)
LD.39	The hospital has a policy that outlines the roles and responsibilities for handling all incoming requests from outside agencies (other hospitals and government) in a timely manner and this includes but is not limited to: LD. 39.1 Medico-legal cases. LD. 39.2 Receiving patients from other hospitals. LD. 39.3 Providing any services for outside hospitals. LD. 39.4 Participation with community events. LD. 39.5 Requests for reports from government agencies.
	Why we have this standard As patients move through a health care organization from entry to discharge or transfer, several departments and services and many different health care providers may be involved in providing care. Throughout all phases of care, patient needs are matched with appropriate resources in and, when necessary, outside the organization. This is usually accomplished by using established criteria or policies that determine the appropriateness of transfers within the organization.
	How the standards will be identified ˜ Document Review Policy handling requests from outside agencies
	Coding Scoring Criteria
	Score 0 (NM)	The hospital does not have a policy for handling outside requests (LD.39.1 \96 LD.39.5).
	Score 1 MM)	The hospital has a policy for handling outside requests but it includes only 2 elements of LD.39.1 \96 LD.39.5.
	Score 2 (PM)	The hospital has a policy for handling outside requests but it includes only 3 elements of LD.39.1 \96 LD.39.5.
	Score 3 (FM)	The hospital has a policy that covers all of the elements in LD.39.1 \96 LD.39.5.
	Teaching Tool(s)
	Sample Document(s)
LD.40	The hospital has the essential administrative policies and procedures that are reviewed and updated every (2) years, that includes but are not limited to: LD. 40.1 Sentinel event. LD. 40.2 Incident report or occurrence, variance report (OVR). LD. 40.3 Medico-legal cases. LD. 40.4 Child Abuse. LD. 40.5 Patient rights. LD. 40.6 Code of conduct for staff. LD. 40.7 Informed consent. LD. 40.8 Conscious sedation. LD. 40.9 No code or don\92t resuscitate policy. LD. 40.10 Dress code. LD. 40.11 Admission, transfer and discharge. LD. 40.12 Transfer to another facility. LD. 40.13 Handling, use and administration of blood and blood products.
	Why we have this standard The organization\92s governance structure is described in written documents.
	How the standards will be identified ˜ Document Review Policies on LD.40.1 \96 40.13
	Coding Scoring Criteria
	Score 0 (NM)	The hospital has less than 25% of the essential Administrative policies.
	Score 1 MM)	The hospital has at least 25% and less than 50% of the essential Administrative policies.
	Score 2 (PM)	The hospital has at least 50% and less than 80% of the essential Administrative policies.
	Score 3 (FM)	The hospital has 80% or more of the essential Administrative policies.
	Teaching Tool(s) The Root Cause Analysis in Response to a Sentinel Event
	Sample Document(s) Informed Consent for Surgical Operations IPP: Informed Consent OVA Form Form - Refusal Of Treatment & Discharge AMA Form: Signature Approvals (DNR) Signature Sheet for Policy and Procedure TQM - Incident Reporting Form Sentinel or High Risk Events & RCA Occurrence Variance Reporting IPP: Identification of Abuse, Neglect, and Exploitation IPP: Code of Conduct IPP: Informed Consent Form: Consent for Termination of Pregnancy Form: Consent for Take Photographs Form: Consent for Invasive Procedure APP: Conscious Sedation for Diagnostic and Surgical Procedures IPP: Do Not Resuscitate (DNR) Code Status Doctors Order Form IPP: Admission to Hospital Protocol Day Surgery Sample Discharge Criteria Policy Management of Transfer to Hospital
LD.41	The hospital has a Human Resource Director qualified by appropriate experience and education.
	Why we have this standard The Qualified Human Resources Director and staff are responsible for recruitment, position classification, wage and salary administration, employee relations, training, employee records, staff benefits, and related Human Resources functions and programs of the hospital.
	How the standards will be identified ˜ Document Review Job description matched with personnel file
	Coding Scoring Criteria
	Score 0 (NM)	There is no Human Resource Director.
	Score 1 MM)	There is a Human Resource Director who does not have a Bachelor\92s degree nor experience in the field for -5 years
	Score 2 (PM)	There is a Human Resource Director who does not have a Bachelor\92s degree but has experience in the field for -5 years
	Score 3 (FM)	There is a Human Resource Director who has a Bachelor\92s degree and more than 3 years experience.
