آخـر مواضيع الملتقى
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معايير الإدارة التي تقييم بالمشاهدة
معايير الإدارة التي تقييم بالمشاهدة
LD.2.PT3 The organization chart is posted in different areas in the hospital
LD.7.PT2 Hospital mission, vision and values statement is publicly posted
LD.15.PT4 Patient and Family rights statement posted in all patient care areas
LD.16.PT2 Availability of General consent form for treatment
LD.18.PT2 Availability of Patient education materials in patient care units
LD.26.PT2 Availability of Comprehensive departmental manuals to staff
LD.29.PT1 Evidence of resource allocation by the leadership for patient and staff safety
LD.30.PT2 Evidence of compliance with no smoking policy
LD.33.PT1 Availability of functional overall paging system for calling in case of emergencies.
LD.33.PT2 Availability of functional bleeps system for calling in case of emergencies.
LD.33.PT3 Availability of functional mobile phones on the ambulance.
LD.34.PT1 Hospital has essential signs materials - Handicap access signs.
LD.34.PT2 Hospital has essential signs materials - All fire exits (at least (1) one emergency exit sign is visible from any point in the facility)
LD.34.PT3 Hospital has essential signs materials - Fire hydrants/fire extinguisher locations.
LD.34.PT4 Hospital has essential signs materials - No entry signs where needed
LD.34.PT5 Hospital has essential signs - Hazardous materials areas.
LD.35.PT0 Leaders actively participating in Quality Improvement projects (Evidence or Projects)
LD.35.PT2 Evidence of resource allocation by leadership for the Quality Management department
LD.35.PT3 Evidence of implementation of QI committee recommendations
LD.37.PT3 Evidence of resource allocation by leadership for implementation of the Hospital wide Management of Information (MOI) plan
LD.38.PT3 Availability of Hospital newsletters and other communication materials
LD.42.PT2 Availability of adequate equipment according to hospital size (Office equipments , computers , software to facilitate HR processes)
LD.54.PT3 Availability of adequate resources for life support certification (internal or external resources)
LD.59.PT1 Evidence of resource availability for duty manager work (including office and telephone)
LD.61.PT2 Availability of adequate resources for safe medical practice
معايير الإدارة التي تقييم بالمقابلة مع العاملين
معايير الإدارة التي تقييم بالمقابلة مع العاملين
LD.2.PT4 The organization chart is included in the hospital orientation program
LD.7.PT4 Hospital staff are aware of the hospital mission, vision and values.
LD.15.PT1 Evidence of patient education on rights and responsibility
LD.15.PT3 Hospital staff are aware of patient rights/responsibility
LD.19.PT2 Evidence of staff awareness of the hospital code of conduct
LD.20.PT2 Evidence of staff awareness of the conflict resolution policy
LD.31.PT3 Evidence of staff awareness of their role in the organization Hospital internal and external disaster plan
LD.36.PT2 Evidence of leaders participation in quality improvement
LD.43.PT2 Evidence of distribution of employee manual during hospital orientation
LD.51.PT2 Staff interview shows evidence of leadership support of staff education
معايير الإدارة التي تقييم بمراجعة السجلات الطبية
LD.16.PT3 Evidence of proper implementation of the hospital General treatment consent policy
معايير الإدارة التي تقييم بمراجعة ملفات العاملين
LD.5.PT1 Hospital Director has degree and/or experience in Hospital Administration and/or Senior Medical staff
LD.5.PT2 Medical Director is Senior Medical staff (Consultant) and/or has experience in Medical staff leadership
LD.5.PT3 Nursing Director has master degree or more than 5 years experience in Nursing staff leadership
LD.5.PT4 Quality Director has degree in Healthcare Administration and healthcare quality with at least 3 years of experience
LD.5.PT5 Clinical Heads have proper certification according to Saudi Council for each specialty
LD.6.PT1 Current job de******ion for Hospital Director
LD.6.PT2 Current job de******ion for Medical Director
LD.6.PT3 Current job de******ion for Nursing Director
LD.6.PT4 Current job de******ion for Administrative Director LD.6.PT5 Current job de******ion for Quality Director
LD.15.PT2 Evidence of staff educational on patient rights
LD.22.PT2 Evidence of pre-employment physical exam and check up
LD.22.PT3 Evidence of appropriate staff immunization and protection
LD.23.PT0 Qualified Finance Department director (A Bachelorate degree in finance with (2) years work experience)
LD.36.PT1 Evidence of leadership educational program on Quality Management concepts, data analysis, PDCA, RCA, and team work.
