JCI Survey Readiness

Handbook

6th Edition Standards for Hospitals

Purpose
This Handbook has been developed with support of our JCI

Champions and Co-Champions to serve as a quick reference for

you to understand the requirements of JCI standards and how

to comply with the measurable elements.

Why is JCI Accreditation Important to Us?

Through effective implementation of JCI Standards, Al

SKMC aims to provide safe and effective care of the

highest quality and value to our patients.

Contact Us

If you need any further clarifications on this handbook, please feel

free to contact the JCI Champions and Co-Champions or Quality

Department. For better understanding, you may refer to policies

mentioned in the Handbook at SKMC Portal.

1|P ag e
 Contents

TIPS ON HOW TO ANSWER SURVEYOR QUESTIONS ............... 3

INTERNATIONAL PATIENT SAFETY GOALS (IPSG) .................. 5

ACCESS TO CARE AND CONTINUITY OF CARE (ACC) ............. 9

PATIENT & FAMILY RIGHTS (PFR) ................................................ 13

ASSESSMENT OF PATIENTS (AOP) ............................................... 18

CARE OF PATIENTS (COP) ............................................................... 25

ANESTHESIA AND SURGICAL CARE (ASC) ............................... 32

MEDICATION MANAGEMENT AND USE (MMU) ..................... 36

PATIENT AND FAMILY EDUCATION (PFE)................................. 46

QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS) ...... 49

PREVENTION AND CONTROL OF INFECTIONS (PCI): ............ 56

GOVERNANCE, LEADERSHIP AND DIRECTION (GLD) .......... 65

FACILITY MANAGEMENT AND SAFETY (FMS) ......................... 68

STAFF QUALIFICATIONS AND EDUCATION (SQE) ................. 88

MANAGEMENT OF INFORMATION (MOI) ................................. 91

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 TIPS ON HOW TO ANSWER SURVEYOR QUESTIONS

Kindly keep the following points in  DO NOT say, “I don’t know’ or ‘that is
mind, when approached by a JCI someone else’s responsibility.” Instead,
you can say “I don’t know, but I’ll find
Surveyor/ Consultant:
the answer for you” IS VERY
ACCEPTABLE ANSWER.
 ID badges must be worn at all times and
 Always answer honestly…if you don’t
at eye level.
know, don’t guess. Don’t try to give the
 RELAX…when a surveyor first
surveyor the answer you think.
approaches you, take a deep breath and
 In your response to the question, be
begin to gather your thoughts.
very specific. Don’t give more
 Practice rules of courtesy and
information than they ask for. Answer
confidentiality.
only the question asked.
 Don’t attempt to hide, ignore, avoid or
 An apology for not knowing an answer
run from them, unless of course you are
is not sufficient. Refer them to someone
involved in a patient care activity that
who knows such as your Charge Nurse
would prohibit you from immediately
or Manager.
responding. In other words, continue
 Avoid using the words “always” or
your work and be certain to greet the
“never” in the answers to their
Surveyor/ Consultants (Good morning/
questions. Instead talk about our
afternoon…).
organization’s standard practices or
 Perform a hand-off communication of
your practice based on our policies and
your patient to a co-worker if you are
procedures.
not able to attend to your patients while
 Show them you are interested,
talking with surveyors.
knowledgeable, & proud of your work.
 Always make sure you understand the
 NEVER argue with the surveyors. If
question before you answer. Ask the
you disagree, let your manager know
surveyor to rephrase the question if you
after your interview with the surveyor.
do not understand what is being asked.
 Stay confident and highlight your
 Respond to questions with confidence –
strengths or the strength of your
you know the answers better than
unit/department.
anyone.
 Know the location of policies, fire exits,
 Keep the conversation professional.
Material Safety Data Sheets (MSDS),
 Answer each question clearly and
meaning of RACE and PASS.
concisely, based on your everyday
 Refer to this JCIA Handbook, JCIA
practice and what you would actually
Standards and Policy Management
do in each scenario.
System as reference tools.

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 You do not have to memorize SKMC understanding of SKMC practice with
Mission/Vision Statement; but know implementing the JCI Standards.
where to find it and read it out to the  To tell about your unit compliance with
surveyors. International Patient Safety Goals
 Support your co-workers…. If you are (IPSG), Department Performance
present when someone is being Measures/KPIs, and Performance
questioned, feel free to add any relevant Improvement Projects.
information.  If asked, how do your work and your
 Managers, …please do not volunteer to department contribute to the SKMC
answer on behalf of your staff. Mission Statement, answer it based on
Surveyors primarily want to interact the service you provide and scope of
with staff….not the managers service for the Department you work.
 If the surveyors or consultants ask for (Refer also to SKMC Strategic Plan).
your name and employee ID, Do Not  Be ready to show Plan of Care, Pain
Panic. This is done during tracers for Assessment and Reassessment, General
employee file review later in the SQE Consent, Patient Education, Admission
session. History and Notes etc. on Salamtak.
Learn how to navigate with ease.
Be Prepared:
 To show documents in Portal such as:
Policies, Guidelines etc. Make yourself
familiar with how to access policies.
Please also read the polices mentioned
in the handbook on portal for better

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INTERNATIONAL PATIENT SAFETY GOALS (IPSG)
The purpose of the IPSG is to promote specific improvements in patient safety. The goals highlight
problematic areas in health care and describe evidence- and expert-based consensus solutions to these
problems. Joint Commission International and the WHO conjointly promoting the following six
international patient safety goals for increasing awareness about these goals and ensure safe delivery
of care.
 Prior to any treatments, procedures, or
IPSG 1: diagnostic procedures, such as taking blood
Identify Patients Correctly or other specimens, POCT, and radiology
Use 2 patient identifiers – For inpatients, ED procedures.
patients, and patients attending for procedures  Prior to medication administration.
in the outpatient specialty clinics 3 and 4, the  And prior to delivering restricted dietary
two identifiers are, the patient’s full name and trays.
medical record number.
[Ref. Doc.: Patient Identification Policy]
For all other outpatients, the two identifiers
are, the patient’s full name and a government
issued ID, preferably, the Emirates ID. IPSG 2:
The patient’s room, bed number or location Improve Effective Communication
must NEVER be used for identifying Effective communication, which is timely,
patients. accurate, complete, unambiguous, and
Patients arriving in understood by the recipient, reduces errors,
the Emergency and results in improved patient safety.
Service area, which Verbal or telephone orders
are unknown and Verbal and telephone patient care orders,
unresponsive (such verbal and telephone communication of critical
as Trauma Patient in ED), comatose or test results, and handover communications,
confused/disoriented and cannot be properly are instances that are impacted most by poor
identified, identification is made by ED staff or communication.
accompanying family member and an
identification wristband will be issued
containing:
 Temporary Name (e.g. Unknown A,
unknown B etc.)
 Medical Record Number

Patient identification must be done: Verbal or telephone orders are discouraged at

 At the time of admission, transfer, SKMC, unless during emergency situations,
discharge, and time of handover. where access to electronic record is not feasible.
When there is a need, the appropriate form
should be used.

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The verbal order must be written down, read During handovers, nurses use the SBAR tool,
back and confirmed to the person while physicians use their standardized tool.
communicating the information by the person
receiving the order. Physicians need to co-sign [Ref. Docs.: Critical Results, Observations
their verbal or telephone orders, or and Findings Policy, Hand-off
acknowledge the critical results of patients Communications Policy, Verbal or
within 24 hours. Telephone Orders Policy]
The complete order or test result (s) is written
down in Doctors order form / Critical result IPSG 3-Improve the safety of high alert
form as received and verbally read-back to the medications
person communicating the information to  High alert medications, are drugs that
confirm. possess a narrow margin of safety. When
Physicians are also expected to document their these drugs are involved in an error, they
recommendations or actions following the often result in serious harm.
receipt of their patient’s critical result.  SKMC has a list of high alert medications,
as well as a list of look-alike, sound-alike
Hand-Off medications. Strategies to mitigate risks
The primary associated with these medications, such as
objective of a independent double checks of clinicians,
“hand off” is to are also available.
provide accurate  Do not mix high-alert medications
information about together, such as insulins and heparin.
a patient’s care, They must also be stored in red bins,
treatment and services, current condition and labelled with a clear, red, High Alert
any recent or anticipated changes. The sticker.
information communicated: during a hand off  Concentrated electrolytes are stored in
must be accurate in order to meet patient safety pharmacy only, except perfusionist OR
goals. trays, for cardiac surgery.
Hand offs are interactive communications  If look-alike, sound-alike medication pair
allowing the opportunity for questioning is present in the unit, store in yellow bins
between the giver and receiver of patient segregated with each other. In addition,
information. Tall Man lettering is used in the medical
Hand offs include up-to-date information record, and medication and bin labels for
regarding the patient’s/ client’s/resident’s care, these drugs.
treatment and services, condition and any  For all High Alert Medications including
recent or anticipated changes concentrated electrolytes, independent
Interruptions during hand offs are limited to double check process must be followed
minimize the possibility that information before dispensing and before medication
would fail to be conveyed or would be administration.
forgotten.

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[Ref. Docs.: High Alert Medications, Look- team. Once the time-out is complete, no one
Alike, Sound-Alike (LASA) Medications, from the team should leave the room.
Concentrated Electrolyte Injections] The Pre-op checklist is used to verify that all
documents and equipment needed for surgery
IPSG 4- Ensure Safe surgery are on hand and correct and functioning
Significant patient injuries, and adverse and properly before surgery begins.
sentinel events can be prevented from
[Ref. Docs.: Safe Surgery and Procedures]
occurring, by following essential elements, as
“Time-Out” and “Sign-Out” must be done in
required by the standard. These are:
Operation Theatre and for all invasive
 Having a preoperative verification
procedures in any another clinical area just
process.
before the procedure conducted.
 Marking the surgical site.
For Neonates and Dental procedures, we have
 Conducting a time-out immediately
separate site verification forms.
before the start of the procedure.
 And conducting a sign-out in the area
IPSG 5-Reduce the risk of health care-
where the procedure was performed,
associated infections.
before the patient leaves.
Hand hygiene is the single most effective
means of preventing healthcare associated
The site is marked in all cases involving
infection.
laterality, multiple structures (fingers, toes,
The term hand hygiene refers to actions
lesions), or multiple levels (spine) with
intended to decrease the number of
“Arrow” prior to the start of any surgical or
microorganisms on the skin, thereby
invasive procedure, with the participation of
minimizing the risk of the transmission of
the patient. A final verification process is
infections from staff to patients, from patient to
conducted, such as a “time out,” to confirm the
staff, and between patient and visitors.
correct patient, procedure and site, using active
Effective hand hygiene is achieved through
communication.
hand washing with soap and water or hand
The surgical or
decontamination with the use of a waterless
invasive procedure
alcohol based hand rub.
site marking, is
At SKMC, we are in compliance with the
done by the person
current CDC guidelines for hand hygiene, and
who will perform
follow the WHO five moments of hand
the procedure.
hygiene.
1. Before touching a patient.
At SKMC, an arrow is used to mark the site,
2. Before doing an aseptic procedure.
except for ophthalmology and dental
3. After a body fluid exposure risk.
procedures.
4. After touching a patient.
The Time-Out is conducted in the location at
which the procedure will be done, and it
involves the active participation of the entire

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5. And, after touching the patient When a patient is determined to be at risk for
surroundings. falls, the patient is flagged. For inpatients:

A yellow Fall Risk wristband is placed next to

the patient's ID band.
And a Lamp or look at me please sign, is placed
on the patients’ door.
Wash hands with liquid soap and water when Examples of interventions done to prevent
hands are visibly soiled and using gloves does patients from falling are:
not replace hand washing.  Placing the bed side rails in up position.
 Placing the call bell within the patient’s
[Ref. Docs.: Hand Hygiene Policy] reach.
 Educating the patient and the family
IPSG 6-Reduce the risk of patient harm members and asking for their cooperation.
resulting from falls  Supervising the patients during
mobilization and ambulation.
 And limiting the patient’s activity
whenever possible.
If FALL occurs, it must be mandatorily
reported through the hospital Safety
Intelligence system.

[Ref. Docs.: Falls Prevention and

SKMC has a process for assessing and Management for Adult and Paediatric
reassessing patients’ falls risk – using the Patients]
Morse Falls Risk Assessment tool for adults,
and the Humpty Dumpty tool for pediatrics.

In certain outpatient locations where nurses

are not present, such as in radiology and
laboratory, the patient access staff conducts a
visual screening process to determine a
patient’s falls risk.

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ACCESS TO CARE AND CONTINUITY OF CARE (ACC)

SEHA and SKMC are in pursuit of a

more comprehensive and integrated
approach toward delivering health
care. The continuum of care, made up
of the following ― integrated system
of services, health care professionals,
and different levels of care, are things
that we consider in SKMC when
providing care for our patients. Our
goal is to correctly match the patient’s
health needs with the service available,
to coordinate the services provided to the patient in the organization, plan for discharge, follow-
up care and transfers between services and hospitals, whenever necessary.

Patient Triage Policy - D-NUR-ED-01-021,

for specific details)
 Whenever required, patients are assessed
and stabilized within SKMC’s capacity,
before they are transferred.

Screening for Admission to the Hospital Delays in Diagnostic and/or Treatment

Patients attending SKMC… Services
 Are screened and assessed appropriately,  All patients will be informed, and their
and are accepted when they fall under the clinical needs taken into account when a
scope of services of the hospital. procedure and/or treatment is cancelled or
 Are transferred, referred, or assisted to delayed for more than 12 hours.
appropriate sources of care, whenever  Patients will be informed of the reason for
applicable. the delay, and provided with information
 Get specific screening tests or evaluations, on available alternatives consistent with
and results are made available, prior to their clinical needs.
patients’ admission, transfer or referral.  Discussions are documented in the patient’s
 Refer to Admission/Care & Discharge of ED EMR.
Patient Policy - C-NUR-ED-01-012  Refer to Delay in Diagnostic and/or
Treatment Services Policy - C-NUR-ED-01-
Patients in the Emergency Department 019)
 Triaged and prioritized using the
Emergency Severity Index (ESI) Criteria Admission to the Hospital
(Refer to the Emergency Department  SKMC has a standardized admission
process (refer to Patient Admission Policy -

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 C-MD-GEN-01-023) and registration record, it contains updated patient medical
process (refer to Outpatient Appointment information (Diagnosis, problems and
Scheduling Process Policy - D-FIN-PAS-01- treatment). It is easy to access and is
008 ) automatically updated after each visit.
 Physicians who has authority to admit  In the clinics and emergency department, all
patients to SKMC are: patients are seen by a nurse and an
 Consultant Grade Physicians assessment is completed. Patients are then
 Designated Specialists with admitting evaluated based on their chief complaint.
privileges  The Nurse and the Physician assess all
(Refer to Most Responsible Physician (MRP) inpatients on admission. In addition, they
Policy - C-MD-GEN-01-005) receive assessments from the dietician and
 Patient needs for preventive, palliative, other services based on needs identified
curative, and rehabilitative services are from on-going assessments.
prioritized based on the patient’s condition  All of these assessments are documented or
at the time of admission recorded in the patients’ medical record.
 Upon patient admission, the patient and  During all phases of inpatient care, there
family receive: will be an assigned Most Responsible
 education and orientation to the Physician (MRP) designated as responsible
inpatient ward for the patient’s care. (Refer to Most
 information on the proposed care Responsible Physician (MRP) Policy - C-
 information on the expected outcomes MD-GEN-01-005)
of care  When a transfer of MRP is required, the
 information on any expected costs current MRP is responsible for personally
related to the proposed care notifying the other physician of the
 There is a patient flow process being intended transfer of care. All requests and
followed at SKMC including patients who acceptance of patient transfer is
are boarded in the ED (Refer to the documented in the patient’s medical record.
following policies: Emergency Department
Referral, Transfer and Admission - D-MD- Discharge, Referral and Follow-up
ED-01-001 and General Case Management  The plan for discharge and referrals, as
Policy - D-NUR-CM-01-001) required, is initiated upon admission and is
 Admission, transfer, and discharge to revised throughout the patient’s hospital
inpatient units providing intensive or stay. Appropriate clinical referrals and
specialized care is guided by their follow up appointments must be made
established admission and discharge before the patient is discharged from the
criteria documents (refer to these inpatient setting. (Refer to General
documents for details) Discharge Policy - C-MD-GEN-01-024)
 SKMC has a process for patients being
Continuity of Care permitted to leave the hospital during the
 A patient’s clinical summary is the first planned course of treatment on an
page when opening the patient’s medical approved pass for a defined period of time.

10
 Ensure that appropriate discussion, frequently and who require the input of
assessment and documentation was in place services from different practitioners in
before patient is allowed to do so. (Refer to multiple settings. Their profile may be
Approved Inpatient Leave from the viewed through the “Ambulatory Tab” in
Hospital - C-MD-GEN-01-036). the patients EMR and it contains their up-
 Patients are provided education to-date medical care. (Refer to
immediately after admission and based on Documentation for Outpatients Requiring
needs identified in the assessment, and are Complex Care - C-MD-OSC-01-010)
given specific education based on identified  The hospital has a process for the
learning needs, which includes discharge management and follow-up of patients who
planning. The assessment for learning notify hospital staff that they intend to leave
needs is ongoing. against medical advice. For further details,
 A complete discharge summary is prepared refer to the LAMA / DAMA / AWOL section
to all inpatients and it includes the of the General Discharge Policy - C-MD-
following: GEN-01-024.
 Reason for admission, diagnoses and Transfer and Transportation of Patients
comorbidities  SKMC will transfer patients as appropriate,
 Significant physical and other findings from referring facilities or to outside
 Diagnostic and therapeutic procedures organizations. There must be written orders
performed and accepting physician for transfers into
 Significant medications, including SKMC or from SKMC to another facility, for
discharge medications the consistent handling of patient transfers
 The patient’s condition/status at the from/to outlying facilities, in accordance
time of discharge with legal and regulatory requirements.
 Follow-up instructions (Refer to Management of Transfers to and
(Refer to the General Discharge - C-MD- from Sheikh Khalifa Medical City Policy - C-
GEN-01-024, and Discharge Summary MD-GEN-01-022)
Content and Completion - C-MD-GEN-01-  All transfers into SKMC (including Critical
042 Policies) Care) must be coordinated through the
 Follow up instructions are given by the Admission/Transfer Center (ATC) to ensure
nursing team, in a format that the the appropriate assigned bed and resource
patient/family understands. It will include allocation is available to meet patient needs.
instructions to return for follow up care,  The ATC will ensure that all
and where and when to obtain urgent or communication between facilities must be
emergent care. As required by the patient’s clearly documented to include, but not
condition, families are likewise provided limited to:
instructions and education on how to  The agreement of transfer
provide competent care.  The reason for transfer
 SKMC has defined complex care  Medical report/ Referral letter
outpatients are patients whose conditions  Inter Hospital transfer form
require complex care continuously and

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  Any other relevant and pertinent  If a patient transfer or transportation has not
clinical documentation and reports been handled in an appropriate way or
 Any special conditions in direct relation deviated from the standards set by SKMC
to the transfer policy, a Safety Intelligence report will be
 DOH Feedback Form/Hospital submitted. Furthermore, the case may be
Discharge Summary referred to the medical director, nurse
 Inter-facility Hospital Transfer supervisor or charge nurse, who will
Documentation Form document the situation and report it to
 The patient is assessed prior to transport to Quality Department for review.
ensure the appropriate personnel,  The Ambulance medical items are checked
equipment and mode of transport is by the ED team every morning and upon
provided to ensure patient safety in the ambulance return from workshop.
accordance with the SKMC Transport Grid. (Refer to Ambulance and Vehicle Service
Request Policy - C-OP-HS-01-063)

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PATIENT & FAMILY RIGHTS (PFR)

Health care organizations work to establish trust and open

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

How are your patients protected from

harm?
 Security personnel are always present in
SKMC and they observe everyone who
enters and leaves the facility.
How are patients informed of their rights  There are CCTVs throughout the hospital
when they seek care in the OSC, ED, or monitored by both Security staff and SEHA
Operation Command Center.
admission to the hospital?
 Additionally, Security Services, and other
 Yes. PFR posters are located throughout
staff are trained to respond to specific
the hospital and it is available in both
emergency operations plan codes, as
Arabic and English.
defined in the EOP Annexes and
 The patient’s rights and responsibilities
Departmental Action Cards.
Posters are posted throughout the facility
in Arabic and English. Patients/Families
receive the patient rights and
How do you know that only authorized
responsibilities information pamphlet, personnel have access to patient
upon admission. It is also be available in information?
waiting areas of the hospital.  All staff members wear a badge that
 Information about patient rights and identifies them by name, department and
responsibilities is provided to each patient Position. Staff is taught to stop/question
in a language and manner the patient those who seek information they are not
understands. entitled to.
Familiarize yourself with the patient’s rights  Computer access is limited to those who
and responsibilities and be prepared to tell the have been given access to information
JCI surveyor about this process. based on their assigned job and area.