	Teaching Tool(s)
	Sample Document(s) Job Description Template Director Human Resources \96 Job Description
LD.42	The hospital has a Human Resource department or unit that is well staffed and equipped according to the size of the hospital.
	Why we have this standard The Human Resources Department of the hospital to serve the best interests of employees. The Human Resources Division is responsible for the administration of all Human Resources policies of the hospital.
	How the standards will be identified ˜ Observation
	Coding Scoring Criteria
	Score 0 (NM)	There is no Human Resource department or unit.
	Score 1 MM)	There is a Human Resource unit that is not well equipped or well staffed
	Score 2 (PM)	There is a Human Resource department that is either well staffed or well equipped.
	Score 3 (FM)	There is a Human Resource department that is well staffed and well equipped.
	Teaching Tool(s)
	Sample Document(s)
LD.43	The hospital has a Human Resource \93Employee\92\92 manual that is given to all new employees during hospital orientation.
	Why we have this standard 1. The employee handbook represents working relationship, and it is important for each employee to understand his/her role as a member of the hospital. This handbook will explain the policies, regulations, pay, and benefits that apply to classified employees. 2. Orientation of new employees are requested to review and complete the New Employee Orientation. 3. The hospital 's mission and purpose; services available to employees; and also provides new employees the opportunity to review hospital policies and select benefits prior to their required employment payroll processing. New employees are required to attend a payroll session, and some of various hospital policies and benefits. 4. In addition to the initial orientation, the supervisor will assist the employee in learning about s/he job, and will explain any departmental policies, special procedures, techniques or processes required in the performance of the duties.
	How the standards will be identified ˜ Document Review Human resource manual (Staff complaints/dissatisfaction)
	Coding Scoring Criteria
	Score 0 (NM)	There is no Human Resource employee manual.
	Score 1 MM)	There is a Human Resource manual but does not include how to handle staff complaints or concerns but is not given to employees during orientation
	Score 2 (PM)	There is a Human Resource manual that is given to employees during orientation but does not include how to handle staff complaints or concerns.
	Score 3 (FM)	There is a Human Resource employee manual that includes how to handle staff complaints or concerns and is given to employees during orientation
	Teaching Tool(s)
	Sample Document(s) Promotional Opportunities Employee Handbook 1 Employee Handbook 2 Employee Handbook 3 Employee Handbook 4
LD.44	The Human Resource \91\92Employee\92\92 manual has a policy for handling staff complaints and/or dissatisfaction.
	Why we have this standard The employee handbook represents working relationship, and it is important for each employee to understand his/her role as a member of the hospital. This handbook will explain the policies, regulations, pay, and benefits that apply to classified employees.
	How the standards will be identified ˜ Document Review ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There is no policy in the human resource employee manual that addresses handling staff complaints or dissatisfaction.
	Score 1 MM)	N/A
	Score 2 (PM)	There is a policy in the human resource manual that addresses handling staff complaints or dissatisfaction and it is not fully implemented
	Score 3 (FM)	There is a policy in the human resource manual that addresses handling staff complaints or dissatisfaction and it is fully implemented.
	Teaching Tool(s)
	Sample Document(s) Complaints Resolution Program
LD.45	The department of Human Resources has a program for recruitment, retention, and development of staff.
	Why we have this standard The Human Resources Department (HRD) function includes a variety of activities, and key among them is deciding what staffing needs you have and whether to use independent contractors or hire employees to fill these needs, recruiting and training the best employees, ensuring they are high performers, dealing with performance issues, and ensuring the personnel and management practices conform to various regulations. Activities also include managing hospital approach to employee benefits and compensation, employee records and personnel policies.
	How the standards will be identified ˜ Document Review Recruitment, retention, development of staff
	Coding Scoring Criteria
	Score 0 (NM)	There is no program for recruitment, retention, and development of staff.
	Score 1 MM)	There is a program for recruitment but no program for retention or development of staff.
	Score 2 (PM)	There is a program for recruitment and development of staff but no program for retention of staff.
	Score 3 (FM)	There is a program for recruitment, retention and development of staff.