LD.41.PT1 Qualified Human Resource director (education and work experience)
LD.42.PT1 Adequate Human Resource staffing and qualification
LD.46.PT3 All job de******ions are competency based and used when selecting employees for hire, internal promotions, and transfer and provided to them on hiring
LD.47.PT2 Evidence of maintaining records of the current professional license, certification, and registration of every medical staff as required by the law (according to the Saudi Council for helathcare specialties).
LD.49.PT1 General orientation is documented in employee file
LD.50.PT3 Departmental orientation is documented in employee file
LD.53.PT2 Performance improvement process is based on the course and skill required (competency assessment records)
LD.56.PT2 Evidence that all staff have timely Probationary period evaluation in their personnel files
LD.57.PT2 Evidence that all staff have timely annual evaluation in their personnel files
LD.58.PT1 Availability of Qualified and experienced Duty Manager (degree in health institute administration or any other equivalent certificate with experience in leadership)
LD.58.PT2 Clearly written and signed job de******ion of duty manager
معاييرfms التي تقييم بالوثائق
معاييرFMS التي تقييم بالوثائق
FMS.1.PT1 Approved Safety management plan that covers Safety of the Building
FMS.1.PT2 Approved Safety management plan that covers Security
FMS.1.PT3 Approved Safety management plan that covers Hazardous materials and waste disposals
FMS.1.PT4 Approved Safety management plan that covers Internal & External Emergencies Plan
FMS.1.PT5 Approved Safety management plan that covers Fire Safety
FMS.1.PT6 Approved Safety management plan that covers Medical Equipment
FMS.1.PT7 Approved Safety management plan that covers Utility System
FMS.2.PT1 Review records availability of budget and invoices to support the safety management programs
FMS.4.PT1 Written policy on No Smoking
FMS.5.PT1 Safety committee terms of references and memberships.
FMS.5.PT2 Safety Committee meets 10 times/year and minutes are reported to hospital director (meeting minutes)
FMS.5.PT3 Evidence of supportive records that for the functions of the committee (i.e. data analysis, incidents/OVR reviews and communication of committee recommendations and risks to heads of departments)
FMS.6.PT1 Written policy and procedures on Safety Facility Rounds
FMS.6.PT2 Evidence of Quarterly Environmental Rounds reports (quarterly reports).
FMS.6.PT3 Evidence of Quarterly Facility Tours records (quarterly reports)..
FMS.7.PT2 Safety officer Communicates in writing with all Department Heads/safety representatives
FMS.7.PT3 Assignment of departmental safety liaison officers/representative
FMS.9.PT1 Civil Defense Gulf Countries Council (GCC) guidelines
FMS.18.PT1 Written policy and procedures on Laser safety FMS.19.PT2 Inventory list of flammables and its MSDS
FMS.20.PT1 Completed OVR form regarding Safety of the building incidents with corrective actions
FMS.22.PT1 Security policy/plan
FMS.23.PT1 Written policies on preventing abduction of children, and neonates/security policy.
FMS.24.PT1 Written policy and procedures on Lost and Found
FMS.24.PT2 Written policy and procedures on Safe keeping of patient belongings
FMS.24.PT3 Written policy and procedures on How to contact the local police
FMS.25.PT1 Written policy and procedures on police involvement in Trauma, Motor vehicle accidents & similar Incident
FMS.25.PT2 Written policy and procedures on police involvement in Drug addicts cases
FMS.25.PT3 Written policy and procedures on police involvement in Manslaughter cases
FMS.25.PT4 Written policy and procedures on police involvement in Violent patient (MR. STRONG)
FMS.26.PT1 Written policy and procedures on Bomb threat (including the role of person receiving threat, the response team, duties and responsibilities of all staff and their action cards, the responsible person who announces the emergency status and calls the local authorities, How to contact the local police, The command center location, and the steps to be taken during the bomb threat
FMS.27.PT1 Security roles are defined in the Internal Disaster plan
FMS.27.PT3 Security roles are defined in the External Disaster plan
FMS.29.PT1 Written policy and procedures on Hospital-wide security rounds and security rounds reports for each shift
FMS.29.PT2 Evidence of security rounds reports
FMS.30.PT1 Completed OVR form regarding Security incidents with corrective actions
FMS.31.PT3 Each department / section has a current list of HazMat used in their area that covers purpose of use, responsible person, and permitted quantity
FMS.32.PT1 Each dept./ section dealing with HazMat has Material Safety Data Sheet (MSDS) relevant to their current list of HazMat
FMS.32.PT2 A compiled list of HazMat used in all dept./ section is available at the Safety department.