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 All staff sign confidentiality statements recommended treatment or procedure, the
upon employment and at re-contracting, risks and complications, benefits and
agreeing to honor the privacy rights of alternatives.” An individual patient’s
patient’s, and agreeing never to share their known risk factors that increase the
computer passwords. likelihood of a poor outcome must also be
part of the discussion.
What is SKMC’s policy on Consent?
General Consent: What is the adult age in UAE?
For Treatment shall be obtained from the all 18 Years old.
patients when they present for treatment:
• Each ED visit What is the validity of informed consent
• Each admission forms?
• Yearly for outpatients 30 days for informed consent.

Correct and complete consent (Informed

Consent) must contain the following:
 To take consent you must have sole
management privileges of that operation
(MRP and specialist only).
 The patient’s MRP if going to do the
operation should take the consent
personally or he can delegate to one of the
privilege specialist who is fully aware
about the said procedure.
Informed Consent:  If the operation is to be done by someone

 Informed consent is a way to involve the other than MRP, the privileged specialist

patients/family with the plan of care. It is a should have the approval of MRP to
medical/legal document which needs to be perform that procedure and to be
completed following the SKMC consent documented in patient file before

policy. performing the procedure. (Best practice)

 A delegated physician cannot further
 The purpose of informed consent is “to
honor the patient’s right to make decisions delegate (sub-delegate) activity to a third

about health care, ensure patient physician without having specific

understanding and prevent allegations of direction and authority from the consent

lack of informed consent.” giver and attending physician.

 The informed consent discussion must be  GPs and Residents should not take

held when the patient is alert and has the consent.

ability to make a rational decision.  Use black or blue ink only and write
 Informed consent begins with a discussion legibly.

between doctor and patient. “The  Procedure must be written in full

without using abbreviations.
discussion includes the condition,

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 Procedure description matched the  To have pain assessed and managed in a
description in the clinical notes. timely manner.
 There must be no abbreviations.  To access spiritual care services available
 The side where the procedure will be in the community if needed.
conducted must be spelled out in full and  To an interpreter and/or translation
match the clinical notes. services.
 The dates of all the signatures must all be  To be free from all forms of harassment or
the same (patient, doctor, nurse witness). assault.
 Any alteration to a completed consent  To receive visitors, unless it would
form must be made before the compromise treatment.
intervention commences and the  To be informed about their medical
alteration must be signed and dated by the condition(s), treatment plan, anticipated
consent giver and the attending physician outcomes in a way they or their
both or by the physician as indicated. family/caregiver can understand
 Patient’s sticker is correct (this is the including: the Risks and Benefits
correct patient information). associated with treatment and a plan for
 General and specific complications are continuity of care following discharge.
listed.  To know the names/ titles of their
 Any procedure intervening with fertility healthcare providers.
must be signed by patient and her  To request for a change of provider or
Husband or father if Patient is Single. second opinion.
 For emergency Cases (E1), there is no need  To request a medical report and access
to obtain consent only Document in the their medical record as permitted by law.
Cerner in Plan of care.  To be informed about their financial
responsibilities.
Patients’ rights and responsibilities  To refuse, discontinue treatment or leave
All patients have the following rights: against doctor’s advice as permitted by
 To receive information about the law.
availability of care, services and how to  To provide prior consent for use before the
access these appropriately. making of recordings, films, or other
 To receive protection if they are images.
vulnerable: i.e.: children, elderly, and
patients with special needs. How the staff is made aware of the patient’s
 To receive care regardless of race, creed, unique needs at the end of life? What is End
color, national origin, gender, age, or of Life care?
disability. End of life is an anticipated death and the end
 To have personal dignity, privacy, culture, stage of a fatal medical condition. End of life
psychosocial & personal values, beliefs care starts, when the patient becomes so
and preferences respected. debilitated, confined to bed, and death is
 To a clean, safe environment. imminent.

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Palliative Care is a multidisciplinary approach  Involving the patient and family in every
seeks to prevent or relieve the Physical, social, aspect of care, including the decision
Spiritual, psychological and Emotional making process for end of life issues.
Distress Produced by a life-threatening  Responding to the psychological, social,
medical condition or its treatment, to help emotional, spiritual and cultural concerns
patient with such conditions and their of the patient and family, including
families, to live as normally as possible, and to children and teens affected by the death,
provide them with timely and accurate prior to, and at the time of the patient’s
information and support in decision making: death. Assuring that all staff caring for the
 By providing relief from pain and other patient are aware of the patient’s wishes
distressing symptoms. and respectful of their decision.
 By integrating psychological, social and
spiritual aspects of patient care. How do you obtain an interpreter for a
 To help patients live as actively as possible patient or family member?
until death.  There is an Interpreter Services under
 To maintain the personal dignity and self- Nursing Division available on SKMC
respect of the patient Portal.
 Interpretation Services is available during
the normal working hours.

If a patient or family member has a

complaint, how do you assist them?
 The goal is managing patient complaints
as early and immediate intervention and
resolution.
 Complaints should be resolved at the level
End of Life Care includes closest to the patient whenever possible.
 Managing Pain aggressively and If the complaint is not resolved. Then the
effectively. Through assessing, managing, Patient Experience Officer will escalate it to
and reassessing technique. complaint office. Senior patient experience
 Providing Treatment of Symptoms will arrange family meeting if needed.
according to the wishes of the patient
family, through assessing, managing and Complaint office will deal with all internal
reassessing technique. complaints to ensure that they are assessed,
 Respecting the patient’s privacy, religion investigated, and resolved within 7 working
and cultural values. days. If the complainant is dissatisfied with
 Communicating and Coordination is feedback, the complaint will be escalated to the
important between the caring team, in a complaints manager for further investigation.
patient centered approach, and between
family and medical team. Following are the 5 main steps for Service
Recovery:

16
 Hear the Story
 Empathize with the patient Patients and Families Responsibilities
 Apologize for not meeting the patient  To bring their insurance card and
expectation Emirates Identity Card with you every
 Respond to the concern and what you can visit.
do in a timely manner  To keep scheduled appointments, arrive
 Thank the patient for giving him the on time or let the facility know in advance
chance to resolve the concern. if they would like to reschedule.
 To Sign a general consent for treatment
Organ Donation after having the scope and limits fully
This process shall be performed through the explained. Children under 18 years old
administration office of organ donation unit. should be accompanied by a consenting,
 The hospital supports patient and family adult family member.
choices to donate organs and other tissues.  To provide complete and accurate
 The hospital provides information to information about their health, including
patients and families on the donation medical history and medications
process.  To let the healthcare providers know if
 The hospital provides information to the they don’t understand the information
patient and family on the manner in which given to them about their condition or
organ procurement is organized. treatment
 The hospital ensures that adequate  To inform the medical team of changes in
controls are in place to prevent patients their condition or symptoms, including
from feeling pressured to donate. pain
 The hospital defines the organ- and tissue-  To follow regulations regarding
donation processes and ensures that the patient/visitor conduct, no smoking and
process is consistent with the region’s visitation timings
laws and regulations and its religious and  To show respect and courtesy to staff and
cultural values. other patients
 The hospital identifies consent  To take responsibility for the outcome(s) if
requirements and develops a consent they decide not to follow the health care
process consistent with those provider instructions and/or treatment
requirements. plan and recommendations
 Staff are trained in the contemporary  To speak up and communicate their
issues and concerns related to organ concerns to any employee as soon as
donation and the availability of possible
transplants.  To pay their bills or make arrangements to
 The hospital cooperates with relevant meet the financial obligations arising from
hospitals and agencies in the community their care
to respect and to implement choices to  To leave their valuables at home or entrust
donate. to Security Department.

17
ASSESSMENT OF PATIENTS (AOP)

What is an Effective Patient Assessment

Process?
The goal of assessment is to determine the care, How soon after admission does the doctor
treatment, and services that will meet the need to complete the Admission Assessment?
patient’s initial and continuing needs. Patient The doctors must complete the admission
needs must be reassessed throughout the assessment documentation within 24 hours of
course of care, treatment, and services. admission.
Reassessment is key to understanding the
patient’s response to the care, treatment, and How are patients with frequent Outpatient
services provided and is essential in visits assessed?
identifying whether care decisions are  Nurses must do regular assessment at each
appropriate and effective. visit.
 Physicians - The medical history must be
Are patient assessments in SKMC updated and physical examination
interdisciplinary? repeated if patient is scheduled for
Yes; Patients visiting the ED and OSC, or admission, or booked for Outpatient
admitted as an inpatient receive an assessment procedure or if medical assessment is older
from various disciplines, as indicated. The than 30 days.
physician and nurse assess patients seen in the
clinics and physicians refer them to other What are the two mandatory elements to be
disciplines including allied health as indicated. documented when an Emergency Surgery is
to be performed?
Are assessments from outside facilities The two Mandatory elements to be
accepted in SKMC? documented by the physician before the
No, SKMC policy requires that all patients surgery are: A brief assessment note & a
transferred from other facilities be assessed preoperative diagnosis.
again when presenting to our facilities for
treatment. How are the needs of patients known or
identified?
How soon after admission does Nursing Information about the patient’s physical,
complete the Admission Assessment? psychological, social, functional and cultural
Written documentation must be completed status is obtained during assessment. A review
within 12 hours of admission of the patient’s medical record, including other

18
discipline’s notes (Salamtak Document
Viewing and Results Review), can help When are your patient’s nutritional and
identify patient needs. functional (activity and rehab) needs
How are the patient’s needs prioritized? assessed? Where are they documented?
Patient’s needs are prioritized as per the This is assessed upon admission and as part of
assessment findings using all disciplines the ongoing assessment daily for inpatients
involved data and using a Multidisciplinary and for outpatients upon each clinical visit. The
approach. findings are documented in the medical
record/ Salamtak.
What is the frequency of the Nursing
Assessment & Re assessment? What do Nurses do for patients with
Within 12 hrs of admission and every 12 hr Nutritional needs?
shifts and before any transfer or discharge. Once the nutritional need is identified, the
nurses notify the doctor. The doctor then refers
What are the assessment criteria for Patient the patient, as necessary, to the clinical
who are deemed chronic or a lower level of Dietitian.
care?
 When the multidisciplinary health care How would nutritional services know about
team determines the patient has reached a patients who are at nutritional risk?
maximum level of functioning and has an If the patient meets any nutritional risk criteria
established routine pattern of care, a as per the screening tool, nurses notify the
patient may be designated for LTC if he/she doctor and the doctor then refers to the
no longer requires acute care. (Refer to dietician as needed. The dietetics then assess
policy C-NUR-CLI-16-007: Long Term the patients for, such as certain lab values or
Care). height/weight ratios.
 Physicians: each patient will be assessed by
a member of the medical/specialty group at Why do we do a daily Nutritional and
least weekly and appropriate progress Functional screening for all our patients?
notes will be recorded. (Refer to policy C- As per SEHA mandate a minimum of every 24
NUR-CLI-16-007: Long Term Care) hours screening is required.
 Nurses: Nursing care will be recorded each
shift & after relevant events. (Refer to How would you know what is restricted in a
policy C-NUR-CLI-16-007: Long Term patient’s diet order?
Care) Doctors and Dietetic staff can place diet orders.
Nurses have access to the approved Diet order
What is the assessment requirement of a which is available in patient’s electronic
patient receiving blood/ blood products? medical record and is auto printed to Food
Assessment of patients receiving blood and Services section for diet delivery to patients.
blood products will be done as per the Blood
Transfusion Policy. (SKMC/ C-MD-LAB-02- How do you assess a special population
006-F-001/ Transfusion Guidelines). group?

19
Special population groups will have their  Refer to Assessment and Care of Patients
assessment individualized based on their who are Vulnerable and/or at High Risk (C-
unique needs and characteristics, so that their MD-GEN-01-010).
needs are identified and addressed. Specific
assessment elements are integrated into the Do you base your assessment of the patient’s
assessment documentation in Salamtak. needs on their age and special needs?
Yes. Nursing assessments are based on age-
Who are the patients identified as special specific criteria and identified special needs.
population (vulnerable / at risk)?
 Children and adolescents (up to 18 years) What does “age-specific” (populations
 Frail/ elderly served) assessment mean and how do you
 Terminally ill/dying patient know about these needs?
 Patients with intense or chronic pain  Different age groups have different
 Pregnant or in labor women psychosocial and clinical needs. For
 Women experiencing spontaneous example, a 2-year old patient requires an
abortions appropriate paediatric blood pressure cuff
 Patients with mental and/ or substance use rather than an adult size.
disorders  Also, for example, when administering an
 Suspected/ alleged victims of abuse and IM medication, an appropriate gauge and
neglect length of needle would need to be
 Prisoners or those in police custody considered in the case of a frail elderly
 Patients in emergency department person who may have decreased muscle
 Patients who are comatose mass.
 Patients on life support
 Patients with infectious or communicable When patient Discharge plan start?
diseases The discharge plan starts from admission time
 Patients who are immunosuppressed to identify the needs.
 Patients receiving dialysis
 Patients in restraints Laboratory Services
 Patients receiving chemotherapy or Are you sending lab tests to other facilities?
radiation therapy Yes, all laboratory tests which are not done at
 Patients at risk for suicide SKMC & sent to other referral labs either in
UAE or outside UAE are done in the stipulated
Who are considered as frail/elderly as per time as per agreed contract and mentioned in
SKMC Policy and how do you assess them? the test catalogues of the offsite referral labs.
 Vulnerable elderly patients are those who
as a result of ageing and/or disease, the What is the Turnaround Time (TAT)?
individual has become vulnerable to Lab TAT is the time from receiving the
environmental and self-generated hazards specimen in the laboratory reception until the
result is verified.

20
Do you have a Critical tests list? Where can A- Ordering physician.
you find it? B- Senior on call physician.
Yes. It can be found in the following lab C- Chief of Service /Head of Department of
policy/ies: (D-MD-LAB-01-011, Critical Result the concerned department.
Notification) D- Lab COS.
E- CMO.

Who is authorized to order laboratory test?

Only physicians are authorized to order
laboratory test.

What is Point of Care Testing (POCT)?

Point-of-care testing (POCT) refers to any
testing conducted outside a lab, near the site
where the patient is located by non-lab staff.

What is a Critical result or a Panic Value? How frequently must the POCT Competency
Panic Value is a laboratory result that indicates be reassessed? Does it mean staff training?
that a patient may have a life threatening Annually.
medical condition that requires immediate
action by a physician. How often is the Correlation study done
between POCT devices?
What must the caller say when Annually.
communicating Critical result?
 Identify himself/herself by Name & What is IQC and PT? Who runs IQC/PT
Employee ID. sample for POCT?
 Take receiver’s Name & Employee ID. IQC is Internal Quality control and PT is
 State purpose of call. Proficiency Testing. PT is performed by POCT
 Identify patient by full name & MRN. coordinator.
 Communicate result with units clearly.
 Ask receiver to read back the result. What is your POCT critical result policy?
 Confirm its correctness. A result is considered critical if listed in the
 Document conversation in CERNER. POCT critical results table.
 Verify the result on CERNER/ Salamtak. Critical results shall be communicated by the
Nurse/Respiratory Therapist/ phlebotomist
Is there any documentation of who performed the analysis immediately upon
communication of Critical result? Where?
test verification.
Yes, in CERNER/Salamtak system. Concerned physician must be informed
immediately.
Who can receive Critical results for In-
patients?
In sequence:

21
All Critical results & their communication to Blood/ Blood products should only be picked
physician must be recorded in Patient’s up by a medical staff (nurse or physician) by
records in Salamtak system. using blood bank transport boxes.

Where can you find the POCT policies & Can blood bank transport boxes be used to
records? store blood/blood component?
In SKMC Policy Management System No. These boxes are meant only to transport
categorized on departments- lab policies- lab blood/blood component not to store.
General- POCT policies. Records are also
available with POCT coordinators. Who is responsible to order emergency
blood/blood component?
What precautions must you use while The physician is responsible to order
performing POCT? emergency blood/blood component by filling
 Universal precautions for infection and signing an “Emergency Transfusion
control. Requisition Form”
 Specific precautions like cleaning the
devices after using them for each patient. During the downtime is there any delaying
on patient results?
What is the type of patient specimens with No, Lab is processing all the samples offline
high-risk category? and send a hard copy results till the system
Blood from patients with Hepatitis B, Hepatitis back.
C, HIV, or Viral Haemorrghic Fever, Sputum
samples from MERSCoV, H1N, TB patients, During the planned downtime is lab
stools from patients with Typhoid, receiving all the samples (Stat & Routine)?
Parathyphoid, C. difficille or Dysentery. Lab receive only STAT.

What is a transfusion reaction? Is it possible to find the patients result in

A transfusion reaction is any signs and Cerner after the downtime?
symptoms that occurs during or after a patient Yes, all the results will be uploading to Cerner
receives transfusion of blood/blood products. when system back.

What should be done in case of a suspected Radiology Services

transfusion reaction? Which Licensing and regulatory body
Call blood bank and send a properly filled standards in the UAE does SKMC Radiology
“Request for investigation of transfusion adhere to?
reaction form. FANR - Federal Authority of Nuclear
Regulation
Who should pick the blood/blood component
from the blood bank and using what? What is an outside source of imaging?
Outside sources are hospitals that cover SKMC
Radiology department during breakdowns

22
and for specialized imaging tests (Nuclear Radiation Safety Officer (RSO) at SKMC
medicine/Vascular intervention) responsible for radiation safety orientation for
all hospital staff, monitoring and protection.
Who are the outside sources of imaging for
SKMC? What are the key measures to be radiation
All SEHA BEs. safe?
Distance from the X-ray source – minimum of
Who is chiefly responsible for imaging 2 meters from the machine. Lead protection
services at SKMC? devices can be used if proximity to the source
Chair of the Radiology Department is unavoidable.

How is staff exposed to radiation/radiation

workers monitored?
 This includes the radiology staff and the
staff working in the Operating Theatres
where the portable C-arm fluoroscopy
machine is used.
 A Thermoluminescent Dosimeter (TLD) is
provided to the above staff. TLDs are
measured every 3 months.
 Dose constraint for SKMC – should not
exceed an average of 0.3 mSv (milliseivert)
Can you act on a provisional CT or ultrasound
per month or 3 mSV per year.
report?
No. You should only act on a finalized report
What are precautions for the pregnant patient
by the Radiologist.
or potentially pregnant?
In case of emergencies, verbally verified
 Last Menstrual Period (LMP) should be
provisional report by the Radiologist is
obtained prior to the X-ray/CT
acceptable provided this is documented – e.g.:
 Radiation procedures should not be
Critical results.
performed 10 days after the onset of their
last menstrual period. Pregnancy test
What does ALARA stand for?
should then be performed
As low as reasonably achievable – this is how
 If the pregnancy test is positive or the
dosing for patients are decided to obtain the
patient is already known to be pregnant,
best possible images with the lowest
the referring physician should be informed
practically possible doses.
and consent obtained.
 Lead shield is placed over the abdomen
Who is the key individual assigned by the
during the procedure.
radiology department responsible for
implementing the radiation safety program?

23
What are steps and precautions for the Biomedical department and Radiology
pregnant staff? Department
 Inform the Radiation Safety Officer ASAP What are measures in place to ensure quality
of Outside sources imaging services?
 Additional dosimeter provided to place SEHA BEs are utilized. Records of Quality
over the abdomen/waist level during Control results performed by the physicist of
pregnancy which is read every month outside sources are annually received.
(should be < 1msV throughout pregnancy).
Minimize exposure where possible.

What are time frame for radiology results at

SKMC?
All STAT orders in 60min
All URGENT orders in 24hrs
All ROUTINE orders within 5 days

Who are primarily responsible for radiology

equipment?

24
CARE OF PATIENTS (COP)

A health care organization’s main purpose is to provide quality patient care. The delivery of
patient care must be coordinated and integrated by all individuals caring for the patient (clinical,
rehabilitation, physical, occupational, respiratory therapists, dietary, nursing, radiology, etc.).

Evidence of care planning includes, but is not

limited to, the following:
Progress or patient care notes, Dictated reports,
Patient and family teaching information, MDT
documentation, Interdisciplinary plan of care
& Medication Administration Records.
How is a patient’s plan of care determined?
Collaborative approach is evident through
Plan of care is determined by collaborative
Communication among treating physicians,
approach among care providers and using data
Nurses and others.
from initial assessments, periodic
reassessments and identified needs. This also
What is the principle of patient care followed
involves the patient and family.
in our hospital?
The principle is “One level of quality of care”
How and when are the patients reassessed?
which aims to provide uniform patient care
Patients are reassessed whenever there is a
that is available in each day of the week and in
change in the patient’s condition and/or
all shifts of the day.
diagnosis and responses to treatment. The plan
of care is reprioritized according to the
Do we have a planning process for care for
changing needs of the patient. Plan of care is
patients?
set for each patient as measurable goals.
Yes, we collect the data from initial assessment,
periodic reassessment and provide the
What is evidence of interdisciplinary and
collaborative care planning? treatment and care.

After a patient’s needs are determined, the

Is there a specified period for developing the
health care team develops a care plan.
plan of care?