	Teaching Tool(s)
	Sample Document(s)
LD.46	The hospital has a policy that requires all categories of staff to have clearly written job descriptions that are reviewed and revised as needed at least every (3) years and: LD.46.1 The job description is used when selecting employees for hire, internal promotions, and transfer. LD.46.2 The job description outlines the necessary knowledge, skills, and attitude to perform the role. LD.46.3 The job description is provided to every employee on hiring and is located in every employee\92s personnel file and departmental manual. LD.46.4 All job descriptions follow a prescribed format. LD.46.5 All job descriptions are competency based
	Why we have this standard Every hospital has to have job description policy which include that the Job descriptions for each department are updated as needed to reflect staffing shortfalls or business needs. Current descriptions are found in the back of each hard cover Employee Manual. The hospital's intent for maintaining job descriptions is to have a floating guideline for each class of employee and for particular skilled positions.
	How the standards will be identified ˜ Document Review Job descriptions ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There is no policy and less than 25% of the positions sampled have written job descriptions. There is a policy less than 40% of the positions sampled have written job descriptions.
	Score 1 MM)	There is no a policy and less than 70% of the positions sampled have written job descriptions. There is a policy and less than 50% of the positions sampled have written job descriptions
	Score 2 (PM)	There is a policy and at least 50% and less than 80% of the positions sampled have written job descriptions.
	Score 3 (FM)	There is a policy more than 80% of the positions sampled have written job descriptions.
	Teaching Tool(s) Job Description Template
	Sample Document(s) Job Description Policy Competency/Performance Evaluation Job Description: Chief Safety Job Description: Clinical Dietitian 1 Job Description: Clinical Quality Review Analyst Job Description: Head of Medical Records Job Description: Head Nurse Job Description: Infection Control Practitioner Job Description: Supervisor \96 Social Work Job Description: Accountant Job Description: Admin Coordinator
LD.47	The organization has an effective process for gathering, verifying, and evaluating the credentials (license, education, training, and experience) of those medical staff permitted to provide patient care without supervision. LD.47.1 The organization maintains a record of the current professional license, certificate, or registration, when required by law, regulation, or by the organization, of every medical staff member.
	Why we have this standard A health care organization needs an appropriate variety of skilled, qualified people to fulfill its mission and meet patient needs. The organization\92s clinical and administrative leaders work together to identify the number and types of staff needed based on the recommendations from department and service directors. Recruiting, evaluating, and appointing staff are best accomplished through a coordinated, efficient, and uniform process. Recruiting, evaluating, and appointing staff are best accomplished through a coordinated, efficient, and uniform process. It is also essential to document applicant skills, knowledge, education, and previous work experience. It is particularly important to carefully review the credentials of medical and nursing staff because they are involved in clinical care processes and work directly with patients.
	How the standards will be identified ˜ Document Review Policy on SQE are verified ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There is no policy that outlines how staff qualifications and experience or skills are verified and there is no evidence of primary source verification in the personnel files.
	Score 1 MM)	N/A
	Score 2 (PM)	N/A
	Score 3 (FM)	There is a policy that outlines how staff qualifications and experience or skills are verified and there is evidence of primary source verification in the personnel files.
	Teaching Tool(s) Credentialing Policy
	Sample Document(s) Medical Credentialing, Privileging, and Promotions Employment Verification, References and Request for Information
LD.48	The hospital has a comprehensive mandatory general orientation that all new employees attend, and the content includes but is not limited to: LD.48.1 The hospital\92s mission, vision, values and organizational chart. LD.48.2 Staff role in disasters and emergencies. (i.e., Fire). LD.48.3 General information about hazardous materials including Material Safety Data Sheet (MSDS). LD.48.4 General information on Infection control and sharps disposal. LD.48.5 Electrical safety. LD.48.6 General information on communication devices: paging, telephone system, and bleeps. LD.48.7 General information on staff evaluation process. LD.48.8 The definition of Adverse events and Sentinel events along with the process of reporting including Who should report, When to report, How to report, and to Whom the report is routed. LD.48.9 The Policy on Abuse and Neglect of Children and Adults LD.48.10 Overview of Credentialing, Privileging and Competency policies. LD.48.11 General information about staff health clinic and its services. LD.48.12 General information about the cultural and social issues in the Kingdom. LD.48.13 General information about the quality and patient safety plan of the hospital and the importance of involvement of every member of staff. LD.48.14 Information on the expected ethical conduct of the staff and the expected professional communication in his/her interactions with others. LD.48.15 Information on protection of patient\92s rights, privacy and confidentiality.