FMS.34.PT1 Reporting radioactive leak, spill or exposure to any hazmat
FMS.36.PT1 Availability of King Abdulaziz City for Science and Technology License for radioactive material
FMS.37.PT1 Written and updated waste management plan
FMS.38.PT1 Written and updated External emergency plan FMS.38.PT2 Code Yellow plan includes Names of all staff called, including their contact numbers and action cards
FMS.38.PT3 Code Yellow plan includes plan includes The Triage areas, their locations, and triage action cards
FMS.38.PT4 Code Yellow plan includes plan includes Identifying the responsible person who announces the emergency state and calls the local authority
FMS.38.PT5 Code Yellow plan includes plan includes The control room location and the person in charge
FMS.38.PT6 Code Yellow plan includes plan includes The total number of beds that can be evacuated
FMS.38.PT7 Code Yellow plan includes plan includes Defining the role of security
FMS.39.PT1 Annual external plan drill reports
FMS.39.PT2 External plan drill tests the timely response of staff to the emergency call
FMS.39.PT3 External plan drill tests the efficiency of communication system, staff skills & their role, evacuation time, how effective the management of crowds was handled.
FMS.40.PT1 Evidence of annual staff orientation to Emergency preparedness
FMS.41.PT1 Code Red plan includes Names of all the staff called in case of disaster, their contact numbers, and action cards
FMS.41.PT2 Code Red plan includes The control room location. FMS.41.PT3 Code Red plan includes the position of the person in charge FMS.41.PT4 Code Red plan includes The duties and responsibilities of each hospital leader, Department heads, and chiefs of units FMS.41.PT5 Code Red plan includes The procedure for relocation of patients FMS.41.PT6 Code Red plan includes Identifying the responsible person who should announce the emergency state and call local authority FMS.41.PT7 Code Red plan includes Defining the role of the safety officer to deal with the electricity supply and medical gas system, to shut them off as needed incase of fire or explosions in the hospital FMS.41.PT8 Code Red plan includes Defining the meeting point for the staff incase of horizontal evacuations (Assembly points) inside the building FMS.41.PT9 Code Red plan includes Defining the meeting point for the full evacuation (Holding Area) outside the building FMS.42.PT1 Comprehensive Evacuation procedure
FMS.44.PT1 Proper scheduling of annual fire drills (4 for inpatient, 2 for outpatient, one for non-clinical).
FMS.45.PT1 Comprehensive fire drill evaluation of all staff on each shift (RACE, PASS, Fire containment, staff performance, evacuation, oxygen and electricity supply shut off).
FMS.46.PT1 Evidence of All staff attendance in fire drill
FMS.47.PT1 Evidence of quality improvement initiatives based on fire drill results.
FMS.48.PT1 Evidence of annual documentation and evaluation of full fire drill.
FMS.49.PT2 Evidence of regular functionality assessment (Inspection Reports).
FMS.50.PT1 Evidence of documented regular maintenance of Fire alarm system.
FMS.51.PT1 Fire Suppression System inspection reports
FMS.55.PT2 Emergency Lights checks reports
FMS.58.PT1 Evidence of scheduled staff training program.
FMS.59.PT1 Medical equipments Plan
FMS.59.PT2 Medical equipments Inventory
FMS.60.PT1 There is a written policy to perform inspection on all new equipment before put into operation
FMS.60.PT2 Evidence of effective PPM Plan for Medical equipments in use
FMS.60.PT3 Each piece of equipment has a checklist for its maintenance schedule, failure incidence, repairs done
FMS.62.PT1 Written policy and procedures on proper tagging of medical equipments
FMS.63.PT1 Written policy on removal of equipment from service
FMS.64.PT1 Written policy on Medical equipment staff training
FMS.65.PT2 Evidence of corrective action taken (sampled OVR)
FMS.66.PT1 Evidence of equipment upgrading/replacement according to PM data
FMS.67.PT1 Written policy on equipment repair through agents/subcontractors, safe electrical wiring, and prevention of cell phone use.