25 | P a g e
Yes, within 24hours of admission as an How often is MDT documentation repeated
inpatient. in critical areas?
On a daily basis of earlier if indicated.
How does interdisciplinary and collaborative
patient care planning occur? How is MDT documented?
This happens by participation of the different It is initiated by the admitting or attending
health care practitioners who work together to physician by selecting ‘MDT
identify the needs of the patient though (multidisciplinary note)’ from the dropdown
physician – nurse patient rounds, multi- menu and using “Free Text” in the encounter
departmental patient rounds, contribution of pathway (until a specific inbuilt template is
nurse managers and through patient & family made available). The note can be titled
discussions. appropriately as ‘Clinical Rounds’, “Team
meetings’ or ‘Family meetings’. The content
What is a multidisciplinary team? should mention the ‘Participants’ and the ‘Plan
It refers to a group of healthcare professionals of care or decisions’.
from a range of disciplines who work together
to address as many of the patient needs as If a physician fails to initiate a MDT note
possible. Can comprise of physicians, nurse after the rounds due to unavoidable reasons,
practitioners, clinical pharmacists, allied health how do other health care providers
specialists, health educators, and social document?
workers. They need to mention in their respective
documentation: “as per MDT rounds with …”
What is MDT Note or documentation?
Document recorded in the patient’s health In case of absence of a MDT note, how do you
record indicating the multidisciplinary care prove that MDT rounds did take place?
provided to the patient.  By mentioning the names/designation of
participants in regular progress notes.
What is MDT Note Work flow?  By demonstrating other health care
The multidisciplinary team members agree on providers’ contribution by way of
specific plan and document the same through consultation notes and by documenting
a standard template having a provision for verbal or telephone conversations.
update.  By being able to navigate and view other
health care providers’ documentation in
Do we have multidisciplinary team rounds in “All Documents”.
the hospital?
Yes Who are the High-risk patients?
High risk patients include, but are not limited
When the MDT documentation is initiated in to:
the critical care areas?  New-born infants and children (less than
Within 24 hours of patient admission. 12 years old), Emergency patients, Patients
with communicable diseases, Elderly

26
 patients (> 65 yrs. old), Immuno- - Medical/surgical needs
compromised patients, Ventilated patients (disruption of lines/tubes;
and unconscious patients, Comatose medically based
patients, mentally challenged patients, confusion/agitation that impacts
Dialysis patients. safety or care)
They are categorized as high risk because they - Presents a threat to self or others.
include patients who: - Interference with medical
 Cannot speak for themselves treatments.
 Do not understand care process - Obtain a valid physician’s order
 Cannot participate in decisions that include a justification or
 Are at increased risk for falls reason for the restraint and the
 Are at increased risk for nosocomial / or duration/time/date.
other infections 2. Assessment/monitoring of restrained
 Are mentally challenged patients:
- Monitor every two (2) hours (or
How do you restrain patients from interfering sooner depending on patient
with their treatment or procedure? need).
On the general care units, we use soft - When removed from restraints,
immobilization devices. Please Refer to document the restraint has been
Restraints Policy. discontinued.

Who should order restraint for the inpatient What are the High-risk services provided in
and how often it shall be updated? SKMC?
Treating physician should place the ‘Restraint Intensive care, Neonatology care services
order’ in the system and the order is valid for Patient with acute medical, cardiac or surgical
only 24 hours and needs to be renewed as and traumatic life-threatening conditions will
needed. admitted into these care areas for further
management, interventions and continuity of
When do we restrain a patient? care for their conditions.
When less restrictive alternatives are Emergency Services
ineffective in protecting the safety of the Patient with acute medical or traumatic life-
patient or others. Restraints should be threatening conditions will be treated at
discontinued at the earliest possible time. Emergency Department (ED) thereby
Clinical justification and other requirements requiring immediate and competent treatment.
must be documented.

What is necessary when placing a patient in

restraints?
1. Determine the reason for restraints Does the High-risk policy identify additional
(which may include): risk?

27
Yes. Additional risks identification e.g.: Deep Do we have policy for each of the high-risk
vein thrombosis, Decubitus ulcer, Ventilator patient groups?
associated infections, Blood exposure in Yes, we have.
dialysis patients, Neurological and circulatory
injury in restrained patients, Central line
infection, Falls.

High Risk Patients Policy Guiding Care

Emergency patients • Emergency Department Referral, Transfer and

Admission (D-MD-ED-01-001)

Comatose patients • Care of Unconscious Patient - Inpatient (C-NUR-

CLI-11-006)

Patients on life support • Care of the Patients on Life Support (C-MD-GEN-

01-019)

Care of patients with communicable • Transmission based precautions (C-QM-IC-05-002)

diseases

Care of patients receiving dialysis • SEHA dialysis policies

Care of patients in restraints • Assessment and Care of Patients Requiring

Restraints (C-MD-GEN-01-047)

Care of vulnerable patient • Assessment and Care of Patients who are

populations, including frail; elderly, Vulnerable and-or at High Risk (C-MD-GEN-01-
dependent children and patients at 036)
risk for abuse and/or neglect

Define pain? Yes. We have a pain management program. All

Pain is unpleasant sensory and emotional patients are assessed for pain at all patient
experience associated with actual or potential contacts. When pain is identified 5
tissue damage or described in terms of such characteristics are assessed, intensity, quality,
damage”. frequency, location and duration. A Pain
The patient’s right to receive appropriate pain Assessment Chart and re-assessment record is
assessment and effective management will be available for all age groups: neonates, children
respected and supported throughout the and adults (Refer to Pain Management Policy).
continuum of care. All patients have a right to the appropriate
assessment and management of pain and
discomfort. The key to successful pain
Does SKMC have a pain management policy? management is to have an active team
approach.

28
 condition changes and there is a need for a
When pain is identified what 5 different tool.
characteristics are assessed?
Intensity, quality, frequency, location and What are the important points staff should
duration. know when transfusing Platelet concentrate?
Platelets should always be run through new
How do you assess pain after procedure/ blood administration set.
surgery?
Pain assessment needs to be done within 15 Within how many minutes is the blood
minutes of arrival to the unit for all post- product transfusion started after receiving in
operative patients and carried out every 30 min the area?
for 2 hours then hourly for 2 hours (see pain Within 30 Minutes
management policy and care of post op
patient). Within how many hours the blood products
should be infused from issuing time?
Does Pain Management policy include age Within 4 hrs.
specific (population served) pain
assessment? How to make sure your patient and family
Yes, we use the several evidenced based pain understand the Health Education?
scales depending on the patient population. Asking them to verbalize their understanding.
Making them perform a return
When are patients assessed/ reassessed for demonstration.
pain?
Upon admission
At Least once every shift.
After pharmacological and non-
pharmacological interventions as follow:
• Oral medication: within 60 min.
• IM medication including opioids: within
60 min.
• IV medication including opioids: within What are the basic activities for the care of the
30min of administration. (but vital signs patients?
will be done immediately after the Planning and delivering care, monitoring,
administration and again every 15 min till modifying care, completing care and follow
one hour is over except for Tramal). up.
• Non-pharmacological: within 60 min.
Who should be informed about the outcomes
Can more than one pain assessment tool be of care and treatment including the
used? anticipated outcomes?
One assessment tool will be used all time Patients and their families.
when assessing the patient, unless the patient

29
Who receive nutritional therapy? What happens if family insisted to bring food
On ‘initial assessment’ patients are screened by from outside in some exceptional scenario?
the nurse to identify those at Nutritional risk. If family insisted to bring food from outside,
When identified she will inform the treating dietitian consultation will be placed to provide
physician who will request dietitian consult education.
and these patients will receive nutritional
therapy accordingly. Do we have any policy in this regard?
Yes , we have the attachment in D-NUR-CD-
Who does the Nutritional assessment and 09-017 (Visitor Entrance to Food Production
when? Area Policy) for guidance to patients and
Nutritional assessment is performed by visitors on bringing food into hospital.
dietitian upon receiving consult from the
physicians. Who is responsible for ordering and
cancelling patient diet?
Patient diet will be requested by Physician.

What are the barriers of Health Education?

 Language and education level
 Values and benefit
 Physical and intellectual level
 Willingness to learn age

Does the hospital offer patients choice of What end of life care does the organization
food preferences? provide?
Yes, patients have a variety of food preferences Managing pain, providing symptomatic
consistent with their condition and care. treatment, respecting the values & religion,
and responding to psychological and cultural
When the relatives or family bring in food preferences, involving patient and family in all
from outside for patients, who is responsible aspects of care including the decision-making
for food safety & storage? process for end of life issues.
When patient have food, brought to the
hospital by visitor’s/family member, SKMC How clinical staff responded to any changes
staff will explain visitor/family member that in in a patient condition?
the best interest of the patient, SKMC has a All clinical staff are mandated to be BLS
strict policy of serving the hospital prepared providers.
food only. Homemade or commercial foods are Repaid response team will respond to any
neither appropriate for the patient nor SKMC deterioration in patient condition.
has any storage or reheating facilities for such All nursing staff are trained during nursing
food. orientation on early warning signs.

30
We have Early Warning Scoring System and During code staffs provide Basic Life Support
Rapid Response Team or Responder policy (C- immediately and Advanced Life Support in
NUR-CLI-02-011). less than 5 minutes.
The hospital has standardized the crash carts
Tell us about the Resuscitation services in in all areas by using same type of defibrillator
SKMC? machines and making available the same
Resuscitation services are available 24 hours, 7 medications on all crash carts.
days per week.

31
ANESTHESIA AND SURGICAL CARE (ASC)

and Surgical Care. The ASC standards are

applicable settings where anesthesia and/or
procedural sedation are used, and surgical and
other invasive procedures that require
informed consent are performed.

The use of surgical anesthesia, procedural

sedation, and surgical interventions is
common, and is a complex process at SKMC.
They require complete and comprehensive Organization and Management
patient assessment, integrated care planning, Anesthesia and sedation administration and
continued patient monitoring, and criteria- use at SKMC is conducted in a uniform manner
determined transfer for continuing care, and is available 24/7. The service is overseen by
rehabilitation, and eventual transfer and the chair of Anesthesia Department, who
discharge. reports to the Medical Division Office. All
Surgery carries a high level of risk, therefore, it activities related to sedation practices,
must be carefully planned and carried out. including procedural sedation privileges for
Information about the surgical procedure and non-anesthetists, are channeled through the
care after surgery is planned, based on the Sedation Subcommittee, which reports to the
patient’s assessment, and documented. Special hospital’s Medical Executive Committee
consideration is given to surgery that includes (MEC).
implanting a medical device, including
reporting of devices that malfunction as well as Sedation Care
a process for follow-up with patients in the JCI has defined procedural sedation as “. . . the
event of a recall. technique of administering sedatives or
Informed consents for both the dissociative agents with or without analgesics
surgery/invasive procedure, and to induce an altered state of consciousness that
analgesia/sedation, must be taken prior to the allows the patient to tolerate painful or
procedures. They should be discussed with the unpleasant procedures while preserving
patients and families by a qualified physician, cardiorespiratory function.” Regardless of the
and is educated on the risks, benefits, potential medication, dose, or route of administration,
complications, and alternatives of each. when a medication is used for the purposes of
There are four areas of focus for the ASC altering the patient’s cognitive state in order to
chapter. These are: Organization and facilitate a specific procedure, it is considered
Management, Sedation Care, Anesthesia Care procedural sedation. For specific details and

32
requirements for sedation, refer to the SKMC  use and dosage of the opiate and
Procedural Sedation Policy (C-MD-ANE-01- benzodiazepine antagonists
009). • Have skills in basic airway management
and manual ventilation using the bag-mask
Which areas at SKMC is procedural sedation valve
performed? • Have current BLS certification and ACLS
• Emergency Department (adult patients) or PALS (pediatric
• Intensive Care Units - Adult and Pediatric patients)
• Endoscopy Additional requirements for clinicians
• Cath Lab monitoring patients under sedation:
• Radiology • Sedation privileges or sedation
• Dental Clinic competencies to monitor patients under
• Neurodiagnostic Department sedation
• Wards performing procedures requiring • Present throughout the procedure to
sedation monitor the patient, administer drugs as
directed by the lead physician and to assess
the effects of the sedation on the patient
• May not be involved in any other tasks
while the patient is sedated, until the
patient has recovered from the sedation or
handed over to the next care provider

Documentation Requirements for Sedation:

Requirements for non-anesthetist physicians • Pre-Sedation Assessment
to be privileged to perform / order sedation:  History and Physical Examination
• Current and valid ACLS (adult patients) or  ASA Level Classification
PALS (pediatric patients)  Airway Assessment (Mallampati
• Completion of the mandatory sedation Score)
training module in Oracle  Plan of Sedation (type and level)
• Conduct a minimum of 5 sedations according to the patient requirements
annually and procedure to be performed
• Monitoring During the Sedation and
Requirements for clinicians administering Procedure
sedation and monitoring patients under  Must be done at a minimum of 5-
sedation: minute intervals
• Trained with the:  Should include physiological
 basic pharmacokinetics and parameters as defined by hospital
pharmacodynamics of the drugs being policy
used including time of onset, duration • Monitoring After the Procedure
of action and dosing  Must be done at a minimum of 15-
 potential for synergism when sedatives minute intervals until discharge from
and analgesics are used together sedation

33
  Should include physiological  No score of “0” in any category of MAS
parameters as defined by hospital  A minimum of 30 minutes stay from
policy the last Narcotic and/or Sedative drug
• Discharge administration (e.g. OR, PACU)
 Patients are discharged if they meet the  A pain score of mild pain (numerical
score required by the Modified Aldrete scale score ≤ 3) or patient’s verbalized
Criteria tolerable level of pain
 Discharge disposition of the patient  A discharge order written from
anesthesia provider
Anesthesia Care • Variations from discharge criteria
Physician assessment requirements for  If and when Modified Aldrete’s Score
patients undergoing anesthesia: (e.g. less than 14), patient will need
• Pre-Anesthesia Assessment anesthesia review unless the score is
• Pre Induction Assessment consistent with the patient’s
 Done to re-evaluate patients preoperative status
immediately before the induction of  Under extenuating circumstances, the
anesthesia responsible anesthesiologist may waive
These two assessments must be documented in the MAS score requirements according
the patient`s record. to the physician’s clinical judgement on
the patient’s condition. A detailed
Monitoring during anesthesia: description of the circumstances shall
• Physiological status is continuously be documented in the EMR.
monitored every 5 minutes during
anesthesia administration and documented Surgical Care
into the patient’s chart • The surgical care planned is documented in
the patient record including the pre-
Monitoring after the procedure: operative diagnosis by the responsible
• Recovery area arrival and discharge times physician before the procedure is
are recorded performed.
• Nurse will provide ongoing assessments • A post-operative surgical report or a brief
(document, when appropriate) and operative note in the patient record before
manage the patient as per PACU the patient leaves the recovery room /
Admission, Assessment and Discharge transferred to the next level of care must
Policy (C-NUR-PACU-02-001) include at least the following:
• Vital signs will be taken every 5 minutes if  Post-operative diagnosis
patient is unconscious and every 10  Name of surgeon and assistants
minutes if patient is conscious  Name of procedure performed and
findings
Discharge from recovery area:  Surgical specimen, if for examination
• The criteria for discharge are:  Complications or its absence during
 A Modified Aldrete’s Score (MAS) of procedure
14/16 or return to pre procedure state

34
  Blood loss and transfused blood, or • Surgical procedures involving the
none permanent implantation of medical
 Date, time and signature of physician devices have special considerations as
• The continuing postsurgical plan(s) is outlined in the Implantable Devices
documented in the patient’s medical record Procedure attached in the SKMC Safe
within 24 hours by the responsible surgeon Surgery Policy (C-MD-GEN-01-009).
or verified by him, if written by a delegate.

35
MEDICATION MANAGEMENT AND USE (MMU)

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

& Up-to-date references. There is also built-in

drug information linked to each medication in
Cerner. Pharmacy provides drug information
anytime.

Do you have a list of medications in SKMC

What laws & regulations applies to the MMU
hospital?
process in SKMC:
Yes, we have SKMC Drug Formulary,
SEHA, MOH, DOH & Federal Laws
maintained by SKMC/SEHA Pharmacy &
Therapeutic Committee (PTC), all additions or
Do you have drug information sources here?
deletions have to be approved first by PTC.
Yes, we have Lexicomp and the SEHA e-
Library which gives us access to Micromedex
36
What do you need to do if patient clinical  Then we have to waste it/flush the drug
conditions needs a medication that is not in solution in the Pharmaceutical waste
your Drug Formulary list? (Yellow bag)
We have a policy and process to follow for  For contaminated (suspected as infected)
Non-Formulary drugs medication, we discard in (Red bag)
following the same process as mentioned
How do you manage ward stock medications above.
in your unit?  The empty syringe & needle are discarded
We have a policy for managing Ward stock. A in the sharp bin.
request to add or delete ward stock to the  This must be witnessed by another staff
nursing unit should come in collaboration & the witness co-signs on that in our
between nurse unit manager and IP pharmacy narcotic log book.
supervisor
How do you discard used Fentanyl patches?
Explain to me how you maintain secure drug  Used fentanyl patches still contain active
storage here? drug, and shall be folded as soon as it is
 Pharmacy is locked with limited access removed so that the adhesive side of the
 Only authorized staff have access to patch sticks firmly to itself, the used patch
medication rooms in the wards shall be disposed into the sharps
 Medication rooms are locked. container. The disposal shall be witnessed
 Pharmacy department is monitored by by another healthcare professional.
CCTV camera.
 Narcotics are kept in double locked Can you explain to me how you administer
cabinets. Fentanyl patches?
 Unit dose cassettes are always locked Make sure you removed the old patch, fold it
during delivery. and discard it as mentioned above. Do not
stick the used patch on the bed side, sheets or
Where do you store your stock of narcotic table. Type the date & time of administration
drugs? on the new patch.
In compliance with Federal Law:
 In a double locked cabinet inside the Who is responsible of maintaining the
medication room or secure area. medication rooms? It is a collaboration
 Register book are stored in a locked place. between pharmacy and nursing team. Nurses
 Charge nurse has the key. maintain it daily and pharmacy will check
 Physical count is being done every shift monthly.
during endorsement between out-going &  Pharmacy department has oversight over
in-coming authorized personnel. medication storage all over the hospital
 Pharmacists do monthly inspection of
Can you explain to me how do you discard the medication rooms, Findings of the
remaining of a narcotic ampoule or vial? inspection are shared with unit managers
 We aspirate the remaining in a syringe for action

37
How many times you record temperature & All bulk containers/bottles must be labelled
what is the acceptable range of temperature & once opened.
humidity? Examples:
There is a policy for this: • Nitroglycerin–(tablet) 8 weeks after
 Recording is every shift opening date.
 Room temperature range is: 18 to 25 °C • Topical–1 months after opening.
 Fridge Temperature range is: 2 to 8 °C • Insulin pens & vials –28 days after
 Freezer temperature range is: -30 to -20 °C opening in room temperature.
 Humidity should be: ≤ 60%
How frequently the pharmacy replaces the
What do you do in case the temp is outside medications in the crash carts/emergency
the range? Kits?
For any fluctuations in the medication room There is a policy for crash cart management
and fridge temperature: and for emergency drugs
 Follow the instructions on the recording  Whenever the crash cart/emergency
form boxes is opened for use for a code.
 Call Biomed Engineer  The pharmacy checks the content of the
 Call pharmacy for advise on drug storage medication drawers in crash cart either
on a monthly basis to check for
When do you remove the expired medications completeness and expiration dates
from your ward stock?
Near expired medications are removed at the How often are crash carts checked?
beginning of the month in which they are As per corporate policy of crash cart
expiring. Usually pharmacy removes them management, the Integrity of the lock on the
during the monthly inspection. . If there is no cart is checked daily and monthly by charge
replacement, it is flagged with the near expiry nurses. And additionally pharmacy checks
date. However, it is the responsibility of the monthly.
nurse to check expiry dates prior to
administration to patients Do you have pediatric supplies in the crash
cart?
Do you get informed about recalled drugs? Standardized crash carts deployed
Yes, through a recall email group. Pharmacy throughout the facility have the necessary
will inspect for recalled drugs from the patient equipment, medications, and supplies for the
care areas and the pharmacy. The recalled management of any cardiac or respiratory
drugs are returned to the pharmacy stores. arrest victim regardless of his/her age.
Broselow pediatric emergency tape, is a color-
How do you make sure that an Opened coded tape measure that is used throughout
Container of medication is not outdated? the world for pediatric emergencies. The
Refer to “Expiration Dating of Open Broselow Tape relates a child’s height as
Containers in Patient Care Areas” Chart, measured by the tape to his/her weight to
which is provided in all patient care areas provide medical instructions including

38
medication dosages, it is needed to calculate Yes. There is a policy for Medication
therapies for each child individually. Verification.
Exception is made for critical situations in:
Do you have a list of Antidotes?  Emergencies where patient clinical status
Yes, Available in the I-share. The list includes would be significantly compromised by the
guidelines for dosing antidotes. delay that would result from a pharmacist
review (such as operating room and
How do you know if the physician is emergency department)
authorized to prescribe medications here?
We have a policy “Prescriptive Authority” for  Where a physician performs or directly
who may prescribe. oversees prescribing, preparation,
Only authorized prescribers have an access in dispensing and administration and
the HIS system to prescribe medications. monitoring of the drug such as (but not
limited to) endoscopies, cardiac
Do you allow use of patient OWN catheterization, interventional radiology or
medications here? diagnostic imaging, surgery or during
We have a policy and we discourage the use cardio-respiratory arrest or other
of Patient’s own medications, but may be emergency situations.
allowed in these situations:
a) That are not part of the SKMC formulary
(Non-Formulary drugs)
b) Temporarily out of stock
c) That are available in limited stock quantity
(examples: due to rare use of medication,
procurement issues, world-wide
shortages) How the medication orders are processed in
d) Patients returning with medications from your hospital?
abroad treatment (after reconciliation with All medication orders entered through
the pharmacy) computer Physician Order Entry (CPOE) are
verified by pharmacist prior to administration.
Do the hospital permit the use of sample All in-patient medication orders that are
drugs? available as a floor stock must be placed in
No, we have a policy for sample drugs. computer Physician Order Entry (Cerner) and
a pharmacist has to verify and review such
Does the hospital permit the use of orders before medication is administered to
investigational drugs? patients.
Yes, we have a policy for guiding the use, In emergency situations, some STAT
storage, dispensing for investigational drugs. medications may be given to patient based on
a licensed physician’s order from the floor
Are all inpatient medication orders reviewed stock before being reviewed by the pharmacist.
and verified by a pharmacist?