	Why we have this standard Physicians, dentists, and others who are licensed to provide patient care without clinical supervision represent those primarily responsible for patient care and care outcomes. Applicable laws, regulations, and the organization identify those permitted to work independently. The organization is responsible for ensuring that these individuals are qualified to provide patient care without clinical supervision and for specifying the types of care they are permitted to provide in the organization. The organization needs to ensure that it has a qualified medical staff that appropriately matches its mission, resources, and patient needs. To ensure this match, the organization evaluates medical staff members\92 credentials at appointment to the staff. An individual\92s credentials consist of an appropriate current license, completion of medical education and any specialty education, and any additional training and experience. The organization develops a process to gather this information, verify its accuracy from the original source when possible, and evaluate it in relation to the need of the organization and its patients. This process can be carried out by the organization or by an external agency such as ministry of health in the case of public organizations. The process applies to all types and levels of staff (employed, honorary, contract, and private community staff members).
	How the standards will be identified ˜ Document Review LD.48.1 \96 LD.48.15 General orientation schedule
	Coding Scoring Criteria
	Score 0 (NM)	There is no hospital general orientation or there is no documentation of a general hospital orientation.
	Score 1 MM)	There is a general hospital orientation but the content contains less than 50% of the elements LD.48.1 \96 LD.48.15.
	Score 2 (PM)	There is a general hospital orientation and the content contains at least 50% and less than 80% of the elements LD.48.1 \96 LD.48.15.
	Score 3 (FM)	There is a general hospital orientation and the content contains 80% or more of the elements LD.48.1 \96 LD.48.15.
	Teaching Tool(s) Organization Structure Orientation Manual Training Needs Assessment Orientation Process Flowchart
	Sample Document(s) Organizational Chart Organizational Chart 3 Staff Orientation Completion Record (English) Staff Orientation Completion Record (Arabic) APP New Employee Orientation Orientation Agenda Orientation Database
LD.49	The hospital\92s general orientation is documented in each employee\92s personnel file.
	Why we have this standard Make sure orientation activities provide a means to test knowledge on the topics presented and that the orientation process is documented.
	How the standards will be identified ˜ Document Review General orientation in employee\92s personnel file ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There is no general orientation documented in the employee\92s file.
	Score 1 MM)	Of the sampled records, less than 50% contain any documentation of general orientation.
	Score 2 (PM)	Of the sampled records, at least 50% and less than 80% contain documentation of general orientation.
	Score 3 (FM)	Of the sampled records, 80% or more contain documentation of general orientation.
	Teaching Tool(s)
	Sample Document(s)
LD.50	All new employees receive a comprehensive departmental orientation conducted by the head of the department and/or designee as outlined by the departmental orientation policy that includes but is not limited to the following processes: LD.50.1 All new employees read the appropriate departmental policies and sign that they have read and understood them. LD.50.2 All new employees read their job description and sign that they have read and understood it. LD.50.3 All new employees receive an assessment of the knowledge, skills and attitude required of the employee to function successfully in his/her position. LD.50.4 All new employees receive education on the proper use of equipment including troubleshooting and reporting malfunctions. LD.50.5 All new employees receive more clarification as needed on all topics provided in the general orientation and this is signed by the employee and immediate supervisor. LD.50.6 Orientation for new employees are located in the employee\92s personnel file.
	Why we have this standard The orientation includes, as appropriate, the reporting of medical errors, infection control practices, the organization\92s policies on telephone medication orders, and so on. Contract workers and volunteer are also oriented to the organization and their specific assignment or responsibilities, such as patient safety and infection control. The organization has to: 1. Make sure all new staff members are oriented to the organization and his/her specific role in the organization. 2. Make sure contract workers are oriented to the organization, job responsibilities and their specific assignments. 3. Make sure any volunteers are oriented to the organization and their specific job responsibilities.
	How the standards will be identified ˜ Document Review Departmental orientation matched with personnel file (Policies signed by employees, job description signed by employee, checklist KSAs and equipment) ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	Of the sampled departments, less than 25% have any documented departmental orientation.