FMS.68.PT1 Evidence of Periodic Preventive Maintenance Program of Elevators
FMS.68.PT2 Evidence of Periodic Preventive Maintenance Program of Generator(s)
FMS.68.PT3 Evidence of Periodic Preventive Maintenance Program of Refrigerators/ Freezers
FMS.68.PT4 Evidence of Periodic Preventive Maintenance Program of Air conditioning system
FMS.68.PT5 Evidence of Periodic Preventive Maintenance Program of Medical gas system
FMS.68.PT6 Evidence of Periodic Preventive Maintenance Program of Medical suction
FMS.68.PT7 Evidenced of Periodic Preventive Maintenance Program of Domestic water system, including water pumps
FMS.68.PT8 Evidence of Periodic Preventive Maintenance Program of Fire water system, including fire pumps
FMS.68.PT9 Evidence of Periodic Preventive Maintenance Program of Boilers
FMS.68.PT10 Evidence of Periodic Preventive Maintenance Program of Plumbing
FMS.68.PT11 Evidence of Periodic Preventive Maintenance Program of Low current and communication system
FMS.68.PT12 Evidence of Periodic Preventive Maintenance Program of Hospital building, Pavement & Ground
FMS.68.PT13 Evidence of Periodic Preventive Maintenance Program of Electrical system
FMS.69.PT1 Evidence of adequate administrative support for equipment procurement and upgrading
FMS.69.PT2 Evidence of adequate administrative support for building renovation PSOI DOCUMENT REVIEW
FMS.70.PT2 Utility failures reports.
FMS.71.PT1 Evidence of annual testing and evaluation of the emergency plan.
FMS.72.PT2 Availability of updated electrical system maintenance records
FMS.74.PT1 Evidence of annual inspection of circuit breakers for critical care areas (Operating room, ICU)
FMS.74.PT2 Evidence of annual inspection of circuit breakers for the blood storage are and laboratory
FMS.74.PT3 Evidence of annual inspection of circuit breakers for alarm system and medical gas system
FMS.75.PT2 Availability of updated generator maintenance (PPM) records
FMS.76.PT1 Evidence of monthly documentation of emergency power testing results on station load for thirty minutes
FMS.76.PT2 All essential hospital areas are covered by the emergency power testing (OR, ICU, L&D, blood storage, refrigerators, elevators, alarm and medical gas systems, fire pumps, and escape routes)
FMS.77.PT1 Evidence of weekly emergency power generator testing without load for ten minutes.
FMS.78.PT1 Evidence of annual emergency power generator testing on full lead
FMS.79.PT2 Availability of updated medical gas system maintenance records
FMS.80.PT1 Evidence of periodic testing of medical gas for pressure, leaks, functions, emergency shut off, and labeling
FMS.81.PT1 Written comprehensive policy for storage, safe handling and delivery of all types of available compressed
FMS.83.PT2 Availability of updated HVAC system maintenance records
FMS.84.PT1 Periodic testing and controlling air flow and pressure in all critical areas is adequately documented (OR, critical care units, L&D, isolation rooms, clean and dirty utility, janitorial closets, and lab)
FMS.85.PT1 Regular Control of temperature and humidity in all critical areas is adequately documented (OR, ICU, recovery room, nursery, patient room, and sterile storage supply).
FMS.86.PT2 Availability of updated water system maintenance records for water availability, chemical testing every 6 month and monthly bacterial testing
FMS.87.PT1 Availability of professional code for sewage handling
FMS.87.PT2 Evidence of proper handling and disposal of sewage (Sewage disposal contract)
FMS.88.PT1 Availability of comprehensive utility drawings for utility line control during emergency
FMS.88.PT2 Evidence of performance evaluation of the utility system and improvement plan
FMS.89.PT1 Evidence of regular inspection of all kitchen equipments.
FMS.90.PT2 Availability of updated laundry equipment maintenance records
معايير الإدارة التي تقييم بالمقابلة مع العاملين
معاييرFMSالتي تقييم بالمقابلة مع العاملينFMS.28.PT3 Security personnel are oriented and trained on their scope of work, location of job de******ion, emergency codes, fire safety and how to extinguish fires
FMS.42.PT2 Staff are aware of Evacuation procedure
FMS.58.PT2 Evidence of staff awareness of using fire extinguishers.