39
The nurse has to document the administration Inpatient Medication labels shall include at a
of the medication to patients in the Medication minimum:
Administration Record (MAR) in Cerner.  Name of medical record number and
Nurses shall monitor patients as per nursing location of the patient
policies.  Generic drug name
What do you do if the medication order is  Dose, dosage from, strength and frequency
unclear or ambiguous?  Route of administration
Nurses don`t administer unclear orders.  Dispense quantity
Pharmacists contact the prescriber for  Expiry date (if not available in the unit dose
clarification. Order will be clarified/corrected package)
accordingly.  Dispensing date
 Auxiliary label and special information as
From where do you get the medications here? required (e.g. high alert, protect from light,
From Pharmacy, which is opened 24/7, there is refrigerate)
always a pharmacist to review the orders and  Medication barcoded information
dispense it.
How do you assure medications are safely
How do you handle STAT orders? administered?
 STAT and NOW orders should be All nurses who administer medications are
dispensed within 30 minutes from order DOH licensed and they have been deemed
entry time. competent and follow the hospital policies for
 Routine orders will be dispensed within 2 administering medications.
hours.
How do you identify patient before
Who prepares medications here? medications are verified, dispensed, and
Pharmacy department administered?
 Nurses prepare orders from floor stock. We use at least 2 approved identifiers: Patient’s
 Nurses will mix the IV preparations in the full name & Medical record number. We never
assigned IV preparation area in the use patient`s room number.
medication room following pharmacy IV
guidelines What are the elements for verification before
administration?
Do you have to label all IV medications here? 8 Rights for medication administration as per
Yes, all medication & IV solutions must be Nurse Administration Policy. Adhere to the
labelled if not immediately administered eight rights of medication administration
Pharmacy dispenses all IV preparations every time medication is administered.
labelled with all details needed for safe 1- Right Patient
administration. a) Verify the order against the patient
b) Identify the patient with two identifiers
Patient medication label content: 2- Right Drug
a) Check the medication label

40
 b) Check the medication order Do you have Antimicrobial Stewardship
3- Right Route Program here?
a) Verify appropriateness for patient and Yes, The Hospital has a program for antibiotic
for the dosage form. stewardship with a committee that oversees
4- Right Time the program.
a) Check the frequency of the ordered ASP team is multi-disciplinary and includes an
medication ID physician, an Infection Control nurse and
b) Verify that is it is the correct time for the Clinical Pharmacists.
dose Guidelines for use of Antibiotics and ASP are
c) Confirm when the previous dose of the available in the Policy Management System.
medication was administer
5- Right Dose What are the strategies implemented here to
a) Confirm that the dose is appropriate for ensure proper Antibiotics use?
patient age, weight, condition (i.e. renal  Antimicrobial Stewardship rounds
or hepatic function, medication serum  Antibiotic restrictions are applied.
levels), or other parameters as  Monitoring Antibiotics use through
applicable ( e.g. BSA) KPIs
6- Right Documentation  Antibiogram is reported annually
a) Document AFTER administration of
ordered medications Can you explain to me how the medication
7- Right Reason reconciliation process is performed?
a) Confirm the rational of this medication Yes
for specific to this patient and patient  Admissions
condition  It is the responsibility of the
b) Consider the need for continued physician to document a complete
administration and accurate medication history
8- Right Response for each patient at the point of
a) Reassess patient to confirm medication access to care to the best of
administration resulted in desired available information from the
effect (i.e. met its purpose) patient and the medical record of
SKMC. The physician shall also
How do you know the medication is due for reconcile the medications prior to
administration? ordering.
We have standard administration time  Transfers
schedule implemented in Cerner, and we  It is the responsibility of the
follow the MAR. transferring physician to review
Do you have to perform double checking and discontinue medications no
with another nurse for all medications? longer required for the patient.
No, Only for High Alert Medications and  It is the responsibility of the
Narcotic & Controlled medications. receiving physician to completely
review and perform transfer

41
 medication reconciliation to appendix of policy C-MD-PHA-03-307: High
(maintain, discontinue and order) Alert Medications).
of the transferred patient.
 Order sentences of high alert
 Discharges medications in physician’s view in
 It is the responsibility of the CPOE are in red font.
physician to review (maintain,  High-Alert Medications must be
discontinue and order) independently double-checked by
medications of the discharged two nurses to visually and verbally
patient. verify the accuracy of the dose and
It is the responsibility of the pharmacist to route of administration prior to
reconcile by comparing the medications the administration.
patient was taking at the time of admission  Both nurses must co-sign the (MAR) in
with that prescribed on discharge. Cerner.
 Upon storage High alert medications
Medication Reconciliation is the process of shall be segregated from other
comparing a patient's medication orders to all medications, and shall be stored in RED
of the medications that the patient has been black bins. Storage locations of high
taking. To avoid medication errors such as alert medications shall be labelled with
omissions, duplications, dosing errors, or drug a clear red ‘High Alert’ sticker.
interactions. It should be done at every  ALL Concentrated electrolytes are
transition of care in which new medications are removed from all nursing units /patient
ordered or existing orders are rewritten. care areas; with the exception of the
Transitions in care include changes in setting, Perfusionist OR trays, containing
service, practitioner or level of care concentrated electrolyte injections for
cardiac surgery, and administration
Who performs medication reconciliation will be under the guidance of the
here? physician.
Physicians.
How has SKMC responded to the
What medications are categorized as High- International Patient Safety Goal dealing
Alert Medications at SKMC? with communication of medication orders?
SKMC identified a list of high alert SKMC has adopted the Computer Physician
medications (Refer to appendix of policy C- Order Entry (CPOE) to reduce/prevent
MD-PHA-03-307: High Alert Medications). transcription errors. At the same time, we have
implemented a list of “Do Not Use”
Do you take extra precautions with “High- abbreviations that should not be used in
Alert Medications?” Cerner documentation. These abbreviations
Yes. We maintain strategies to reduce risk are not to be used anywhere in the electronic
associated with high alert medications (Refer or manual medical record documentations.

42
Do you accept verbal or telephone orders? Medications that look alike or sound alike have
Yes, there is a corporate policy. been segregated in medication storage areas to
Verbal and telephone orders for medication reduce the risk of errors.
orders in SKMC are accepted only in A list of Look Alike Sound Alike medication
emergency situations like codes or during the has been developed and distributed
procedure. We follow procedure of verbal throughout the hospital, and the list is updated
order which is (Physician identifies the based on reported incidents.
patient correctly, spells out medication order The use of Tallman is applied in the labeling
with full details, staff writes down the on the and HIS.
approved Verbal/Telephone order form as it is
being communicated then reads it back, then
physician confirms the order).
 Ordering through TEXT messages is not
allowed.
Do you have any look-alike, sound-alike
When do physicians sign the drugs in your area?
Verbal/Telephone orders or enter it in The pharmacy publishes an updated list which
Cerner? is available on every patient care area. Sound
Within 24 hours. Alike - Look Alike Medications. Examples:
ALPRAZolam LORazepam
How do you monitor Medication effects? aMILoride amLODIPine
Nurses:
 Monitoring of medication effect and side Are patients allowed to self-administer any
effect as per pharmacy drug index and medications?
reassessment of pain medication as per There is a policy.
Pain Assessment policy. Patient self-administration of medications
within SKMC is allowed for:
How does SKMC deal with “IV concentrated  Comfort medications (for example, topical
potassium?” creams) with minimal risk may be
It is included the policy “Concentrated considered for self-administration of
Electrolytes” medications by patients.
Concentrated potassium chloride and  Selected patients for medication use and
potassium phosphate are considered as High compliance for educational purposes.
alert medications and may not be stored in Selected patients shall have adequate manual
patient care units and they are dexterity and cognitive function and the ability
stored/prepared in the pharmacy only. to demonstrate sufficient knowledge of their
medications and its administration.
What are the safety measures for dealing with Self-administration of narcotics and controlled
“look alike/sound alike” medications? drugs is prohibited except when given through
Patient Controlled Analgesia (PCA)

43
Physician will prescribe it in HIS, pharmacy Nurses inform physician on duty and
dispenses it, nurse will educate the patient and supervisor to decide if patient needs treatment.
assess his ability to administer the medication Then the allergy has to be documented in
and nurse should monitor the patient while patient profile in Cerner.
self- administering the medications and dose
will be charted in MAR. How do you handle Hazardous Drugs here?
 We have a list of the hazardous drugs
What happens to medications after they are available in the system.
discontinued?  Hazardous drugs are categorized as
Discontinued medication (including IV) shall Cytotoxic, non-Cytotoxic and
be returned to pharmacy if they are Unused chemicals.
and intact in the original container. Partially  Pharmacy publishes a Hazardous
used bulk medications such as inhaler, Drugs PPE guidelines for Nurses to
ointments, etc. should be discarded in follow
pharmaceutical waste (Yellow bag)
What has been done to reduce the risk of
Do you report medication errors? How? medication errors in your area?
Yes, all staff members are expected to report All medications are being verified by
medication errors. Reporting is anonymous pharmacy before administration to patient.
and non-punitive just culture encourages All medications are being independently
reporting of medication errors. double checked by licensed pharmacist before
All medication errors reports are reviewed and being dispensed to patients or nursing units.
trended by medication safety officer with Limited concentrations of medications are
coordination of location manager where the available as per our formulary.
error has occurred. Developing the strategy to reduce harm and
Medications errors are reported by completing the precautions for High-Alert Medications.
the Safety Intelligence (SI) report in the system. Established a process of independent double
checking during preparation, dispensing and
Do you report Near miss incidents? administration.
Yes, through Safety Intelligence as well, it is a Identifying patients using 2 unique identifiers
good opportunity to learn and improve our before drug administration – Full Name and
processes. Medical Record number.
High Alert Medication, Narcotics, before they
Can you tell me the difference between administered the drugs to patients are
medication errors and adverse drug independently double checked.
reactions? If patient has a known allergy documented in
Adverse drug reactions are Non-preventable. patient profile, it will give an alert if ordered
again, also it shows on patient information
And how about adverse drug reactions, how banner in patient profile, and it shows on any
do you report them? medication label for this patient.
Report the ADR in Safety Intelligence.

44
Refer to the different pharmacy policies in the Is it allowed here to share INSULIN pen
SKMC Policy Management System. devices between patients if we change the
needles?
What are the PPEs you need to handle High No, it is not allowed to share insulin pens to
Risk Hazardous Drugs? avoid infections and medication errors with
insulin pens, each patient has his insulin pen
labelled from pharmacy. Pharmacy attaches
the patient label on the pen barrel not the cap
to avoid mix up of insulin pens in nursing unit.
Nurse administers insulin as per dose and
protocol. Insulin is a high alert medication and
2 nurses have to double check prior to
administration and co-sign in e-MAR.
The expiry date of INSULIN pens is 28 days
after opening and to be stored in patient
cassette drawer.

How do you monitor the effects of

medications on patients?
There is a multidisciplinary approach in
SKMC to monitor the effect of medication in
patients;
The Multidisciplinary Approach as:
 Pharmacy: Drug-drug interactions, Drug-
food interactions, adverse drug reactions
reporting in SI System and patient
electronic file.
 Laboratory results: sub therapeutic or
toxic levels/labs.
 Each health care provider is eligible to
How do you store multi-dose vials after evaluate patient for a suspected adverse
opening? drug reaction in SI System and patient
Pharmacy publishes “Expiration Chart for electronic file.
Open Containers” for all the patient care areas.  Nursing documentation in Cerner,
All Multi-dose vials are labelled & dated upon reports Side effects, Adverse drug reaction
first use, Check rubber integrity before use. reporting.
Nursing and Physician monitor the therapy
outcomes.

45
PATIENT AND FAMILY EDUCATION (PFE)

SKMC provides education that

supports patient and family
participation in care decisions
and care process.
All education activity at SKMC
is overseen and coordinated
through PFE taskforce.
Patient and family education
helps patients to participate in
their care and to make informed
care decisions. All staff that
interact with the patient, families/significant others and participate in their care are responsible
to provide comprehensive multidisciplinary patient education.
Effective education thus begins with assessment of patient and family learning needs.
Education needs to be a coordinated effort among the health care staff so that education is
individualized and focuses on what the patients / families need to learn.
The purpose of patient education is to improve healthcare outcomes by educating patients and
their families in the promotion of healthy behaviours which aid recovery and encourage them to
adopt a healthier lifestyle through a multidisciplinary personalized educational approach.
The main goals are: -
 Reduce patient/ family anxiety related to disease or hospitalization.
 Enhance patient’s and family’s ability to participate in healthcare decisions
 Ensure the educational needs of each patient are assessed and recorded to maximize the
health promotion encounter.
 Provide patients/ families with current and accurate information in order to maintain a
healthy lifestyle and/ or cope with their illnesses.
 Reduce unnecessary utilization of healthcare services. (E.g. Unnecessary OSC/ ED Visit,
readmission)
 Enhance patient and families’ ability to understand health status/ prognosis/ outcome.


Learning needs SHOULD BE ASSESSED

/REASSESSED: -
o UPON patient admission
o On daily base and when patient’s condition
or needs change.
o Before discharge.
When are your patient’s education needs o Each outpatient visit
assessed/ reassessed?

46
Documentation evidence needs to be available  The plan of care, treatment and services,
in patient Medical record (DOCUMENTED IN disease process and diagnosis.
I VIEW  Safe and effective use of medication and
medical equipment
What is the patient education process?  Medication, Potential interaction
Education process consists of the following between medication and other /food
steps: -  Warning signs and when to get
 ASSESS (Assess patient learning needs& immediate medical care
Assess educational barriers, health  Anesthesia and surgical consent
education history)  Pain Management
 Plan the education  Community resources
- Whom to be taught?  Affective : Rehabilitation technique,
- Individualize the educational plan attitude, Beliefs and values
based on learning needs assessment,
patient condition and patients’ goals What are the learning barriers you may face
and objectives. during patient and family education?
- Select the appropriate method of The learning barriers include: -
education (demonstration, explanation,  Language and education level,
printed material, audio-visual materials  Values and beliefs,
…etc.)  Physical and intellectual level
 Implement the education: choose the  Readiness to learn,
appropriate education moments, create a  Age and culture
proper learning environment, You should  Sensory impairment
have the knowledge, time and  Pain and acuity of illness
communication skills
 Evaluate the effectiveness of education In case of language barrier or low literacy level
(return demonstration, verbalization, needs  Bring translator
reinforcement …etc.)  You can draw and explain.
 Document in SALAMTAK  Provide information in simple words and
 Reassess /refer (consultations) ask patient to verbalize his/her
understanding by using his/her own words.
What are the recommended educational topics  If patient is a child and cannot understand,
to be provided to the patients and their educate parents and use pics
families?
The patient is educated about the following and Who is responsible for patient and family
other as per learning needs assessment: education at Sheikh Khalifa Hospital?
 Psychomotor: Physical skills such as Patient education is integrated process and it’s
injection usage, machines usage…etc. the responsibility of all health care providers
 Cognitive: Knowledge and (physicians, nurses, dietitians, physiotherapist,
understanding of facts such as respiratory therapists. etc.) To provide

47
comprehensive multidisciplinary patient Documentation by multidisciplinary team
education. occurs on SALAMTAK PATIENT RECORD

How do you select the Educational Methods?  Doctors: power Note

 Educational methods and learning  Ancillary & Nurses: power chart- AdHoc
resources should be selected according to  Learning needs assessment in I /View
 Disease and Patient Condition,  To view the previous education done by
 Learning needs, Age-specific and Patient other health care providers check document
learning preferences viewing.

How will you manage in case of language What resources are available to assist you with
educational barrier? patient education?
 Utilize the multinational staffs available in  SKMC patient and family education policy
your unit /clinic if the language you need is  Printed educational material in Arabic and
not available. English.
 Check the language assistant directory in  SEHA portal/ Tathqeefi , SEHA eLibrary-
SKMC iShare. Lippincot Advisor, Lexicomp Handouts,
 If the language you need still not available Drugs handouts
in the directory.  Trained health care providers for specific
 There is an Interpreter Services under diseases (Diabetes, RT, PT, dietitians and
Nursing Division available on SKMC lactation consultant)
Portal.

How do you document Patient/Family

education?

48
QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS)

The goal is to support SKMC with comprehensive approach ensuring Medical Staff, Nursing
Staff, Allied Health Staff and Administration staff will work in collaboration to quality
improvement and patient safety that influences all aspects of facility’s operation.
Sheikh Khalifa Medical City’s (SKMC) Quality Improvement and Patient Safety (QIPS) program
provides a framework to monitor, assess and improve the quality and safety of care delivered to
patients, leading to a timely, effective, efficient, and patient centered healthcare system.
This approach includes:
 Department-level input and participation into the quality improvement and patient safety
program;
 Use of objective, validated data to measure how well processes work;
 Effectively using data and benchmarks to focus the program; and
 Implementing and sustaining changes that result in improvement.

In addition, to ensure both quality improvement and patient safety, SKMC QIPS programs are:
 Leadership driven;
 Seek to change the culture of an organization;
 Proactively identify and reduce variation;
 Use data to focus on priority issues; and
 Seek to demonstrate sustainable improvements.

The SKMC QIPS program is aligned with

 SEHA’s vision, mission and values, and its strategic themes and initiatives
 SEHA’s Quality Department Objectives
 Emirate of Abu Dhabi’s Department of Health (DOH) requirements.
 Joint Commission International (JCI) standards

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

49
 link between Quality Department and their
department staff and assist in identifying,
prioritizing, evaluating, monitoring,
improving, sustaining, and validating their
quality activities outcomes through using
quality tools and methods.
What is our Approach (method) to
performance improvement? How are the What is your responsibility for improving
staff and physicians involved in performance care and services?
and continuous improvement? It is everyone’s responsibility to look for
The overall program for quality and patient opportunities to improve care and services.
safety in a hospital is approved by the When you see opportunities, discuss them
governing entity SEHA, with the hospital’s with your Department Head and participate in
leadership defining the structure and making improvements. Also, incorporate
allocating resources required to implement the performance improvement principles and
program. values into your everyday work processes.
Leadership identifies the hospital’s overall
priorities for measurement and improvement, How has your department improved care or
with the department/service leaders services in the last 12 months?
identifying the priorities for measurement and Surveyors often ask staff to explain staff role in
improvement within their department/service. improving care. Plan ahead and speak with
a) All performance improvement activities in confidence about something you or your
the hospital are guided by the annual department did to improve care or services for
Quality Improvement and Patient Safety patients/ families. Your department manager
(QIPS) plan (C-ORP-PIA-01-001). can help you prepare for this question. When
b) All staff and physicians are responsible for possible, the answer should be expressed in
and involved in performance improvement measurable outcome statements, e.g., we
activities through KPIs and PI Projects reduced fall rate from X to Y) or we increased
either through ongoing data collection, patient satisfaction rate from A to B).
analysis of results, development of action
plans, and/or measurements of success or What is a function or process that you have
team participation in Performance personally improved in your area?
Improvement projects. Be confident to explain the continuous
c) The SKMC Quality Council monitors the improvement activity/project you are involved
performance and continuous improvement in. Or give example of any Best practices you
activities reported by every Department were involved in and have sustained.
and provides required support and
guidance. How is Performance Improvement (PI) or
d) In addition, all departments have Quality continuous improvement projects chosen?
Ambassadors/Champions who serves as a

50
Priority is given to high-volume, high-risk, The quality program staff are constantly
high-cost or high problem prone Processes and involved in training and communicating
any regulatory body/accreditation body quality and patient safety issues throughout
requirements and performance measures. the hospital. SKMC Hospital Quality Dept.
In addition, the Key Performance Indicators Staff are assigned as quality link and advisory
(KPIs) are selected based on strategic priorities member to every Clinical and Non-Clinical
set by SEHA. Institutes/Departments.
In the SKMC portal, there is also Quality
Do you know the results and Department site where all the information,
recommendations for the QI projects done on quality resources/materials, Quality and
your Unit/Department? performance reports, Clinical Quality and
If asked, be prepared to show the surveyor the patient safety measures, Regulatory KPIs,
Performance Improvement Project reports for Quality improvement projects, etc. are
your unit / Department Quality activity data published and communicated. Quality Dept.
shown in your Quality Board. E.g. Staff are integral part of Quality Council and
Department/Institute KPI tracking, the QI Quality Staff attend Quarterly meetings.
Projects submitted during Quality Week
celebrations. The projects uploaded in SKMC What are Performance Measures/Key
Quality Management iShare site under Quality Performance Indicators (KPIs)?
Improvement Project Database. Performance Measures/KPIs are a set of
What Performance Improvement model is quantifiable measures that the organization
used at SKMC? uses to measure the performance over time. It
SKMC uses PDCA Cycle/Deming Cycle. is also called Key Performance Indicators
(KPIs).