	Score 1 MM)	Of the sampled departments, the departmental orientations contained at least 25% and less than 50% of the elements.LD.50.1 \96 LD.50.6.
	Score 2 (PM)	Of the sampled departments, the departmental orientations contained at least 50% and less than 80% of the elements LD.50.1 \96 LD.50.6.
	Score 3 (FM)	Of the sampled departments, the departmental orientations contained 80% or more of the elements LD.50.1 \96 LD.50.6.
	Teaching Tool(s)
	Sample Document(s) New Employee and Transfer Checklist
LD.51	The leadership supports education for staff by granting financial support and/or time off for staff to attend educational activities.
	Why we have this standard 1. Staff must receive appropriate education and training to remain effective and the 2. Leadership must support this and provide the necessary resources. This is a patient safety issue. 3. Hospital must make sure there is adequate space, human and material resources for effective educational efforts.
	How the standards will be identified ˜ Document Review Attendance lists + Education Schedules ˜ Interview ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There are no documented educational activities for hospital staff.
	Score 1 MM)	There are minimal educational activities and no sponsorship for financial support for external educational events.
	Score 2 (PM)	There is evidence of educational activities that are well attended but do not occur on a regular basis. There is minimal or no sponsorship financially for external educational events.
	Score 3 (FM)	There is evidence of educational activities that are well attended on a regular basis and documented financial sponsorship for selected staff to attend external educational events.
	Teaching Tool(s)
	Sample Document(s)
LD.52	The hospital has an educational program (academic program) with an ongoing schedule of educational activities and training based on hospital need.
	Why we have this standard The hospital must use and assess the data when planning the hospital \91s ongoing educational program. This ensures that resources are used wisely and assists with staff receiving the right education. And the to make sure that the hospital designs the ongoing educational program for all staff based on needs.
	How the standards will be identified ˜ Document Review Academic program schedule
	Coding Scoring Criteria
	Score 0 (NM)	There is no academic program.
	Score 1 MM)	There is an academic program but it does not have regularly scheduled events and/or is not based on hospital need and or is not implemented
	Score 2 (PM)	There is an academic program that has a regular schedule and is based on hospital need and is not implemented
	Score 3 (FM)	There is an academic program that has a regular schedule and is based on hospital need and is implemented
	Teaching Tool(s) Education Plan
	Sample Document(s)
LD.53	Department heads recommend, implement and evaluate the necessary courses and skills to update and maintain staff\92s competence to provide care. This process is linked to performance improvement and documented in the employees file.
	Why we have this standard Staff must receive appropriate education and training to remain effective and competent and this should be documented in their file
	How the standards will be identified ˜ Interview ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	There are no written documents that department heads recommended any courses or skills to update staff competence to provide care and the process is linked to performance improvement
	Score 1 MM)	In 3 out of 10 files, there are written documents that department head\92s recommended courses to update their staff competence and the process is linked to performance improvement
	Score 2 (PM)	In 6 out of 10 files, there are written documents that department head\92s recommended courses to update their staff competence and the process is linked to performance improvement
	Score 3 (FM)	In 8 out of 10 files reviewed there are written documents that department head\92s recommended courses to update their staff competence. and the process is linked to performance improvement
	Teaching Tool(s)
	Sample Document(s) Staff Education Plan
LD.54	The leadership ensures that appropriate medical and nursing staff maintains current certification in BCLS, ACLS, NALS, and ATLS by: LD.54.1 Supporting all critical care physicians and nurses to maintain certification in BCLS, ACLS, and NALS as appropriate to the age groups. LD.54.2 Supporting all Internal Medicine physicians to maintain certification in BCLS and ACLS. LD.54.3 Supporting all surgical physicians to maintain certification in BCLS and ATLS. LD.54.4 Supporting all pediatric physicians to maintain certification in BCLS, NALS, PALS or appropriate to the age groups.
	Why we have this standard Staff who provide patient care must have resuscitative competencies evaluated at appointment and every 2 years afterwards. This is a patient safety issue.
	How the standards will be identified ˜ Document Review Policy (Who is required for BCLS, ACLS, PALS, ATLS), Educational records in personnel files ˜ Interview ˜ Sampling
	Coding Scoring Criteria
	Score 0 (NM)	Less than 25% of the sampled personnel records that physicians and nurses have appropriate certifications (LD.54.1 \96 LD.54.4).