FMS.64.PT2 Evidence of appropriate training of healthcare professionals on operating the assigned medical equipments and handling possible hazards.
FMS.65.PT1 OVRs are used to report medical equipment related incidents
FMS.70.PT3 Evidence of proper implementation of the utility failure plan.
معايير FMS التي تقييم بمراجعة ملف العاملين
FMS.3.PT1 Facility Management and Safety Plans orientation attendance records in employee file
FMS.7.PT1 Full time, trained Safety officer with a minimum of 5 years experience
FMS.8.PT1 Assignment of staff trained in safety per 150 beds
FMS.28.PT1 Assigned qualified security officers according to the size of the hospital
FMS.28.PT2 Security Officer Job De******ion
FMS.31.PT2 Staff training on HazMat ( attendance sheet)
FMS.35.PT2 Staff are trained in the use of protective equipment
FMS.72.PT1 Qualified and trained staff are handling the PPM of electrical System
FMS.75.PT1 Qualified and trained staff are handling the PPM of electric generator(s)
FMS.79.PT1 Qualified and trained staff are handling the PPM of the medical gas system
FMS.83.PT1 Qualified and trained staff are handling the PPM of heating, ventilating and air conditioning (HVAC) System
FMS.86.PT1 Qualified and trained staff are handling the PPM of water System
FMS.90.PT1 Qualified and trained staff are handling the PPM of laundry equipments
معايير fms التي تقييم بالمشاهدة
معايير FMS التي تقييم بالمشاهدةFMS.67.PT2 Evidence of restricting Cell phone use in High risk areas (ICU, OR, Cardiology) and elimination of extension cords.
FMS.73.PT1 All electrical outlets are identified for voltage
FMS.73.PT2 All electrical outlets are identified for source (essential/ prime)
FMS.81.PT2 Evidence of proper storage, safe handling and delivery of compressed.
FMS.82.PT1 Evidence of Proper labeling of the gas exhausts to the hospital roof (lab safety gas, central vacuum gas, scavenger gases, and BMT lab gas)
FMS.84.PT2 Evidence of compliance with air flow and pressure requirements for all critical areas
FMS.85.PT2 Evidence of compliance with required temperature and humidity in all critical areas
FMS.89.PT2 Hoods fans are in good operating condition, and free from grease
FMS.89.PT3 Hood filters are cleaned weekly, and no *****ng done with missing filters
FMS.89.PT4 Refrigerators are connected to emergency power
FMS.89.PT5 Regular temperature monitoring of the cold room
معايير التمريض التي تقييم بالوثائق
معايير التمريض التي تقييم بالوثائق
NR.1.PT1 Approved Nursing Organization chart (including names/titles of the nursing leaders are clearly displayed on the organizational chart up to Head nurse level /nurse manager/nursing educator & patient educator)
NR.1.PT2 The nursing organizational chart includes all direct patient care areas and indirect nursing services (i.e., Operating Room, Endoscopy, Renal Dialysis Unit, Recovery Room).
NR.2.PT2 Nursing Director Job de******ion
NR.3.PT1 Approved mission, vision, values and goals
NR.4.PT1 Approved Nursing strategic plan by Hospital Director
NR.5.PT1 There is a written operational plan for nursing department
NR.6.PT1 Evidence that Nursing Leader/representative participation in essential (hospital-wide) committees as reflected in Terms of reference and meeting minutes
NR.7.PT1 There is a current Nursing scope of services developed by the Nurse Leader and the leadership
NR.8.PT1 Evidence of development of units' current standards of care is clearly written based on the scope of services of the hospital
NR.9.PT1 Patient admission Policy is available and current (Approved by nursing director and reviewed every 2 years)
NR.9.PT2 Written policy and procedures on Basic hygiene of patients and skin care (Approved by nursing director and reviewed every 2 years)
NR.9.PT3 Written policy and procedures on Nursing role in Patient and Family Rights and Responsibilities (Approved by nursing director and reviewed every 2 years)
NR.9.PT4 Written policy and procedures on transcribing physician orders (Approved by nursing director and reviewed every 2 years)
NR.9.PT5 Guidelines of Nursing patient assessment (Approved by nursing director and reviewed every 2 years)
NR.9.PT6 Guidelines of Nursing patient education (Approved by nursing director and reviewed every 2 years)
NR.9.PT7 Written policy and procedures on general Infection Control (Approved by nursing director and reviewed every 2 years)
NR.9.PT8 Written policy and procedures on physician call (Approved by nursing director and reviewed every 2 years)
NR.9.PT9 Written policy and procedures on Intra facility patient Transfer (Approved by nursing director and reviewed every 2 years)
NR.9.PT10 Written policy and procedures on patient discharge (Approved by nursing director and reviewed every 2 years)
NR.10.PT1 Nursing staff meetings are held on a regular basis and reflected in meeting minutes
NR.10.PT2 Nursing Management meetings are held on a regular basis and reflected in meeting minutes
NR.11.PT1 Nursing quality plan is developed and in line with Hospital wide quality plan
NR.11.PT2 Evidence of Indicators monitoring reports on Medication errors.