Why are Performance Measures important?

Measurement is a critical part of testing and
implementing changes; measures tell a team
whether the changes they are making actually
lead to improvement. With Performance
Measures in place we can set appropriate
goals, develop strategies to reach them and
evaluate our progress.
An important use of performance
How does Quality Department communicate measurement is to provide feedback to clinical
quality information to hospital wide staff practitioners on their actions. Performance
with regard to quality improvement and measurement systems should be monitored
patient safety strategies, quality frequently to ensure alignment with other
improvement resource, quality measures health system mechanisms and to identify
outcome, issues and areas of improvements? areas for improvement.

51
In SKMC, what are the different Performance Department leads are communicated to Senior
Measures/ KPIs, being monitored? Management Committee and action plans are
SKMC monitors Performance Measures from addressed accordingly.
SEHA and DOH, in addition to
Service/Department specific KPIs. In SKMC, what system is used to report
incidents, near misses, risks
What are some of your departmental KPIs events/occurrence variance?
and how are you performing on them? Safety Intelligence (SI) system is our reporting
Be prepared to answer this question in system for incidents, near misses, sentinel
consultation with your Department Head or events and risks/unsafe conditions related
Manager. You can find the results for SKMC patient, staff, facility, and visitor issues. (Learn
KPIs on Quality Management iShare site which how to locate and access and use Safety
is updated on a regular basis. Intelligence (SI) system).

What is Data validation and what is the How are Incidents Scored?
process adopted in SKMC for Data  Unsafe conditions / near-misses are scored
validation? Harm Score 1 – 2
Data validation is an important tool for  Incidents that reached patients are scored 3
understanding the quality of the data and for -5
establishing the level of confidence decision  Incidents whereby harm caused to patients
makers can have in the data. Data validation are scored 6 - 9
becomes one of the steps in the process of
setting priorities for measurement, selecting What is a Sentinel Event?
what is to be measured, extracting or collecting A Sentinel Event is an unanticipated
the data, analysing the data, and using the occurrence of patient safety event that reached
findings for improvement. a patient and resulted in death, permanent
Refer to SKMC Policy C-QM-PIA-01-007 Jawda harm or severe temporary harm, not related to
Performance Management Policy. the natural course of the patient’s illness or
underlying condition. Definition of
How are the Departmental and Institute Occurrences that Must Be Reported under the
Level Quality improvement tasks, process Sentinel Event Policy at SKMC are:
and outcomes - Key Performance measures 1. Suicide
and also challenges communicated to SKMC 2. Unanticipated death of a full-term
Leadership and Quality Dept.? infant
3. Discharge of an infant to the wrong
SKMC have structured Quality Council Team family
chaired by CEO and CQO. Quarterly Forum 4. Abduction of any patient
meeting scheduled with Institute/Department. 5. Elopement
Every Institute and Department leads presents 6. Hemolytic transfusion reaction
Quarterly the Quality improvement and 7. Rape, assault
patient safety reports. The challenges raised by

52
 8. Surgery on the wrong patient, wrong communicate the lessons learned to the
site or wrong procedure concerned department. Refer to C-QM-PIA-
9. Unintended retention of a foreign 01-005: Sentinel Event Reporting Policy.
object in a patient after an invasive
procedure/surgery. How does the organization identify and
10. Severe neonatal hyperbilirubinemia reduce adverse events and safety risks?
11. Prolonged fluoroscopy It is through Risk Assessment and Failure
12. Fire, flame, or unanticipated smoke/ Mode and Effects Analysis (FMEA). An FMEA
heat/flashes occurring during patient is a team-based, systematic, and proactive
care. approach for analyzing a high-risk process and
13. Any maternal death or severe maternal identifying ways the process can fail, why it
morbidity (related to the birth process). might fail, and how it can be made safer. Its
Please refer to SKMC Incident Reporting and purpose is to prevent problems before they
Management Policy (C-QM-PIA-01-003), occur.
Sentinel Event Reporting Policy (C-QM-PIA-
01-005) for details of types of Sentinel event to As per JCI, what are the 5 categories of risks
be reported as required by SEHA as well that would impact a hospital?
Regulatory body (DOH) There are several categories of risks that can
have an impact on hospitals. These categories
What will you do if you identify or are of risks include
involved in a Sentinel Event or Potential  Strategic (those associated with
Sentinel Event? organizational goals);
 Remove any immediate threat or danger to  Operational (plans developed to achieve
the patient or facility organizational goals);
 Notify your Manager and Quality  Financial (safeguarding assets);
Department (follow C-QM-PIA-01-005:  Compliance (adherence to laws and
Sentinel Event Reporting) regulations); and
 Report the incident through Safety  Reputational (the image perceived by the
Intelligence System public).

How are Sentinel Events managed at SKMC? What are the essential components of SKMC
Once a Sentinel Event is identified, Quality Clinical Risk Management Program?
Department will notify DOH and SEHA, SKMC has developed a Clinical Risk
submit a Preliminary Assessment Report, Management Program (C-ORP-PIA-01-002)
coordinate with involved department/s for A which includes the following essential
Root Cause Analysis (RCA), submit RCA and components
action plan to DOH and SEHA within 45 days 1. Risk identification: Sources of information
from the date of the event or when made aware include proactive risk assessments, adverse
of the event. event reports, past accreditation or
Quality Department will ensure action plan is licensing surveys, medical records audits,
implemented following an RCA and will

53
 quality improvement and patient safety  Reporting all unanticipated events in
committee reports, etc. accordance with the incident reporting and
2. Risk analysis through different methods as sentinel event policies.
Root-cause analysis, Failure mode and
effects analysis and process reviews. What is Root Cause Analysis/RCA?
3. Risk prioritization according to the risk’s A Root Cause Analysis (RCA) is a systematic
inherent severity , Probability and approach to understanding the causes of an
detection as well as in the context of the adverse event and identifying system flaws
hospital’s strategic priorities and resources that can be corrected to prevent the error from
4. Risk control by lowering the probability of happening again.
an adverse event (i.e., loss prevention) and  RCAs are retrospective: they look back at
eliminating, or minimizing harm to an error that occurred.
individuals and/or the  RCA is not appropriate in cases of
financial/reputational/ Strategic/ negligence or willful harm.
Operational/ Compliance severity of losses  Laying events out in chronological order is
when they occur (i.e., loss reduction) one way to understand the past, but when
5. Risk monitoring by evaluating the we start to group events into categories, we
effectiveness of actions taken to control begin to see them in a different way.
risks and evaluating the Clinical Risk  Focusing on system causes, rather than
Management Program blame, is the central feature of root cause
analysis.
 An RCA team consists of four to six people
from a mix of different professionals.
 It’s important for clinical and
administrative leaders to support RCAs.

How do you as a staff are committed to

Quality Improvement, Patient Safety and
Risk Management?
Answer as relevant and keep some examples
ready.
 By participating in performance
measurement (KPIs) or improvement (PI
project) activities, as assigned.
 By submitting ideas for improvement to
your manager
 Reporting any safety risks or concerns.

54
If a sentinel event occurs, Root Cause Analysis Safety Intelligence (SI) web based system is
(RCA) is performed to determine the “root used. SI is Web-based reporting tool used in
cause” of the event, and make necessary capturing information about safety-related
changes to structure/processes to prevent it incidents, near misses, unsafe conditions
from happening again. reviewing; analyzing and identifying trends to
The RCA must be completed within 45days of assist improve healthcare services, processes
event occurrence/identification. Each RCA is and environment.
followed up with action plans.
One useful tool for identifying factors and What is SKMC Risk Management program?
grouping them is a fishbone diagram (also The SKMC Clinical Risk Management program
known as an “Ishikawa” or “cause and effect” provides a framework to monitor, assess and
diagram), a graphic tool used to explore and improve the quality and safety of patient care
display the possible causes of a certain effect. delivered, leading to a safe integrated
healthcare system serving the people of the
What system does SKMC Hospital staff use Emirates of Abu Dhabi.
to report sentinel events, incidents, near
misses, unsafe conditions, risks
events/occurrence variance?

55
PREVENTION AND CONTROL OF INFECTIONS (PCI):

The goal of the organization’s Prevention & Control of

infection program is to identify Healthcare Associated
Infection (HCAI) and to reduce the risks of acquiring
and transmitting infections among patients, staff,
doctors, contract workers, volunteers, students and
visitors within SKMC Hospital by envisage the
strategy to minimize the risk of acquiring HCAI by
developing appropriate policies and procedures,
providing staffs, patients and visitors education in
infection control, and ensuring that policies and
practices in infection control have been implemented
throughout SKMC Hospital.

SKMC establishes and maintains a comprehensive

Infection Prevention and Control Program within the standards of regulatory agencies of UAE, JCI,
and the recommendations of CDC and guidelines of DOH. The prevention and control of infection
manager, infection Preventionist team are assigned to carry out the daily functions of the Infection
Prevention Program as outlined by the Prevention & Control of Infection Control Committee (PCI).
Unit managers and each health care providers are responsible for ensuring the compliance with every
infection prevention control policies of SKMC

Everyone in the hospital.

What are the information resources available

for PCI program?
 PCI SKMC policy manager.
 SEHA ,DOH & EHSMS Guidelines
Which are the two major goals of PCI  Centre for Disease Control (CDC, USA),
program? WHO, APIC& NHSN guidelines.
Goal 1: Protect the patient, from acquiring a
healthcare associated infection from the How does PCI committee concerns/updates
hospital are communicated to the frontlines?
Goal 2: Protect the healthcare worker, visitors PCI consists of multidisciplinary team. Each
and others from acquiring a healthcare team takes back the info to their relevant team.
associated infection while working in the Updates are communicated thru weekly
hospital. Nursing Leadership meetings also thru unit
meeting huddles.
Who is responsible for implementation of
PCI program?

56
Have you received education on PCI? How 4. Sharps safety (engineering and work
often are you required to attend in-service practice controls).
education on PCI? 5. Safe injection practices (i.e., aseptic
There are two separate PCI education technique for parenteral medications).
programs exist in the hospital. The PCI 6. Sterile instruments and devices.
orientation education is given to all employees
at the time of joining the employment in What are transmissions based precautions?
SKMC. The second PCI mandatory online Transmission-Based Precautions are the
education and quiz is compulsory for all staff second tier of basic infection control and are to
to complete once in a year. Unit Nurse be used in addition to Standard Precautions for
Educators, educate front liners on relevant patients who may be infected or colonized with
infection prevention competencies. certain infectious agents for which additional
Infection Preventionists educate the frontline precautions are needed to prevent infection
team on respiratory protection program, transmission
Prevention Bundles, PPE donning/doffing Contact Precautions
training etc...  Use Contact Precautions for patients with
known or suspected infections that
How do you prevent the spread of infections represent an increased risk for contact
among patients, visitors, employees & in transmission. Example –any patient with
hospital environment? Multi Drug Resistant organism
By complying with IPC policies and colonisation/Infection (as decided by PCI
procedures which is not limited to Improve Committee during the annual RA or as
compliance with Standard Precautions, Hand directed by SEHA/DOH.), patients with
Hygiene, Transmission Based precautions, viral haemorrhagic fever, patients with
Respiratory protection program etc… diarrhoea etc.
 Ensure appropriate patient placement in a
What are Standard Precautions? single patient space or room if available in
Standard Precautions are the minimum acute care hospitals
infection prevention practices that apply to all
patient care, regardless of suspected or
confirmed infection status of the patient, in any
setting where health care is delivered. These
practices are designed to both protect DHCP
and prevent DHCP from spreading infections
among patients. Standard Precautions include
Hand hygiene:  Use personal protective equipment (PPE)
1. Hand hygiene. appropriately, including gloves and gown.
2. Use of personal protective equipment (e.g., Wear a gown and gloves for all interactions
gloves, masks, eyewear). that may involve contact with the patient or
3. Respiratory hygiene / cough etiquette. the patient’s environment. Donning PPE
upon room entry and properly discarding

57
 before exiting the patient room is done to  Use personal protective equipment (PPE)
contain pathogens. appropriately. Don mask upon entry into
 Limit transport and movement of the patient room or patient space
patients outside of the room to medically-
necessary purposes. When transport or
movement is necessary, cover or contain
the infected or colonized areas of the
patient’s body. Remove and dispose of
contaminated PPE and perform hand
hygiene prior to transporting patients on
Contact Precautions.
 Use disposable or dedicated patient-care
equipment (e.g., blood pressure cuffs). If  Limit transport and movement of
common use of equipment for multiple patients outside of the room to medically-
patients is unavoidable, clean and disinfect necessary purposes. If transport or
such equipment before use on another movement outside of the room is
patient. necessary, instruct patient to wear a mask
 Prioritize cleaning and disinfection of the and follow Respiratory Hygiene/Cough
rooms of patients on contact precautions Etiquette.
ensuring rooms are frequently cleaned and
disinfected (e.g., at least daily or prior to Airborne Precautions
use by another patient if outpatient setting) Use Airborne Precautions for patients known
focusing on frequently-touched surfaces or suspected to be infected with pathogens
and equipment in the immediate vicinity of transmitted by the airborne route (e.g.,
the patient. tuberculosis, measles, chickenpox,
disseminated herpes zoster).
Droplet Precautions  Source control: put a mask on the patient.
 Use Droplet Precautions for patients  Ensure appropriate patient placement in
known or suspected to be infected with an airborne infection isolation room
pathogens transmitted by respiratory (AIIR) If AIIR is not available masking the
droplets that are generated by a patient patient and placing the patient in a private
who is coughing, sneezing, or talking. room with the door closed will reduce the
Examples are Bacterial Meningitis, likelihood of airborne transmission until
Pertussis, and Mumps. the patient is either transferred to a facility
 Source control: put a mask on the patient. with an AIIR or returned home.( Ensure a
 Ensure appropriate patient placement in a portable air purifier is place in the room in
single room if possible. In acute care such scenarios)
hospitals, if single rooms are not available,  Restrict susceptible healthcare personnel
utilize the recommendations for alternative from entering the room of patients known
patient placement considerations in the or suspected to have measles, chickenpox,
Guideline for Isolation Precautions. disseminated zoster, or smallpox if other

58
 immune healthcare personnel are Pressure, Paper strip will be blown
available. inward.
 Use personal protective equipment (PPE)  Engineering will do daily checking of
appropriately, including a fit-tested the air pressure countersigned by the
NIOSH-approved N95 or higher level charge nurse.
respirator for healthcare personnel.  If the reading is changed to POSITIVE
 Limit transport and movement of (+) Permanently, Call Facilities
patients outside of the room to medically- department immediately.
necessary purposes. If transport or
movement outside an AIIR is necessary, Do you have a Triage or screening tool for
instruct patients to wear a surgical mask, if communicable disease?
possible, and observe Respiratory Yes – It is part of ED triage assessment tool
Hygiene/Cough Etiquette. Healthcare This tool can be used in ED, OSC and in
personnel transporting patients who are on inpatient.
Airborne Precautions do not need to wear a
mask or respirator during transport if the What are the 3 elements in the Communicable
patient is wearing a mask and infectious disease screening tool? Three I’s
skin lesions are covered.  Identify signs and symptoms and exposure
 Immunize susceptible persons as soon as history (Travel, sick/Animal contact)
possible following unprotected  Isolate and use PPE
contact with vaccine-preventable infections  Inform –supervisor, Infection control and
(e.g., measles, varicella or smallpox). DOH

What is AGP? What is the process of isolating a patient?

AGP- Aerosol Generating Procedures such as Nurse can initiate the isolation physically by
nebulization, suctioning, placing the patient in the room with isolation
intubation/extubation, bronchoscopy etc. poster then entry in Cerner with date and time
started
What is TNPI? Nurse documents in the admission screening
TNPI- Temporary Negative Pressure Isolation. isolation entry or the 1st isolation entry put
An alternative for AIIR where you place date and time started and sends to physician
airborne infectious patient in a private room for Verification and signature.
with HEPA filter. SKMC IPC policy manual has reference for
specific isolation guidance. Infection
How is Negative Pressure Room (AIIR) Preventionists and IC oncall can be another
checked? resource when needed
 A digital monitoring device is located
in front of isolation room that shows What is cough/Respiratory etiquettes?
the air pressure reading. It is part of standard precaution practices
 Tissue paper check – can also be used to where it prevents the spread of infection by
determine if the room is Negative

59
covering the mouth with tissue or placing Doffing: Gloves, goggles (or face shield),
mask while coughing. gown, surgical mask, hand hygiene.

What are blood borne pathogens? Do you use sharps containers for all sharps?
Blood borne pathogens organisms found in How are the containers disposed of? Who is
blood and certain other body fluids that, if responsible for disposing of them?
transmitted, are capable of causing disease in a In SKMC sharps containers (robust puncture
contacted person e.g. Hepatitis C (HCV), proof) are located in all areas where sharps are
Hepatitis B (HBV), and HIV (the virus that used. When the sharps container is 2/3 filled,
causes AIDS) are the main blood borne the nurse seals them and HK staff place the
pathogens. container in red bag. HK will place it in big
waste container in dirty utility room to be
Where do you disposed of infectious waste? collected by HK staff. It will be stored in locked
Red waste bag medical waste room until it will be collected by
contracted waste company for processing.
Where do you disposed of domestic waste?
Black waste bag What is the proper method of needle
disposal?
What is PPE? Give examples. Avoid recapping. Dispose in the sharp box at
Personal Protective Equipment (gown, mask, the point of use.
goggles, gloves, head cover when necessary)
What do you do when you sustained Needle
When to use and discard Personal Protective stick Injury or Sharp injury?
Equipment?  During Business Hours (0800 -1600,
 Personal Protective Equipment is used Sunday-Thursday): Employee contacts
when we anticipate a blood or body fluid OH Clinic and goes to the OH clinic to have
exposure or any kind of contamination. initial assessment as a ‘walk in’- register at
 PPE is removed after that procedure before Central Registration
coming out of the room.  Outside of Business Hours: Employee
 PPE should not be worn in the hallways in reports to Emergency Department (ED),
appropriately Surgical Pavilion if the incident occurs
Surveyor will look for the appropriate use of during the period of 1600 to 0800 hours, on
each PPE. Know the rationale of use if asked. weekends or holidays.
 Employee informs immediate supervisor /
Do you know the location of PPE In your person in charge in their department.
unit?  Employee completes an occurrence report
If not, find out from your Unit Manager using Safety Intelligence (SI) online.

Donning/Doffing sequence of PPE. How would you handle blood or body fluids
Donning: Hand Hygiene, gown, surgical mask, spill in a unit?
goggles or face shield (if required), gloves

60
 Ensure isolation of spill area by placing wet We follow WHO 5 moments of hand hygiene,
floor board or alerting nearby staff about and they are
the spill  Before touching a patient,
 Call the housekeeping  Before clean/aseptic procedures,
 After body fluid exposure/risk,
How do you care for a patient with TB?  After touching a patient, and.
Follow Air borne isolation precautions.  After touching patient surroundings
Patients with TB or suspected of having TB Wash hands after completing personal
preferably be kept in isolation room with functions such as using the restroom and
negative pressure. Healthcare worker or any before and after eating.
person entering in the room or examining the
patient with TB must wear N95 mask. Any staff How do you wash your hands?
who provides care to the TB patient has passed Wash all surfaces of hands with soap and
in the N95 fit test. water, make lather with rubbing hands
together, being careful to clean under and
How often N95 fit testing is done for around fingernails and ends of fingers
healthcare workers with direct contact with following the WHO 6 techniques for hand
patients? hygiene for 15 -20 seconds.
Yearly and whenever staff had a major weight
gain or loss or had any major facial Do you know the six steps/techniques of
reconstructive surgery. hand hygiene and can you correctly perform
it?
Do you know your Hepatitis B antibody titer?  Rub hands palm to palm
If No please have it tested or check with  Right palm over left dorsum with
Occupational health clinic interlaced fingers and vice versa
for record.  Palm to palm with fingers interlaced
 Back of fingers to opposing palms with
What is the normal Hepatitis B protective fingers interlocked
antibody titer?  Rotational rubbing of left thumb clasped
>10miu/ml. in right palm and vice versa
 Rotational rubbing, backwards and
Did you receive the seasonal influenza forwards with clasped fingers of right
vaccine? hand in left palm and vice versa
It is highly recommended for healthcare
workers to receive seasonal influenza vaccine When should you decontaminate hands
every year to protect themselves and their using the alcohol-based hand rub?
patients from the serious consequences of When hands are not visibly soiled or
influenza which include H1N1 strain. contaminated with blood/body fluids
following the WHO 6 techniques for hand
When should you wash your hands? hygiene for 20 -30 seconds or until dry.