	Score 1 MM)	At least 25% and less than 50% of the sampled personnel records demonstrate any evidence of appropriate certifications (LD.54.1 - LD.54.4).
	Score 2 (PM)	At least 50% and less than 80% of the sampled personnel records contain the appropriate certificates (LD.54.1 - LD.54.4).
	Score 3 (FM)	80% or more of the sampled personnel records contain appropriate certificates (LD.54.1 - LD.54.4).
	Teaching Tool(s)
	Sample Document(s)
LD.55	The needs identified for training and education are based on, as appropriate: LD.55.1. The hospital mission, vision, and values LD.55.2. The patient population served and the type and nature of care provided by the hospital and the department/service LD.55.3. Individual staff member\92s education and training needs LD.55.4. Information from quality assessment and improvement activities LD.55.5. Needs generated by advancements made in health care management and health care science and technology LD.55.6. Findings from department/service performance appraisals of individuals LD.55.7. Findings from review activities by peers, if appropriate LD.55.8. Findings from the organization\92s plant, technology, and safety management programs LD.55.9. Findings from infection control activities
	Why we have this standard The hospital\92s mission and scope of services guide the leadership to determine the types of training and education program needs.
	How the standards will be identified ˜ Document Review ˜ Interview
	Coding Scoring Criteria
	Score 0 (NM)	There are no policies which help to identify training and educational needs of staff
	Score 1 MM)	Less than 50% of the elements of LD.55.1 - LD.55.9 are present to help identify training and educational needs of staff
	Score 2 (PM)	Greater than 50% and less than 80% of the elements of LD.55.1 \96 LD.55.9 are present to help identify training and educational needs of staff or greater than 80% of the elements LD.55.1 \96 LD.55.9 are present and not fully implemented
	Score 3 (FM)	80% or greater of the elements of LD.55.1 \96 LD.55.9 are present and fully implemented to help identify the training and educational needs of staff.
	Teaching Tool(s) Education Needs Assessment
	Sample Document(s)
LD.56	The leadership has an effective process to evaluate staff within the probationary period of employment and this includes: LD.56.1 A policy that outlines the roles and responsibilities for evaluating staff during their probationary period. LD.56.2 Documentation in the employee\92s personnel file.
	Why we have this standard There must be standardized methods to evaluate the effectiveness of employees working in the hospital; at the time of appointment, then at defined times afterwards. There must be documentation contained in the personnel department that reflects this process for all staff. The hospital is repressible to have a process for evaluating staff during the probationary period, and afterwards is known by all supervisory staff.
	How the standards will be identified ˜ Document Review (Personnel files)
	Coding Scoring Criteria
	Score 0 (NM)	There is no policy that outlines the roles and responsibilities for evaluating staff during their probationary period
	Score 1 MM)	There is a policy that outlines the roles and responsibilities for evaluating staff during their probationary period and less than 50% of the sampled files contain documentation
	Score 2 (PM)	There is a policy that outlines the roles and responsibilities for evaluating staff during their probationary period and greater than 50% and less than 80% of the sampled files contain documentation
	Score 3 (FM)	There is a policy that outlines the roles and responsibilities for evaluating staff during their probationary period and greater than 80% of the sampled files contain documentation
	Teaching Tool(s)
	Sample Document(s) Form: Probationary Assessment Form: Employee Self-Assessment
LD.57	The leadership has an effective process to evaluate staff at least annually and this includes: LD.57.1 A policy that outlines the roles and responsibilities for evaluating staff at least annually. LD.57.2 A comprehensive evaluation form that covers all aspects of expected performance levels as outlined in his/her job description (e.g. competence, attitude, etc). LD.57.3 Documentation in the employee\92s personnel file. LD.57.4 All staff reading and signing their evaluation.
	Why we have this standard The organization defines the process for and the frequency of the ongoing evaluation of staff abilities. Ongoing evaluation ensures that training occurs when needed and that the staff member is able to assume new or changed responsibilities. While such evaluation is best carried out in an ongoing manner, there is at least one documented evaluation each year for each staff member. Each staff member in the organization has a record with information about his or her qualifications, results of evaluations, and work history. These records are standardized and kept current.
	How the standards will be identified ˜