NR.11.PT3 Evidence of Indicators monitoring reports on Patient falls.
NR.11.PT4 Evidence of Indicators monitoring reports on Pressure ulcers.
NR.11.PT5 Evidence of Indicators monitoring reports on IV therapy (adherence to the policy).
NR.11.PT6 Evidence of Indicators monitoring reports on Hand washing (adherence to the policy).
NR.11.PT7 Evidence of Indicators monitoring reports on Nurses role in cardiopulmonary resuscitation (adherence to the policy).
NR.11.PT8 Evidence of Indicators monitoring reports on Infection Control.
NR.12.PT1 Evidence of data aggregation and analysis by Nursing department and is used for decision making for improvement
NR.13.PT2 Job de******ion of infection control liaison nurse
NR.13.PT3 Documented infection control activities
NR.14.PT1 Patient care delivery system policy is available and current
NR.15.PT1 There is a defined policy in regard to the assessment of patient acuity defining the unit staffing based on pre-established criteria (e.g. patient care hours, Full time employment).
NR.15.PT2 Criteria based staffing plan is available
NR.15.PT4 Evidence of calculations prior of nursing staff allocation
NR.16.PT1 Written policy and procedures on nursing Recruitment
NR.16.PT2 Evidence that Nursing Recruitment process is based on credentials, departmental needs, reference checking, and past employment checks
NR.17.PT1 Written and approved plan for retention.
NR.17.PT2 Nursing retention plan monitoring mechanism (i.e.satisfaction surveys, complaints processing)
NR.18.PT1 Evidence of standardized method for Nurse assignment (based on skill level, appropriate qualifications, nursing licensing boards).
NR.19.PT1 Written policy on nursing scheduling for productive and nonproductive time including education/training and committee and meetings
NR.19.PT2 Written policy on Assignment of overtime and On-call when needed
NR.19.PT3 Written policy on Vacation schedules
NR.19.PT4 Written policy on Education/training activities
NR.19.PT5 Written policy on nursing Participation in designated committees
NR.20.PT1 Evidence of cross-trained nurses competencies in central nursing office and/or units
NR.21.PT2 Educational program for the non-nursing staff
NR.22.PT1 Roles and responsibilities of Nursing supervisor/coordinator after working hours including patients with medical/surgical emergencies or change of condition
NR.22.PT2 There is a system for coordinating nursing activities after duty hours for Dying patients
NR.22.PT3 There is a system for coordinating nursing activities after duty hours for Violent patients
NR.22.PT5 There is a system for coordinating nursing activities after duty hours for All incident reports completed by nurses
NR.22.PT6 There is a system for coordinating nursing activities after duty hours for Any adverse medication incidents
NR.22.PT7 There is a system for coordinating nursing activities after duty hours for Any Sentinel events
NR.26.PT1 Evidence of Nursing staff regular performance appraisal process with feedback from multiple sources.
NR.27.PT1 Nurse participation in location of staff
NR.27.PT2 Nurse participation in location of space needs
NR.27.PT3 Nurse participation in location of equipment allocation
NR.32.PT1 Written policy on maintaining adequate supplies (Par levels ) including emergency situation
NR.32.PT2 Evidence of Nursing department monitoring the supplies provision process and takes necessary actions for improvement
NR.35.PT1 Written policies on patient confidentiality
NR.36.PT1 Written hospital policy on OVA
NR.37.PT1 Written hospital policy on sentinel event
NR.38.PT1 Availability of current a proved list of hospital abbreviation
NR.39.PT1 Written policy on vulnerable patients
NR.39.PT2 There is a written policy that addresses nurse's action and responsibilities in the prevention of infant/child abduction
NR.39.PT4 There is an assigned hospital code such as Code Pink in case abduction occurs
NR.41.PT1 Written policy and procedures on Nursing Documentation (legible handwriting, signature, date, time, response to treatment, corrections, no use of white out, one approved language for documentation).