61
Do you know the WHO five moments of Do you know emerging and re-emerging
hand hygiene? infections of recent times which affected
1. Before patient contact SKMC?
2. Before any aseptic procedure Covid 19 Pandemic Crimean Congo
3. After contact with blood and boy fluids Haemorrhagic fever, PTB. Etc.
4. After Patient contact
5. After contact with patient’s environment What are the Cleaning and disinfecting
solution used for equipment?
How do you notify Infectious diseases and Cavi wipes - Use 2 wipes (First wipe to pre-
occurrence of infections in your ward/unit? clean the surface. Second wipe to disinfect the
Through notifying infection control team and surface). Wait for 2-3 minutes to use the surface
through electronic Infectious disease again. Wet contact time: 2- 3mins
notification (IDN) to DOH. Biotek & Cryoside - Clean the surface with
biotek, then wipe cryoside wait for 10 minutes
What type of PCI Key performance indicator then wipe it off.
is run on monthly basis in every clinical unit? Bleach- used for spore forming microorganism
Hospital acquired, (C.difficile) and Ebola viral disease (EVD)/
 VAP/VAE - Ventilator Associated Crimean Congo Hemorrhagic fever (CCHF).
Pneumonia/ Ventilator Associated events Contact time is 10 minutes.
 CLABSI - Central Line Blood Stream
Infection Do you use point of use cleaning before
 SSI - Surgical Site Infection sending the used instruments to CSSD?
 CAUTI - Catheter associated Urinary Tract Yes-We used enzymatic form solution to keep
Infection the instruments wet and prevent drying of
 MDRO-Multidrug resistant organisms debris immediately after procedure.
 Hand Hygiene The instruments are then stores in a leak proof
 Central line bundle compliance container and CSSD collects it.

Where you can look for PCI data, and audit or How do you ensure the sterility or expiry of
stats reports? Sterilized instrument?
In the unit based Quality Board. It is event related (No expiry date) - Items are
considered sterile unless the integrity of the
Do you know if anyone monitoring Hand packaging is compromised (wet, Open,
Hygiene in your unit? What is the compliance damaged)
rate?
Infection Control Links is monitoring the HH Do you have an antibiotic stewardship
in each month. Compliance rate is uploaded in program (ASP)? Do you have a policy?
Nursing I SHARE SITE. Yes. SKMC have an active Antibiotic
stewardship Committee chaired by ID
department chair and liaison with,
Microbiology, clinical pharmacy, and Infection

62
control team, to provide guidance to front line emergency response system and or
clinicians on judicious and proper use of organization resources.
antibiotics, review and update annual
antibiogram in view of local epidemiology Responsibilities:
guided by antimicrobial annual report 1. Emergency Department:
Notification:
What is Code DELTA? Nursing supervisor/Bed Manager/
This plan is designed to outline the basic Prevention and Control Infection Manager
infrastructure and operating procedures E-notification to DOH
utilized to mitigate, prepare for, respond to Patient Placement:
and recover from infectious disease mass Liaise with Bed manager to admit the
causality situations that impact the routine patient directly to the assigned unit as per
operating capabilities of SKMC facilities. Code Delta patient placement options if it
To provide for an effective response to a real or is a highly infectious disease (HID) case,
risk of influx of infectious patients getting referred/ transferred to SKMC with
To establish a plan for management of pre referral.
potential & actual mass causality caused by If the patient is already at the door, then
Infectious Disease. Entity that may present at triage the patient in EDA Room 15 and
any point of entry into the SKMC Healthcare admit the patient as per Code Delta patient
system placement options after consultation with
To ensure that SKMC is better prepared to Infection Control
effectively recognize and respond to an If it is cluster of other infectious disease
infectious disease mass causality event cases, follow ED infectious disease
Purpose of Code Delta Activation: management as per P-A-6 Appendix of
Alert/activate designated staff to respond and EOP.
prepare for receipt of surge of Infectious Patient Transfer: Ensure patient is safely
patients beyond the capacity of the transferred to assigned room/unit/hospital
organization or Highly Infectious disease that as per Code Delta procedure and disease
overwhelms the emergency response system. specific guidelines.
Code Delta Alert versus Code Delta 2. Unit Manager or the Most Senior Staff in
 Code Delta Alert: Applies when there is the department:
a suspected highly infectious diseases or Most senior staff or Manager takes charge
cluster of communicable disease patients of the situation – giving instructions to
which may result in overwhelming the other staff members and monitoring
emergency response system and or departmental response
organization resources. 2.1 Determine whether curtailment of
 Code Delta: Applies when there is a normal activities is required.
confirmed highly infectious diseases or 2.2 If Code Delta Alert/Code Delta is
cluster of communicable disease patients activated:
which may result in overwhelming the a. Assign competent staff and a
trained observer to support for

63
 PPE DONNING and DOFFING 3. Staff Members ( Physicians and Nurses):
HID 3.1 Comply with Isolation precaution and
b. Assign individual to log onto PPE requirement based on IC policy
computer, open Outlook, monitor and procedure
email for communications 3.2 Minimize number of staff involved in
coming from Command Center provision of patient care to the absolute
and pass on the broadcast necessary
messages to Person In Charge of 3.3 Maintain record for Healthcare
the area. workers and any other visitor entering
c. Contact Command Center if patient room
more staff or other resources are 3.4 Refer to disease specific guideline /
required e.g. for managing policy for patient care management
additional patients who may 3.5 Notify Communicable disease
have been transferred / admitted department at DOH via online
to your unit. notification system
d. Ensure a record is maintained to https://bpmweb.DOH.ae/UserManage
document times/actions (HICS ment
214) 3.6 Follow DOH directive for managing
e. Document communication dead bodies based on their diagnosis
(internal / external and ensure color coding is followed as
communication) (HICS 213) per Care of the deceased patient C-
2.3 Nursing units review the patient NUR-CLI-16-001
daily census and identify who can be 3.7 Notify Mortuary 02 819 6666 /6644
transferred to another unit, before transferring a HID body
transferred to another facility or 3.8 Refrain from using the telephone (both
discharged to home (in case land lines and mobiles) except for code
additional actions of this nature need response
to be taken). 3.9 Calls to the Emergency Department
2.4 Information is entered into ‘electronic must be limited to urgent hospital
whiteboard’ and updated every 30 matters
minutes on the half hour. 3.10 Calls from family / friends of casualty
2.5 The downtime procedure / form is patients may be directed to Family Pool
used when the electronic system is – do not forward call to Emergency
not functioning and is delivered to Department
Command 3.11 Elevators are to be used only for
Center. transporting patients or equipment;
they are not to be used for any other
purpose. Staff, visitors etc. should use
the stairs.

64
GOVERNANCE, LEADERSHIP AND DIRECTION (GLD)

Providing excellent patient care is leadership

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

How is SKMC Hospital strategic plan

developed? There are several ways in which resources are
Information is gathered from many sources: allocated:
SEHA, the Senior Team, management staff and  Each department director and nurse
members of the medical staff participate in manager develops a budget based on
planning future direction and programming for their plans for services, the number of
the organization. patients and the needs of the services
provided.
How are resources such as staff, finances and  Department directors, administration,
equipment allocated? nursing and allied health set staffing
guidelines that are based on
 The scope of care provided by each priorities are set for the items to be
department or service. Medical and purchased.
nursing use the zero based budget plan
for each unit /service that is How are these discussions/decisions
standardized across the SEHA BE’s communicated?
 Input from the medical staff leadership  Department Chairs Meetings
and from the departments is actively  Staff meetings
solicited and included in the process.  Town Hall Meeting
 Each department requests the capital  Hospital Standing Committee Meetings
equipment it needs on an annual basis.  Senior Management Committee Meetings
 This information is reviewed and
studied by several different Do you know where to find the SKMC
interdisciplinary groups of directors. Mission Statement?
Physician input is included and

65 | P a g e
Yes. They are posted on SEHA Portal and can access the Scope of Services on SKMC
SKMC CEO ishare site. Portal.

Do you have a chain of command? Can you tell Do you know what the hospital Quality Plan
me how you would handle an issue (patient or is?
personal) if you were not getting an The hospital has a written quality program
appropriate response? revised and updated annually which focuses on
Yes. We have a chain of command. With patient quality management and improvement issues
issues, we would notify our senior according to in all areas of patient centered care. The Quality
the reporting hierarchy. Personal issues, can be department supports quality projects across the
discussed with Unit Manager. If this does not services.
solve the problem, appointment request with Refer to Quality Improvement and Safety
the Senior Team member can be made Program on Policy Management System.
according to my chain of command (e.g. if I am
a nurse, first my CN, Nurse Manager, ADON What is your understanding of the SKMC
and if unresolved then the Chief Nursing safety program?
Officer. The hospital has a written safety program
which focusses on a range of areas including,
How do you receive communication about safety and security, hazardous material, fire
changes in the organization? and safety, medical equipment and utility
We have regular monthly staff meetings where system management.
we discuss issues and our Unit Manager gives
us feedback on questions that we raise and What is your understanding of a Culture of
information from the Management meeting, Safety?
minutes are available for staff unable to attend. • The Hospital establishes and enforces a
Email communication is used often from Unit Quality Improvement & Patient Safety
Manager to convey information. Program that promotes accountability and
transparency.
How do you know what type of current • The Hospital follows and enforces the
services that are offered throughout SKMC SEHA Standards of Conduct.
Hospital? • All employees receive education and
As a staff member you can refer to the scope of information on the Hospital’s culture of
service for the service or department. The scope safety program through various on-going
of service includes the types of patients events.
managed by specific teams/units. It includes the • The Hospital uses a SEHA-wide, real-time,
admission and discharge criteria, the functional online quality monitoring system to
relationship between departments, the monitor safety and effectiveness by
mechanism to coordinate patients care and reporting incidents and near-miss events as
staffing positions as well as future planned detailed in the Incident Management Policy.
services and these are located on the portal. You Any staff can report issues related to safety
culture without fear of retribution. As much

66
 as possible, system issues are identified needs, for example security services,
through the incident investigations. housekeeping services, catering, laundry,
• The culture of safety is measured using transport, medical equipment maintenance,
regular surveys and monitored by various SEHA dialysis service, waste management etc.
means, with the results used to implement The responsibilities of maintaining valid
improvements in identified areas. contract are under Support Services
Department.

What do you do as an organization to improve Do we do Human Subject research in SKMC?

culture of safety at SKMC? Yes.

What will you do if you have an ethical

dilemma regarding the medical care of your
patient?
You can share your concern with your Unit
Manager and if unresolved, they will escalate it
to the Medical Ethics Committee.

Do you have a Code of Conduct?

Yes, HR Department has a Code of Conduct
policy (as part of the HR Manual) which is
available on their department’s iShare site.
Link of HR
policy: http://portal.seha.ae/SKMC/departme
Do you have any contracted services in
nts/HR/HR%20Policies/Forms/DocumentsVie
SKMC?
w.aspx
Yes, there are a number of contracted services
at SKMC to meet patient and management

67
FACILITY MANAGEMENT AND SAFETY (FMS)

Health care organizations work to provide a safe, functional,

and supportive facility for patients, families, staff and visitors.
This requires effective management that strives to reduce and
control hazards and risks, prevent accidents and injuries, and
maintain safe conditions.
Within this chapter there are six elements/components:
1) Safety and Security
2) Hazardous materials
3) Emergencies
4) Fire safety
5) Medical Technology
6) Utility systems

(PMS)’ under ‘Environment Health &

Safety’ location

Facility Inspection:
 Facilities and Construction
Management (FCM) follows a planned
SAFETY:
schedule of inspection & maintenance
Definition:
of utility systems throughout the
 Safety refers to ensuring that the
facilities.
building, property, medical and
 Environment Health & Safety (EH&S)
information technology, equipment,
conducts Occupational Safety &
and systems do not pose a physical risk
Health (OSH) internal inspections &
to patients, families, staff, and visitors
audits to ensure non-conformance are
(FMS4.2).
identified and approved corrective
action plans are implemented as per
Written Policy, Procedure, Program or other
SKMC Standard OSHMS Audit and
Written Document:
Inspection (C-QM-EHS-11-008). OSH
 In compliance with JCI requirement
inspection plan (schedule) is developed
FMS.4 ‘Safety Management Program’
year in advance and unplanned random
has been developed which is available
OSH inspections are also carried out as
in ‘Policy Management System (PMS)’
needed. Inspection reports are sent to
under ‘Environment Health & Safety’
departments and uploaded on
location for staff access and awareness.
InsideSKMC portal (Link: Click Here
Link: Click Here
Inspection 2020 and Click Here
 Other policies mentioned below are
Inspection 2019 )
available in ‘Policy Management System

68 | P a g e
  EH&S Links / Department Managers EH&S department follow-up with
ensure action items are completed. departments to ensure action items are
 Completed and follow-ups are properly where contractors do not have access to
documented. SI system.
 Other preventive programs are  Incident Investigation: Incidents /
established to proactively identify risk Accidents are investigated as per SKMC
and plan for and follow-up on corrective policy ‘Work Related
action. Preventive programs includes, Exposures/Injuries/Illness and
but are not limited to: audits & Employee Accident/Incident
inspections, practice drills on Investigation (C-OP-EHS-00-005).
emergency response, hazardous  Root cause(s) are analysed and action
materials management program, plan is developed to prevent a
education, awareness, training & recurrence. RCA & action plan are
competency of staff, risk assessment, documented in SI system, Abu Dhabi
etc. Occupational Safety & Health Center
 Environment Health & Safety (EHS) (OSHAD) Form e.g. G2 or ‘After Action
Committee: Oversees and directs the Report’ etc.
planning, coordination, development,  EH&S Links / Department Managers
implementation and monitoring of maintain the copy of incident
implementation of OSHMS programs. investigation report and ensure action
(Link: Click Here - EHS Committee) items are completed.
 EHS Links post minutes of meeting and
key messages on the notice board / Hazard Identification & Risk Assessment:
communicate in departments for staff  Definition ‘Risk’: Risk is the product of
awareness and compliance. the likelihood of occurrence of an
undesired event and the potential
Accident / Incident and Investigation: adverse consequences which this event
 Incident Reporting - All workplace may have upon (Risk = Likelihood
incidents involving employees, patients (Frequency) x Consequences).
and other persons shall be reported  Definition ‘Hazard’: Hazard is
immediately following the incidents, as anything with potential to cause harm.
per the SKMC policy ‘Incident  Definition ‘Consequences’: The
Reporting and Management (C-QM- outcome of an incident. A single
PIA-01-003). incident can generate multiple
 Incidents / Accidents are reported using consequences, and the initial
the Safety Intelligence (SI) system consequence of an incident can escalate.
(Link: Click Here)  Definition ‘Risk Assessment’: The
 SKMC contracted staff (contractors & process of determination of risk, usually
sub-contractors) are to report any in a quantitative or semi quantitative
incident / accident to their SKMC manner.
managers for reporting in SI system

69
 EHS Links and Department Managers Management of Change – C-
conduct ‘departmental risk QM-EHS-10-004)
assessment’ and develop an action plan o Before work activities begin (e.g.
with input from key stake holders using new Contractors, new task, new
SKMC approved departmental risk equipment etc.)
assessment template. o Presence of a high level of risk
 Completed department risk associated with a specific work
assessments are uploaded on activity (e.g. confined space,
InsideSKMC (under Environment hotwork); etc.
Health & Safety Section) by EHS Links / o Such risk assessment documents
Department Managers; Link: are maintained by end-user
http://portal.seha.ae/SKMC/sites/qmd/ departments, Facilities &
OHS/Generic%20Departmental%20risk Construction Management, etc.
%20assessment%20reports/Forms/AllIt o Departments obtains MOC
ems.aspx approval from Chief(s) on MOC
 Environment Health & Safety (EH&S) approval form.
Department conducts an annual review o Link on InsideSKMC: Click Here
of ‘SKMC Risk Register’ with input
from key stakeholders and maintains Safety during Demolition, Construction, or
the records in compliance with OSHAD Renovation:
and Department of Health (DoH)  Risks associated with construction
requirements. ‘SKMC Risk Register’ is activities are assessed, control measures
available on InsideSKMC (under are implemented in accordance with the
Environment Health & Safety Section) – hierarchy of controls as per SKMC
Link: policy C-QM-EHS-11-005 (OSHMS Risk
http://portal.seha.ae/SKMC/sites/qmd/ Management) and EHSMS-SOP-FCM-
OHS/SKMC%20Risk%20Register/Form 10-001 -OSH Management during
s/AllItems.aspx Construction Work and control
 Management of Change (MOC) measures are taken to prevent injury,
Process: The risk assessment is an illness and disease to persons who
ongoing process and may be might be exposed to risks arising from
undertaken at various times including construction activities.
below as per SKMC policy C-QM-EHS-  Permit to work (PTW) procedure is
11-005 (OSHMS Risk Management): followed with demolition, construction
o When planning or making a & renovation projects by Facilities &
change to a work procedure, Construction Management (FCM)
activity and/or practices; which includes:
o When introducing new plant, o Pre-construction risk assessment
equipment, materials or (PTW risk assessment template
substances into the workplace; has been customized for this
(as per SKMC policy on OSHMS

70
 purpose to include required o Infection Prevention and
areas as per JCI & OSHAD) Control Education
o Infection Control risk o Work Stress Management
assessment (ICRA template is o Compliance & Ethics
followed) o Covid 19 Back to Work
 Required areas of the pre-construction o OSHMS
risk assessment include: o Fire Safety
o air quality; o Customer Services
o infection control;  Other safety related trainings are
o utilities; carried out by EHS Links within the
o noise; departments as identified necessary
o vibration; based on departmental ‘Training Plan’
o hazardous materials; and ‘EHS Competency Summary
o emergency services, such as Record’.
response to codes; and  EHS Links / Department Managers
o other hazards that affect care, ensure training and competency of their
treatment, and services. staff and contractors are carried out
 Notice and warning signs are posted at within the year. Training attendance
the demolition, construction, or records and competency evaluation
renovation sites for safety and records are maintained within the
awareness. departments.
 Related documents e.g. PTW, PTW risk  Links to ‘EHS Training Plan’, ‘EHS
assessment, ICRA etc. are maintained Competency Summary Record’ and
by Facilities and Construction ‘Hazard Specific Competency
Management Department. Templates’ are available on
 Contractor compliance is monitored, InsideSKMC (Under EH&S) - Link:
enforced, and documented EHSMS- Click Here
SOP-FCM-10-001 -OSH Management
during Construction Work.
HAZARDOUS MATERIALS:
Safety Training and Competency Program: Definition:
 Completion of annual mandatory  Hazardous Materials: Solids, liquid or
refresher trainings is the responsibility gaseous materials having properties that are
of each employee. Annual mandatory harmful to human health or severity
refresher trainings include: affecting the environment, such as materials
o Emergency Preparedness and that are toxic, explosive, flammable or
Business Continuity emitting ionizing radiation (Refer
Management 2020 introduction section of Abu Dhabi OSHAD
o Facilities Management Program SF - COP – ‘Hazardous Materials’ for
o Manual Handling & Ergonomics details).

71
 World Health Organization (WHO)  End-users request hazmat via Product
identifies hazardous materials and waste by Evaluation Committee/Purchasing
the following categories: Department.
o Infectious  Purchasing Department makes it a
o Pathological and anatomical condition of sale for the vendor to supply
o Pharmaceutical the product’s safety data sheet.
o Chemical  Contractors obtain approval from SKMC
o Heavy metals Services (for any hazmat they bring on
o Pressurized containers site).
o Sharps Safety (F Safe Use – Handling, Segregation &
o Genotoxic/cytotoxic Storage:
o Radioactive  End-user departments are responsible for
 SKMC follows United Nations Globally safe storage of hazardous materials and
Harmonized System (GHS) for hazmat wastes.
classification and symbols.
Written Policy, Procedure, Program or other HazMat Registry (Inventory) / Safety Data
Written Document: Sheets (SDS)/Material Safety Data Sheet
 In compliance with JCI requirement FMS.5
‘Hazardous Materials Management
Program - C-QM-EHS-02-001’ has been
developed to address issues related to
inventory, handling, storage, and use of
hazardous materials which is available in
‘Policy Management System (PMS)’ under
‘Environment Health & Safety’ location for
staff access and awareness. Link: Click
Here
(MSDS):
 SKMC General Services policies on
 Hazmat binder with registry
‘Contracted Waste Management Services’
(inventory) & MSDS/SDS are available
deal with hazardous wastes.
in each end-user department.
 Other policies mentioned below are
 Soft-copies of departmental hazmat
available in ‘Policy Management System
inventory are available on
(PMS)’ under ‘Environment Health &
‘InsideSKMC’ Portal (under
Safety’ location.
Environment Health & Safety) Link:
Key Components: SKMC Hazardous
Click Here
Materials Management Program Policy (C-
 Hazmat registry (inventory) include:
QM-EHS-02-001)
o Name of the hazardous materials;
Ordering – Identification, Selection &
o Manufacturer of the hazardous
Approval:
materials (where necessary);
o Hazardous class;
o United Nation (UN) Code;

72
 o SDS/MSDS; International Best Practices for hazmat
o Location of the hazardous classification and symbols.
materials;Quantity of the  Placards are available in SKMC with
hazardous materials onsite different types of symbols (including
GHS) for staff awareness.

 Sample of SDS / MSDS

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

PPE (Personal Protective Equipment) /

Bottles with Workplace Decanting and Spill Procedure:
Workplace Labels Labels  End-user Departments ensure hazmat is
stored/handled/decanted in suitably
 Link to workplace labels, hazard ventilated area.
classification placard, hazmat  End-user Departments provide PPE to
segregation table etc. and others : Click staff.
Here  Spill kits are accessible to be used in
spillage / Staff are aware in spill
Hazard Classification / Symbols: procedure.
 SKMC follows United Nation’s Globally  Spills are reported in SI system and via
Harmonized System (GHS) and Emergency Operations Plan (e.g. ‘2222’)
as needed.

73
 Compressed Gases and Air: Link - Click
Here
 Policy on Compressed Gases and Air -
Cylinders and System (C-QM-EHS-03-
006) is available in PMS portal under
Environment Health & Safety.
 Medical gas panel signage (procedure to
Chemical Spill Kit Chemotherapy Drug turn off gas) should be present next to
spill Kit medical gas panel.
 Distribution gas map indicates which
areas are controlled by the valves in that
medical gas panel and should be available
next to medical gas panel.
 Medical gas (panel) isolation valves
Body should be unobstructed.
Spillage
Staff Training, Competency & Awareness  Medical gas cylinders are labeled in a
/ Roles and Responsibilities: legible manner (as to contents of cylinder).
 Training / Competency for staff &  Medical gas cylinders are stored indoors
contractors handling hazmats are in secured area. Medical gas cylinders
completed in the departments during have appropriate signage. Link: Click
orientation & annually as refresher. Here
 General awareness for all other SKMC  Medical gas cylinders are segregated and
staff in hospital orientation & through stored by contents of the cylinders using
on-line mandatory training ‘Facilities ‘full’ and ‘empty’ posters. Link: Click Here
Management Program’.  Large gas cylinders are stored upright and
Safe Disposal / Legal, Regulatory and secured by chain.
other requirements e.g. JCI: Chemotherapy: Pharmacy, Housekeeping &
 Process for hazardous materials waste Nursing are responsible to establish policies
removal from end-user departments – and procedures for safe handling, storage, use
Link: Click Here and disposal of chemotherapy products, to
 SKMC Support Services manages monitor compliance and to take corrective
disposal of hazmat and wastes. action when required. (See Pharmacy,
 Disposal are carried out via approved Housekeeping and Nursing standards
contractor in compliance with available on ‘Policy Management System
Departmental of Health (DoH) & Center (PMS).
of Waste Management Abu Dhabi
requirements.  Radioactive Materials and Waste:
 ‘Legal Registry’ is maintained where Radiology is responsible to establish
legal requirements are documented – policies and procedures for safe
Link: Click Here handling, storage, use and disposal of

74
 radioactive materials and waste, to Management System (PMS)’ under
monitor compliance and to take ‘Environment Health & Safety’ location for staff
corrective action when required. (See access and awareness. Link: Click Here
Radiation Safety standards available on Other policies mentioned below are available in
‘Policy Management System (PMS). ‘Policy Management System (PMS)’ under
 Medical and Infectious Waste: General ‘Environment Health & Safety’ location
Services-Housekeeping and Infection
Control are responsible to establish Fire Risk Assessment:
policies and procedures for safe  An ongoing assessment of compliance with
handling, storage, use and disposal of the fire safety code and hazards are carried
medical and infectious waste materials out. The assessment is documented in
and waste, to monitor compliance and SKMCwide Fire Risk Assessment (EHS-
to take corrective action when required. RA-43 60 61) Click Here. The assessment of
Waste management shall be in risks includes but not limited to the
compliance with UAE regulations following:
(Refer to Infection Control Manual and  Pressure relationships in operating
General Services Policies). rooms
 License, Permits, Approvals and Other  Fire separations
Necessary Documentation: The  Smoke separations
department responsible to purchase or  Hazardous areas (and spaces above the
dispose of hazardous materials is ceilings in those areas) such as soiled
responsible to obtain a license, permit, linen rooms, trash collection rooms, and
approval and other necessary oxygen storage rooms
documentation required for any specific  Fire exits
hazardous material and waste as  Kitchen grease-producing cooking
required by the relevant federal and devices
Abu Dhabi authorities and to retain  Emergency power systems and
copies for of these documents. ‘Legal equipment
Registry’ is maintained where legal  Medical gas and vacuum system
requirements e.g. license etc. are components
documented – Link: Click Here  Other fire related hazards

FIRE SAFETY : Fire Prevention, Detection & Fighting

Written Policy, Procedure, Program or other Equipment & Systems:
Written Document: Fire Detection and Alarm Systems:
In compliance with JCI requirement FMS.7 ‘Fire  Fire Alarm System – Fire break glass and
Safety Management Program - C-QM-EHS-03- fire alarm are installed throughout the
001’ has been developed for the prevention, facility and are connected to an alarm
early detection, suppression, abatement, and panel.
safe exit from the facility in response to fires and  Departments that have a known hearing
non-fire emergencies. It is available in ‘Policy impaired employee must identify this

75
 information in their response procedure Storage of Flammables:
(Refer to EOP Appendix J-A-04: Evacuation  Types of Cabinets - Flammable products
Plans for Patients, Employees and other should be stored in a closed metal cabinet
Persons with Special Needs) Click Here or flammable cabinet.
 Smoke/Heat Detectors – are installed in  Locations of Storage - Flammables should
SKMC and are designed to be activated be stored in secure areas that are well
automatically by smoke or heat. Activated ventilated and away from sources of heat
detectors will identify the location of the and electrical equipment.
detector on a main alarm panel/stand-alone  Warning Signage - should be mounted on
panels in the building. storage cabinets that indicate ‘Flammable’
 Installing and Uninstalling caps on fire materials are stored inside.
detection system Contractor /  Hand Sanitizer Dispensers – Alcohol
Subcontractor personnel working under based hand sanitizer dispensers e.g. Purell
Facilities and Construction Department is etc. should be installed and/or stored away
responsible for the installing and from electrical sources e.g. electrical
uninstalling caps on fire detection system sockets, electrical switches, WoWs
where needed. No other individuals are (computer on wheels) etc. and away from
authorized to install and uninstall the caps heat sources e.g. electro-cautery machines,
on the fire detection system photocopiers, heating appliances etc.
Fire Extinguishing System: Smoke Extraction System:
 Fire Hoses – Available at places. Smoke extraction is the responsibility of
 Fire Extinguishers - Fire extinguishers are Facility & Construction Management
available every 20 meters. Two types of fire Department. Locations where smoke
extinguisher are present in majority of extraction system is present in SKMC -
SKMC sites: carbon di-oxide (black color / Entrance of each ward in Surgical Pavilion.
red color) and dry chemical / dry powder Portable smoke extractors are available
(red color). A non-magnetic type of fire with FCM to be used as needed in any area.
extinguisher is only present in MRI section Portable smoke extractor is moved to area
of Radiology. as required.
 Automatic fire extinguishing systems – Emergency Lighting:
such as sprinkler System, FM200 systems  Is installed to provide lighting in the
are installed by Facilities and Construction event of power failure. Emergency
Management in areas as required by UAE Lighting is installed by Facilities and
regulations, or as deemed appropriate by Construction Management in areas as
SKMC. Locations where sprinkler system required by UAE regulations and as
is present in SKMC: Example: Executive deemed appropriate by SKMC.
Building (all floors), Ward D0, D1, D2 Combustibles and Housekeeping:
(Medical Pavilion), Central Stores (Surgical  All departments are responsible to
Pavilion), Mussaffah Warehouse, New minimize volume of combustibles such
Emergency Department & Peds Emergency as paper, rubbish, debris, etc in
Department workplace to prevent fire.

76
  Items must be stored in a manner that resistance of each compartment as required by
permits paths of walkway / egress and UAE legislation and SKMC requirements.
must not be stored within 50 cm of
ceiling. Fire Doors:
 Automatic Closure of Fire Doors - Fire
Electrical Equipment Safety (see SKMC policy doors are connected to the alarm system so
on Electrical Equipment Safety – C-OP-GEN- that the magnet will de-energize when the
01-030 for details on electrical equipment safety fire alarm is activated, providing automatic
requirements - Click Here): closure of fire doors in the surgical
 Department Managers have overall pavilion. As renovations are planned for
responsibility to ensure electrical other buildings, then this feature will be
equipment in the areas of their added where possible in the building and
responsibility is tested and tagged as safe alarm system design.
for use.
 Facilities and Construction Management  Fire Door Requirements - Facilities and
Department have overall responsibility to Construction Management are
test non-medical electrical equipment and responsible to install 2-hour fire rated
extension cords, including Information doors in all fire exit corridors.
Technology (I.T.) and Photocopier  Fire Doors with Access Control Locks -
equipment. Fire doors that have access control locks
 All Hospital owned electrical appliances should be connected to the alarm system
for heating food will be in rooms so that the magnetized lock will de-
designated as kitchens, staff rooms, staff energized when the fire alarm is
lounges or pantries only activated, providing free access to fire
 See SKMC policy on Electrical Equipment doors.
Safety – C-OP-GEN-01-030 for prohibited Fire / Emergency Exit Doors / Doors:
electrical items and exceptions.  Fire / Emergency exit doors, stairwells,
 Use of burning materials e.g. incense, and hallways should be kept
bukhoor, candles and any source of flame unobstructed.
are strictly prohibited at SKMC.  Fire / Emergency exit doors including
 All staff shall be aware of the emergency stairwells should be kept closed. Doors
escape plan and firefighting systems in should not be propped, wedged, taped,
their area. or tied open.

Passive Fire Protection Measures: Managing Risk during Construction/

Fire Compartments: Renovation:
Are designed to effectively prevent the spread  Safe Exits – If exits are compromised
of fires into other compartments and contain during construction / renovation,
the heat and smoke within the compartment of alternate exits will be identified prior to
origin. FCM determines the size and fire commencing work.

77
 Signage for altered fire exit routes - required to maintain safe work area
Signage will be installed prior to and to remove at a frequency
commencing work if fire exits routes determined by Facilities and
need to be temporarily altered. Construction Management, as
 Work Permit - Contractors notify / obtain outlined in work contract.
approval from end users, Facilities and  Smoking – Contactors /
Construction Management, Infection subcontractors are required to comply
Control, Environment Health & Safety with the UAE law & SKMC ‘No
and Security Department prior Smoking’ policy.
commencing work. Work Permit is
posted at construction / renovation site. Fire Abatement & Fighting Equipment and
 Hot Work Permit - Hot work permit is Systems’ Inspected, Testing, and
issued by Facilities and Construction Maintenance:
Management for any operation involving
– open flames or heat spark in  Responsibility for Inspection -
construction and renovation areas and in Facilities and Construction
a few maintenance and servicing Management is responsible for
activities. Hot work permit is issued to inspection of fire equipment and
ensure required precautions are met, facilities such as fire hoses, fire
prior to commencing and for the duration extinguishers, wet risers, sprinklers,
of the work. suppression systems, fire alarm
 Orientation of construction workers - systems, lighting, signage, fire exits
Orientation education on fire and (regular and with access control), fire
emergency response at SKMC are doors & automatic closer of fire doors
provided to construction company and automatic ventilation control or
staff by Facilities and Construction shut off in all buildings and on grounds
Management Department prior to of all SKMC facilities.
commencing on-site work.  Frequency of Inspection - Facilities and
 Safety Inspection of Individual Work Construction Management inspects fire
Sites – Construction Company equipment and maintain records for
Supervisors in charge of each project each equipment, as per the planned
are required to inspect their work site. preventive maintenance schedule
Facilities and Construction (inspection of fire extinguishers, hoses,
Management Project Managers wet risers, dry risers, sprinklers,
assigned to each construction / suppression systems and fire pump
renovation project are responsible to systems) and update the inspection
ensure inspections and corrective labels.
actions are completed as per policy,  Maintenance of Fire Equipment &
and records are maintained. Record Keeping - Facilities and
 Removal of debris / garbage – Construction Management is
Contractors / subcontractors are responsible for equipment maintenance.

78
 Maintenance records are maintained by
Facilities and Construction
Management.
 Inspection – EHS related inspection is
carried out by EH&S department as per
planned EHS Internal Inspection Refer to Emergency Operations Plan (EOP Link on
Schedule. your computer Desktop)
 Department Responsibility:
Departments are responsible to report Risk Assessment (Departmental and Hospital-
FCM for any deficiency for correction. wide)
SKMC has completed Risk Assessment (RA) is
Eliminating or Limiting Smoking within conducted and reviewed annually. The purpose
SKMC: of the RA is to determining the type, likelihood,
 SKMC is a ‘no-smoking’ facility by law. and consequences of hazards, threats, and
 “No-smoking is maintained at all events:
locations in buildings and on SKMC  Departmental Risk Assessment (available
grounds. within the department)
Drill, Training, Disaster Response Process,  Operational Enterprise Risk Management
Disaster Responders & Staff Education: See or ERM (available on EOP Link on your
‘Disaster Preparedness’ section. computer Desktop)
Staff & Patient Evacuation: See ‘Disaster (also known as Hazard Vulnerability Analysis
Preparedness’ section. or HVA)

EOP Education / Training

Disaster Preparedness Program
Orientation, education and targeted training
SKMC is developed, maintains, and tests an
are provided to ensure staff is knowledgeable
emergency management program to respond to
and competent about the EOP. SKMC will
emergencies and natural or other disasters that
ensure:
have the potential of occurring within the
 New employees receive Emergency
community.
Preparedness/Fire Training a part of new
Responsibility for the Emergency Management
employee orientation / employees receive
Program is assigned to Environment Health &
general information about the hospital’s
Safety (EH&S) department.
EOP as a part of new employee orientation
Emergency Management Program is monitored
 Employees receive Emergency
by Emergency Preparedness and Business
Preparedness/Fire Training refresher
Continuity Management Committee.
training annually and records available in
Current Emergency Operations Plan (EOP) and
Human Resource department
other related documents are available in EOP
 Hospital department managers are held
link on each computer desktop and inside
accountable for their employees being
SKMC
introduced to and competent in their roles in
emergency mitigation, planning, response
and recovery.

79
 Hazard specific trainings and competencies All Hazards Plan
for concerned employees are assured by The EOP utilizes an ‘all-hazards’ plan format to
department managers (e.g. Department – provide a basic framework for responding to a
specific training) wide variety of emergency / disasters (key
 Human Resources and hospital departments hazards and vulnerabilities) and following this
are documenting and continuously process:
monitoring the valid medical and technical  Base Plan addresses similar actions that
certification of staff (e.g. BLS. ACLS, PALS, commonly occur in a variety of
ATLS etc.) as per DOH, SEHA and other circumstances. These actions provide a ‘base
legislative requirements plan’ for responding to unexpected events.
 Annexes provide guidance for dealing with
Exercises (Drills) specific events / functions (e.g. Fire / Smoke).
As part of its emergency preparedness, SKMC Emergencies / disasters that are identified as
will new risks based on the SKMC annual
 Establish an annual Exercise and Evaluation hospital Risk Assessment (RA) are added in
Program (SKMCEEP) (schedule of drills) the current list of annexes.
 Drills have measurable objectives  Appendices provide specific details in
established before an exercise and are support of an annex (e.g. Forms to be used in
conducted and evaluated from a multi- support of an annex).
disciplinary perspective, with identification Refer to Emergency Operations Plan (EOP Link on
of opportunities for improvement. your computer Desktop)
 Document drill observations, opportunities
for improvement and corrective action plans Departmental Action Cards
for each exercise, and implement actions in a  Department / units are responsible to
timely manner following each exercise. develop incident/code response ‘Action
 Reports of drills identify recommendations Cards’ using SKMC format / template.
for improvement, responsibility for action, Communications utilizes log sheet for
timelines for completion of task and status guidance and documentation.
on follow-up. Documentation includes list  Managers are responsible to ensure their
of participants or departments involved in employees are knowledgeable and
each drill. Reports are circulated to competent in their roles during EOP
appropriate Managers, Directors and Chiefs activation.
in the organization for review and action on  Action Cards must be updated annually or
recommendations. frequently if required and submitted to
Note: Environment Health & Safety (EH&S)
Related Drills/Exercises reports and documentation Department for inclusion in the on-line EOP
are available in respective department (e.g. Fire and documents.
Evacuation Drill Report) and Environment Health Refer to your Departmental Action Cards
& Safety Department
Organization Assignment of Roles and
Responsibility

80
SKMC maintain an Emergency Management  Staff provides ‘name, department, building
Team that consists of SKMC personnel who are and details of the situation’.
assigned to specific emergency roles and  When the Switchboard Operator is advised
responsibilities. Each position on the SKMC of an incident or situation the Switchboard
Emergency Management Team identified a Operator will notify a pre-determined
primary and an alternate person for the response team and announce over the public
position. address (PA) system.
Refer to Departmental Action Cards and Emergency Refer to Departmental Action Cards
Operations Plan related to roles and responsibilities
Level of Emergency Code
Emergency Hotline Number  Code Alert is something where you need
technical people to evaluate and correct -
SKMC Main Campus 2222 this may need to escalate to a code
Behavioural Science Pavilion (BSP) 3888  Code is required: When the entire hospital
Diabetes & Endocrinology Clinic 1350 needs to be informed and staff take actions
Abu Dhabi Blood Bank (ADBB) 1717 according to their departmental Action Plans
Mussafah Warehouse Refer to Departmental Action Cards
(for Fire/Smoke Call, '999' then 999
'2222') Emergency Codes (Refer Annexes and
Appendices for details)
Communication Plan for Incidents
Urgent situations may occur that require Red Fire / Smoke
Orange External Disaster / Mass Casualty
immediate assessment and corrective action.
Green Internal Disaster / Evacuation
Usually these situations are resolved by a
Aggressive Behavior / Violent
response team without activating an EOP Code. White
Person
Examples include, but are not limited to loss of Yellow Missing Adult Person
power, water leaks, etc. Each response team has Hazardous Material Release
Brown
a Leader@Scene. Radiological Exposure / Spill
Black Suspicious Object / Bomb Threat
Amber Missing Child / Child Abduction
Initial & Chain of Notification of Urgent or
Silver Weapon / Hostage Situation
Emergency Situation Utility Failure & Essential Services
Gold Outage
 Employees inform the Switchboard of an IT System Planned Outage / Failure

emergency situation (e.g. smoke, fire, flood, Grey Weather Warning

Delta Infectious Disease
loss of utilities etc.) by calling Switchboard
Pink Pediatric Cardiac Arrest
and providing information on what they Blue Adult Cardiac Arrest
have observed. Refer to Emergency Telephone Poster within the
 Staff call Switchboard Operator when they department
observe an urgent situation which requires
emergency assessment/response. Public Address (PA) Announcement
Notification