NR.42.PT1 Written policy and procedures on Nursing assessment of admitted patients ( patient history, drug allergies, patient condition, psychosocial status, pain assessment, nutritional status, discharge planning)
NR.43.PT1 written policies on Nursing reassessment at appropriate interval
NR.44.PT1 Written policy & procedure on patient care plan
NR.46.PT1 Written and updated policies and procedures on medication administration and monitoring
NR.49.PT1 Written and updated Policy and procedures on narcotics and controlled substances management that is in line with MOH laws and regulations
NR.49.PT5 Documentation of used and unused (wastage) narcotics and controlled substances must adhere to MOH laws and regulations
NR.50.PT1 Written multidisciplinary policy and procedure of restocking of crash cart medications and equipments
NR.50.PT3 Evidence of Routine (minimum monthly) checking and documentation of all medications and equipment in the crash cart (crash cart log book)
NR.51.PT1 Written and updated multidisciplinary policy and procedures on telephone orders (read back, cosign with 24 hours, 2 nurses verify the order)
NR.52.PT1 Written and updated multidisciplinary policy and procedures on verbal orders (repeat back, Signature by the physician immediately)
NR.53.PT1 Availability of written multidisciplinary policy and procedure on Blood and blood products (handling, use, administration 2 patient identifiers, 2 nurses verify patient identity prior to blood drawing and administration)
NR.54.PT1 Availability of written policy and procedure on patient restrain Written policy and procedure on patient restrain (physician order with type of restraint/length of time restraint used, nursing assessment/reassessments, assessment with circulation checks at least every hour, interventions for side effects related to major tranquilizers, dignity and rights protected, alarm system)
NR.55.PT1 Written and updated policy and procedure on newborn identification
NR.57.PT1 Availability of written multidisciplinary policy and procedure on patient transfer within the facility
NR.60.PT3 Written criteria on assessment and reassessment of pain intensity, pain character, frequency, location and duration also, patient education
NR.62.PT1 Availability of planned and documented orientation program for every nursing staff member
NR.64.PT1 Written comprehensive Nursing education program (include training on equipment, infection control, BCLS every 2 years, competencies in settings assigned, quality improvement, fire safety, disaster, blood, hazardous materials, restraints, lifting and transferring patients, and unit specific requirements)
NR.65.PT1 Comprehensive written policy and procedures on Nursing competencies (assessment& reassessment, medications, IV therapy, infection control, fall, oximetry, placement of tubes and catheters, sterile dressing, skin care, blood sugar testing, chemical spills, blood and blood products)
معايير التمريض التي تقييم بالمشاهدة
معايير التمريض التي تقييم بالمشاهدة
NR.14.PT2 Implementation of patient care delivery system functional team, total care
NR.29.PT1 Availability of all adequate Basic supplies and equipment of Unit stock (including patient scales, stretchers with safety straps, vital sign equipment, wheelchairs with safety straps, sharp box, foot stools, lifting device, soft restraint, bed rails, devices equipment to prevent skin breakdown, patient call bells, oxygen and suction, emergency call)
NR.30.PT1 Availability of a separate clean storage spaces in nursing units
NR.30.PT2 Availability of a separate dirty utility room that meets the standard requirement
NR.31.PT1 Availability of Nursing policy manual in each nursing unit
NR.31.PT2 Availability of Current nursing practice books (not less than 5 years old) in each nursing unit.