81
 Code Alert (unconfirmed event): When tender operating procedures and
announcement is a ‘Code + Color + Alert + departmental action cards
Location’ - only pre-planned Responders go  Annex G: Utilities Failure and Essential
to the area Services Outage Annex
 CODE (confirmed event): When  Clinical/Support Activities: throughout
announcement is ‘Code + Color + Location’ – the EOP and in departmental Action
All staff responded as per EOP and Cards of clinical areas
Departmental Action Cards.  Business Continuity Plans (e.g. to manage
Refer to Departmental Action Cards manpower, equipment, alternate care
sites etc.)
Business Continuity Plan  Surge Capacity Management Plan
 SKMC Business Continuity Plans (BCP) are Refer to Emergency Operations Plan (EOP Link
developed to describe how the organization on your computer Desktop) and Policy Manager
will respond to and recover from
disruptions. Fire/Smoke Emergency Response
 These disruptions can be localized threats The acronym ‘RACE’ will be used to remind
(e.g., earthquakes, fires, floods, bombs, etc.) staff of the steps to follow when responding to
or global threats (e.g., Flu Pandemic) fire: Rescue, Alarm, Contain and Extinguish.
Refer to assigned Business Continuity Plan This information shall be posted with fire
extinguishers, added to a card in the ID badge
Resources holder and documented in the Fire/Smoke
 SKMC has access to resources and (Code Red Alert / Code Red) Action Cards for
capabilities, which, when used effectively in all units and departments.
a disaster, will enhance the preservation of In the event of fire, think “RACE”:
life and property.
 SKMC identifies organizational capabilities R – Rescue: : Remove all people from
and response in the critical areas to manage immediate danger to an
resources during events, include alternative unaffected area of the
building
sources, clinical activities, alternative care
A – Alarm: : Activate nearest manual
sites etc.
fire alarm (break glass);
 Annex O: Crisis Communication Annex
Call Emergency Contact
 Annex R: Staff Resource Annex Number
 Annex L: Assets, Stocks, Pharmaceuticals, C – Contain: : Close doors between you
Consumables Annex and the fire or smoke as
 Annex Q: Medical Equipment – you exit the area
Emergency Management E – Extinguish : Only if safe to do so, do not
 Safety Management Program take unnecessary risks
 Security Management Program
 Staff responsibilities – outlined in The acronym ‘PASS’ will be used to remind
Emergency Operations Plan, policies, staff of the steps to follow when using a fire
extinguisher: Pull the pin, Aim at the base of the
fire, Squeeze the handle and Sweep side to side.
82
This information shall be posted with fire Center will determine where patient &
extinguishers, added to a card in the ID badge staff are to be relocated if entire building
holder and documented in the Fire/Smoke is evacuated.
(Code Red Alert / Code Red) Action Cards for Patient ‘Order of Evacuation. The
all units and departments. facilities follow a plan for patient order
P - Pull Pin of evacuation, following these three
A - Aim at base of fire steps to identify and move patients to
S - Squeeze Handle safer areas. The responsible team on a
S - Sweep Side to Side patient area will identify which category
Refer to Departmental Code Red Action Card each patient falls into for evacuation
Evacuation (ambulatory, wheelchair, non-
Managers are responsible to establish ambulatory). Patients are moved from
procedures specific to their own department or the area by following this order for
unit, documented in the Fire/Smoke and evacuation:
Internal Disaster/Evacuation Annexes and o Ambulatory
following the principles of progressive building Group all ambulatory patients and lead
evacuation and patient order of evacuation. them together to the next safe area
o Wheelchair
 Progressive Building Evacuation. The Move these patients to the next safe area
facilities follows a plan for progressive in wheelchairs if additional wheelchairs
building evacuation, following these four or personnel are required, notify the
steps to progressively move employees, Command Center to identify your
patients and other persons to safer areas: requirements.
o Room Evacuation - moving to an o Non Ambulatory
alternate room on the same ward or Patients are moved by bed, stretcher or
unit. on patient rescue sheets.
o Horizontal Evacuation - moving to a Refer to Departmental Code Green Action Card
safe area on the same floor.
o Vertical Evacuation - moving to an Emergency Dependent Care
alternate floor, preferably one floor Emergency Dependent Care has been
down. established and may be activated to manage
o Building / Total Evacuation - moving emergencies when personal responsibilities of
out of the building and congregating at staff conflict with the SKMC’s responsibility for
the assigned assembly points until providing patient care.
informed by Area Fire Warden or Civil
Defense of next step– either “all clear” Employee’s dependent will be cared in Child
to re-enter the building or everyone to Psychiatry Clinic in BSP while parent is recalled
be moved to an alternate facility. to workplace during disaster situation. If Child
Instruction to evacuate the entire Psychiatry Clinic is not available for some
building would come from the reason, dependents will be allocated in Surgical
Command Center. The Command

83
Pavilion, Ground Floor next to Ward A - - Find the due date
Paediatrics. - If the due date matching current date OR
overdue, Biomed to be informed for a
Refer to Emergency Operations Plan (EOP Link on further action
your computer Desktop) under Annexes – Annex R:
Staff Resource Annex

MEDICAL TECHNOLOGY
The Medical Technology Program of SKMC is
designed to assure selection of appropriate
medical equipment to support the medical care Procedures to be followed when medical
processes and to assure effective preparation of equipment has an issue
staff responsible for the use of or for the • Open work order in CAFM
maintenance and repair of the equipment. • Decontaminate the equipment - ’ Portable/
It assures continual availability of safe, effective Movable ’
equipment through a program of planned • Send it to Biomed workshop
maintenance, timely repair, ongoing education
and training, and evaluation of all events that Single Patient Use Device
could have an adverse impact on the safety of Medical devices that may be used for more than
patients or staff. one episode on one patient only. The device
The Biomedical Engineering department is may undergo some form of processing between
responsible for performing preventive and each use but must never be used on more than
corrective maintenance as well as acceptance/ one patient.
installation of new medical equipment's.
Single Use Device
The medical device is intended to be used on an
individual patient during a single procedure
and then discarded. The item will carry the
marking on its packaging.

Device Recall Management/Incident

Preventive Maintenance Frequency:
Investigation
 For General/ Generic equipment's - Once a
Biomedical Engineering Department, in
Year
conjunction with a variety of user departments,
 For Life Support/Critical equipment's - As
including SEHA, maintains a tracking system,
per manufacturer recommendation
identified as ECRI Recall Tracking System,
which encompasses all available hazard and
Identify dates on equipment in SKMC & their
recall information with appropriate corrective
validity
action and reporting.
Look for the Green and the Yellow labels on the
device. Green sticker is Inspection Maintenance
UTILITY SYSTEMS
Sticker and Yellow sticker is Safety Test Sticker.

84
SKMC Facilities Management Department, performing Health Safety Environment
under Operation Division establishes and (HSE) regulation through-out the process.
implements systematic program to ensure that • Review and design new electro-mechanical
all Electro-mechanical utility systems operate systems as per project need.
safely, effectively and efficiently. • Ensure the sustainability of all utility
Critical Equipment under Utility systems are : system are achieved.
• Air Conditioning • Perform and monitor PPM and CM
• Fire Fighting activities of all utility systems as per
• Medical Gas approved PPM program (HVAC, Water
• Water supply system, Elevator etc.)
• Steam generation SKMC staff can notify FCM for any failed
• Drainage critical utility system by calling 2179/2458 - 24/7
• Pneumatic Tube Systems Elevators or through CAFM system.
• Low Voltage Electrical Power Panels
• Lighting Systems When Code Gold Facilities can be activated:
• Uninterruptible Power Supply “UPS” (Utility System Failure & Essential Services
• Fire Alarm System Outage)
• Closed-Circuit Television “CCTV” etc.. • Power Outage (Switch to Generator Power)
All utility systems under Facilities and • Power Outage (Generator Failure)
Construction Management are included under • Flooding / Water Leaking
Planned Preventive Maintenance Program • Gas Leak / Smell
“PPM”. • Loss of Elevator / Passenger Trap
• Fire Alarm Activation
Our Engineering team complies with the • Loss of Medical Gas
Healthcare standards and meet Local regularity • Loss of Medical Vacuum
requirements. (JCIA, DOH, OSHAD, ADCD • Loss of Nurse Call System
etc.) • Sewer Stoppage / Blockage
As per FCM policy the approved temperature • Loss of Water Supply
and relative humidity is maintained between • Water Determined to be Non-Potable
21-24 Deg.C and 30-60% respectively. (drinkable)
• Loss of Heating, Air Conditioning or
FCM team responsible for but not limited to: Ventilation Service
• Design, implement, maintain and operate • Loss of Public Address System
any electro-mechanical system at SKMC. • Loss of Pneumatic system
• Participate and conducting study to
evaluate existing electro-mechanical Utility Systems in Critical Area;
equipment for renovation or expansion • Electrical Power
projects. • Uninterrupted Power Supply (UPS)
• Plan, Monitor and ensure all maintenance • Generator Power
activities in SKMC are carried within • Medical Gas
planned schedule and ensure quality by • Medical Vacuum

85
• Air Conditioning System o Assists with the control of visitors,
• Fire Alarm System patients, and unauthorized person
• Nurse Call System especially at identified high risk areas
• Water supply and Drainage system o Responds to alarms
• Firefighting system o Physical security of the facility or
building
SECURITY MANAGEMENT PROGRAM o Escort people / patients
Important Security Services Contact o Helipad Area Management
Numbers: o Lost and Found Reporting and
Security Hotlines: (Emergency Situation) Safekeeping
• SKMC Main Campus - 3999 o Coordinates activities with law
• BSP - 3888 enforcement and public safety agencies
Security Desks: (For inquiry / assistance) o Conducts security well-being checks
• SKMC Main Campus - for employees and staff members
2049/3600/ 050-8181372 working in a department alone.
• BSP - 4241/4159 • Responds to emergency situations such as
• ADBB - 1750 but not limited to:
• Diabetic Center - 1350 Aggressive Person / Violent Behavior, Fire
• Mussaffah Warehouse - 1149 / Smoke, Missing Person/Child, Weapon /
Hostage Situation, Suspicious Object /
Security System/Control Available: Bomb Threat, etc.
• Uniformed Security Personnel / Guard
• Door Access System (Electronics) SKMC Badges / Identifications:
• Manual Punch Locks • Employee Identification
• Key Cylinder Lock Human Resources issues an official
• CCTV System identification badge to all staff members –
permanent, locums, outsourced, students
Security Services and Resources Offered: and volunteers. All are required by hospital
• Responds to security incidents and policy to wear their ID badge whenever
documents follow-up actions they are on duty in the Hospital Premises.
• Identifies security risks and vulnerabilities The identification badge is designed to
• Responds to requests such as locking or assist security staff, employees, patients,
unlocking doors, patients assists and visitor and visitors to identify staff and ensure
services appropriate access to employee entrances
• Investigates hospital incidents: and security sensitive areas or functions.
o Unsafe/unsecured conditions • Contractors / Official Visitor
o Missing property Each department is responsible to provide a
o Suspicious activity list of personnel coming to the hospital to
o Vandalism Security Office and/or advice them to wear
o Accidents / Traffic Accidents their company badges with picture while

86
 official visitors will be used Visitor badge by o Outpatients and the general public
Security Services. (visitors) are not provided identification
• Vendor or Medical Representative badges.
Identification
Vendors and other business representatives Physical Security Tips at Workplace:
are required to register with Purchasing • Securing your workstations
Department, where they are oriented to the • Be Observant / Vigilant
policies and procedures of the institution • Take Care of Your Personal Belongings
and issued a temporary badge and Vendor • Report all suspicious activity to the
Visit Form security or proper authorities
• Patient Identification • When unlocking doors, do not allow
o Emergency Department patients are issued unauthorized or unknown individuals to
an identification bracelet when they are follow behind you.
registered.
o Hospital inpatients are issued an
identification bracelet by the nursing
unit at the time of admission.

87
STAFF QUALIFICATIONS AND EDUCATION (SQE)

A health care organization needs an appropriate variety of

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

 If we are not assigned to the area of our

expertise, we are given additional training
and experience so that we can perform the
job we are assigned.

Is each staff member oriented to his or her job

Where are staff responsibilities defined? prior to being given the responsibility?
Staff responsibilities are defined in their Job Yes, in addition to the general orientation there
Descriptions, Medical Privileging for Doctors is departmental orientation during the
and in SKMC hospital and nursing policies and probation period.
procedures. Staff members are responsible for
knowing what is in the policies and procedures
and for following their job description.

Do your qualifications match the

requirements of the unit / clinic where you are
assigned to work?
Yes,
How were you oriented to your job and your
 First selection and CVs sourcing is made
responsibilities as an employee?
based on the PQR and the need of the
 Every employee have a copy of his job
hospital.
description, signed by him/her.
 During the interview and recruitment
 Every new employee is expected to attend
process all the documents gathered based
the general orientation, and department-
on the PRQ and Job Requirements are
specific orientation.
reviewed along with our training and
 For nurses, additionally they will attend
qualifications. We have to produce
nursing orientation.
documents that support our qualifications.

88
How does the hospital know you are
competent to perform your job?
For nurses:
 Orientation to the organization/annual and
core competencies.
 Ongoing competency assessment on
entrance and yearly, each department
assesses their staff members on a select
number of items that are high-risk, low- What is the process adopted in SKMC for
volume or problem-prone, point of care verification and evaluation of the
testing, for example on operating the blood ‘Credentials’ (License, education, training,
glucose monitor. You should be able to competence and experience) of the Medical,
discuss how your department assesses your Nursing, Allied Health Staff?
competence including age appropriate Al SKMC Hospital uses the outsourced service
competencies. by DOH, which is ‘Dataflow’. The Credential
 Continuous Nursing Education (CNE) verification process is linked with DOH
 Nursing competencies licensing process for New as well as renewal of
 Performance Improvement plan DOH licenses or any change of the professions.
 Departments Workshop
 Mandatory Trainings As a medical staff am I allowed to provide
 I-Perform—Performance Management clinical services in SKMC before the
verification of Credentials and granted
For physicians privileges?
At the initial appointment: Absolutely No. At the time of joining the
 Based primarily on information and verification of credentials must be completed as
documentation received from outside the well as the privileges will be granted.
hospital. It includes but not limited to:
specialty education programs, letters of As a Medical Staff, how could I be granted
recommendation and any quality data that with ‘Clinical Privileges’?
be released to the hospital. These outside There is objective, evidence based process in
sources identify at least the areas of place for granting the privileges starts by
presumed competence. completing the application by the medical staff
 Through FPPE during the first three months and ends by approval of the Privileging
and OPPE for reappointment Committee.

What is the validity of the granted ‘Clinical

privileges’ in SKMC?
The granted privileges are valid for 2 years.

89
What is the process for ‘Reappointment of In regards to clinical privilege delineation at
Clinical privileges’ in SKMC? reappointment: Medical staff members may
The reappointment and the renewal of have their privileges continued, limited,
privileges process is the process of reviewing reduced or terminated based on:
every 2 years the medical staff's file to verify:  The result of OPPE review process
 valid license  Limitations placed on individual's
 absence of disciplinary actions privileges
 the medial staff member is physically and  The request of the practitioner
mentally able to provide patient care &  The hospital findings from an evaluation of
treatment a sentinel or other events
 The file contains sufficient documentation  The health of the practitioner
for seeking new or expanded privileges. The result of this review process every 2 years
must be documented in the medical staff's file.

90
MANAGEMENT OF INFORMATION (MOI)

Providing patient care is a complex endeavor that is

highly dependent on the communication of
information. The sound and effective management
of information can help to improve individual and
hospital performance in patient care, governance,
management, and support processes.

Because we all depend on information to provide

patient care and services, our goal is to ensure that information is complete, accurate, timely, and
readily accessible when and where it is required. This must be accomplished having the sensitivity
and confidentiality of the information safeguarded at all times.

 Locking or signing out the computer

accesses of staff after a device use.
 Automatic locking of opened computer
devices left idle after certain period of
time.
 Access to the electronic medical record
is audited periodically to monitor
Information Management unauthorized access.
 SKMC maintains the confidentiality,  Individuals/entities requesting copies of
security, and integrity of its data and medical records are referred to Health
information through the following: Information Management Department,
 Only staff who are authorized, can where the information is released based on
view a patient’s Medical Record. the release of information process, and
 Access to computers and to Health required documents and consents.
Information System require secure  SKMC staff are NOT allowed to access their
passwords. own medical record, even if they have been
 The granted access level and privileges granted access to the Health Information
reflect the staff role within the facility. System. Staff needs to follow the same
 Patient’s files are protected from process as regular patients by making a
unauthorized viewing, loss, and kept request to the HIMS department.
secure by:  SKMC is not allowed to dispose any
 Keeping inpatient files inside the medical record in compliance with the
nurse’s station, and only authorized SEHA Circular MD/02-2010. This means
staff members have access. that the retention period of patients’
 Tracking patient files at any time they medical records is indefinite.
are moved from the HIMS department  There is a list of approved abbreviations,
or patient care areas. and they are the ones that can ONLY be

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 used for documentation. SKMC also has a own documents. The Head of the
list of Do-Not-Use abbreviations, and departments, Chair of Services, Unit
clinicians documenting in the patients Managers, and Committees review their
chart must refrain from using them. relevant policies on a timely manner and
However, abbreviations are never to be submit the changes to Quality Department
used on: for approval. Once approved, Quality
 informed consent Department uploads all polices/procedures
 patient rights documents on the Policy Management system.
 discharge instructions  SKMC policies and procedures are
 discharge summaries required to be reviewed every 2 years and
 other documents patient or family may all the programs or plans, Emergency
read or receive on patient’s care. Preparedness Policies and OSHMS
 Refer to the following documents for more documents are reviewed on an annual
information and details: basis.
 C-OP-HIMS-01-001 Access to Patient  Whenever documents are revised, it is
Information and Medical Records expected that the changes are reflected in
 C-OP-HIMS-01-015 Patient the revision history section of the
Information Privacy and documents or the policy system.
Confidentiality  Refer to the Policies and Procedures
 SEHA Information Security Policy Management Policy - C-QM-PIA-01-001
 C-IT-IT-01-007 Access Control Policy
 C-IT-IT-01-022 Access Control Medical Record
Procedure  The patients’ medical record at SKMC is
 C-IT-IT-01-011 Network Access available for every patient assessed or
Control Procedure treated by SKMC.
 C-IT-IT-01-012 Application Access  Patient medical records must be factual,
Control Procedure consistent and accurate. Documentation,
Orders/actions must be signed by the
Management and Implementation of person carrying out the order/action, as
Documents soon as possible after the episode or
 Valid hospital policies are posted in the encounter has occurred. This should be
SKMC Policy Management System. within 24 hours of the episode or
 All SKMC staff have access to the encounter.
documents posted in the policy  All components of the patient’s medical
management system for viewing and record generated within the hospital shall
reading. be kept together in a unit record, under one
 All policies, procedures and medical record number, comprised of
programs/plans of the hospital are original documents.
managed by the Quality Department, with  There are standards for documentation
the exception of Laboratory documents, as followed by clinicians at SKMC to ensure
the Laboratory department manages their that the specific content, format, and

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 location of entries for patient medical  Copying entire H&P and/or other
records is done in a consistent manner. documents into the discharge summary
 The medical records of emergency patients  Copying of all diagnostic test results,
should always include the following: regardless of significance
 Arrival and departure times  Copying of all medications regardless
 Conclusions at the termination of their of significance
treatment  Using screenshots of another note or
 The patient’s condition at discharge from another system
 Any follow-up care instructions  Compliance monitoring on the practice of
 SKMC has defined who are authorized to copy-and-paste is conducted by HIMS
make entries in the patient’s medical department, through monthly chart audits
record, and proper access has been and is reported to the Head of the
provided to them. Departments and CMO, and summaries to
 When documenting on paper, entries must the Medical Executive Committee, for
be written legibly, in permanent black ink review and action.
and in such a manner that they cannot be  Compliance with timeliness, legibility and
erased; dated, timed and signed; pencil and completeness of the medical record is
colored ink must not be used. Grammar, assessed using the following:
spelling and capitalization rules should be  HIMS department is conducting chart
followed in paper and electronic audits on specific documentation
documentation. requirements and deficiencies are
 Alterations/Corrections to manual records communicated by the HIMS staff to the
must remain legible by using a single line concerned staff and their Head of
to score out the information to be corrected. Departments
Correction must be accurately dated,  The open and closed record review is
timed, and signed. The use of correction also one of the tools used. The review is
fluid or tape is not allowed under any conducted by a multi-disciplinary
circumstance. An addendum is a late entry team, and the chart review results are
that is used to provide additional shared by the Manager of Health
information related to a previous entry by Information Management Department
the author or attending physician. with the concerned staff and their Head
Electronic correction will follow the same of Departments, Medical Records
guideline. Committee, Medical Executive
 SKMC has a process to address the proper committee and to the SKMC Quality
use of copy-and-paste function. As per Council as well.
SKMC policy, the following scenarios are  Refer to the following documents for more
the criteria considered violation of the information and details:
Copy and Paste policy:  C-MD-HIMS-01-002 Authors of
 If a note is identical to previous, Medical Record Documentation
without notation of previous author  C-MD-HIMS-01-009 Physician
Recording Standards

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  C-NUR-ADM-01-063 Nursing  Medical record forms used during
Documentation Policy Downtime events will be maintained
 C-MD-GEN-01-055 Copy and Paste permanently in the paper-based
Policy medical record, regardless of whether
the information is entered in Salamtak
Information Technology in Health Care system or not.
 All relevant workflows and forms related  Non-medical record forms used during
to the Salamtak downtime practice should Downtime will be maintained as
be accessible for reference and use by all documented in section specific
staff in the department. New employees Downtime plans.
should be trained on downtime procedures  Refer to the Appendices of the
as part of their department training. The downtime policy for department-
downtime policy should be referred to in specific processes to follow during
the event of planned and unplanned downtime and recovery.
downtimes.  Refer to the Downtime Plan for Hospital
 Points to remember: Information System (Salamtak) Policy - C-
 Healthcare providers should follow IT-IT-01-015, and in the Emergency
standard documentation practices Operations Plan Icon/Link in the desktop -
while documenting in paper medical Code Gold I.T., for more information and
records. details.

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