NR.31.PT3 Availability of infection control manual in all nursing units
NR.31.PT4 Availability of safety manual or safety policies in all nursing units
NR.31.PT5 Availability of Operating manuals or information on the safe use of equipment in all nursing units
NR.31.PT6 Availability of Lab information to assist the nurses in correctly obtaining specimens in nursing units
NR.31.PT7 Availability of Dietary manual in all nursing units
NR.34.PT1 Availability of patient spaces to ensure patients privacy
NR.34.PT2 Proper identification of Male and female room
NR.35.PT2 Evidence of implantation of patient confidentiality process (no evidence of unauthorized access to the medical record, no public conversations concerning patients, no public postings of patients information)
NR.38.PT2 Nursing adherence to approved abbreviation list
NR.39.PT3 Evidence of Prevention of unauthorized access to the area
NR.45.PT2 Evidence of Implementation of preoperative preparation Policy
NR.46.PT2 Evidence of implementation of medication administration and monitoring policies
NR.48.PT1 Availability of medication storage and preparation spaces
NR.48.PT2 There is a standard medication list for stock medications
NR.48.PT3 Medication storage areas are locked at all times except when nurses are preparing medications
NR.48.PT4 Medication preparation areas have good lighting, are clean and located in a closed area to avoid distraction
NR.49.PT2 Availability of Narcotic safe box /storage spaces, secure with double /doors locks
NR.49.PT4 The nurse in charge of each shift counts the narcotics and verifies the narcotic count with the incoming nurse in charge and documents
NR.54.PT5 Availability of alarm system in the room and at the nursing station for immediate help and/or assistance
NR.55.PT2 Evidence of compliance with the newborn identification policy (water proof ID band, baby and mother ID band, immediate after birth)
NR.56.PT2 Keeping the patient covered when attending to his/her physical needs
NR.68.PT2 There is documentation of all employee injuries with preventative actions taken for future risk reduction.
معايير التمريض التي تقييم بالمقابلة مع التمريض
معايير التمريض التي تقييم بالمقابلة مع التمريض
NR.3.PT2 Nursing staff can state the nursing department mission, vision, values and goals
NR.5.PT2 Operational plan is prepared with nursing leaders (head nurses) participation
NR.18.PT2 Allocating staff according to patient type and acuity on unit.
NR.33.PT1 Nursing staff adhere to patient and family rights policies (informed consent, Communication of patient/family concern)
NR.36.PT2 Nurse are aware of and implement of OVR system (able to complete the report/form)
NR.36.PT3 Nurses are aware of reportable occurrences (medication error, patient fall, wrong procedure, etc.)
NR.37.PT2 Nurse are aware of and implement of sentinel event system (able to complete the report/form)
NR.37.PT3 Nursing staff are awareness of types of sentinel event
NR.40.PT1 Nurses orientation of medical equipment use, trouble shooting and report of male-functioning
NR.47.PT1 Evidence of Implementation of medication administration policies emphasizing the 7 rules of medication administration
NR.49.PT3 The keys of the narcotic cabinet are kept with the charge nurse at all times
NR.50.PT2 Evidence of compliance with policy and procedure of checking and restocking of crash cart (Staff interview in different units)
NR.57.PT2 Evidence of nurses implementation of patient transfer policy within the facility.
NR.58.PT2 Evidence of staff awareness of family education at referral or discharge.
NR.59.PT1 Nursing awareness of End of life care and assessment and documentation to the response to the psychological, emotional, spiritual and cultural concerns of the patient and family
NR.64.PT3 Evidence of nursing staff knowledge, awareness, and skills
NR.66.PT2 Evidence of awareness of nursing staff about safety, security and medical equipment operation and maintenance
NR.67.PT2 Evidence of awareness of ALL nursing staff on their role during mock event
|مواقع النشر (المفضلة)|
|الكلمات الدليلية (Tags)|
|معايير, المجلس, المركزي, التقديم, تطبيق, ومراحل, كيفية|
|مواضيع مشابهه ننصح بقراتها|
|الموضوع||كاتب الموضوع||المنتدى||مشاركات||آخر مشاركة|
|معايير الجودة الخاصة بالسجلات الطبية من المجلس المركزي لاعتماد المنشآت الصحية||mustafa khalid Al-Jarrah||ملتقى المواضيع المكررة والمحذوفه||1||04-13-2011 01:39 AM|
|Cebahi المجلس المركزي لإعتماد المنشآت الصحية||محمد الثقبي||ملتقى المواضيع العامة||0||03-29-2011 07:46 PM|
|اجتماع عاجل لمعالجة ضعف تطبيق معايير العدوى||الهلالي||منتدى وزارة الصحة||3||12-27-2010 04:46 PM|
|تطبيق معايير الجودة في قسم الرعاية الصيدلية||عبيررر||ملتقى الرعاية الصيدلية||3||05-21-2010 12:01 AM|
|دورة تطبيق معايير الجودة بقسم التغذية في المستشفيات||أروى عبدالله||ملتقى التغذية||0||09-11-2007 06:25 PM|
|أدوات الموضوع||إبحث في الموضوع|
|انواع عرض الموضوع|