Joint Commission International Accreditation Survey

13 – 17 September 2015
Day One, Sunday – 13 September 2015

Physician Dr. Bonny Chen Nurse Ms. Salma S. Jaffer Administrator Mr. Robert Christmas Clinician Mr. Elijah J. Gilreath
Time
Dr. Mohammad Al
Escort Escort Ms. Mary Ann Dasalla Escort Ms. Elizabeth Rajan Escort Ms. Analyn Palacios
Jumaan
0745-
Team meeting with Survey Coordinator and Translator
0800
Opening Conference and Agenda Review
0800
Attendees: All KFHU Staff
0820
Venue : Auditorium ground floor Building 500
Orientation to the Organization’s Services
0820-
Attendees: All Chairpersons, All Supervisors, Charge Nurses
0900
Venue : Auditorium ground floor Building 500
Leadership for Quality and Patient Safety Interview, (Part 1)

Attendees: Dr. Khalid Al Otaibi, Dr. Mohye Al Wahhas, Dr. Mohammad Al Shahrani, Dr. Mohammad Al Jumaan, Dr. Ahmed Al-Kuwaiti, Ms. Nada Al Amri, Ms. Sausan Saleh, Dr. Raed
0900- Bukhari, Dr. Abdullah Aljoudi, Dr. Yasser Al Jehani, Dr. Haifa Al-Turki, Dr. Walid Al Bakr, Dr. Mohammad Hussain Al Qahtani, Dr. Dakheel Al-Dakheel, Prof. Akram Al-Khadra, Dr.
1000 Abdullah Al-Huweish, Dr. Hanan Al-Ghamdi, Ph. Abdullah Al Asmari, Ph. Nadia Ismail, Ms. Susan Al Yami, Ms. Khadija Al Hijab, Dr. Thenarrasu, Mr. Muhil Sakthivel, Yolanda P. Mateo,
Analyn Palacios, Romelia Dalacat, Elizza Esmediana, Rosalyn P. Noche

Venue: F-03 1st floor Building 500

1000- Document Review
1200 Attendees: Yolanda, Analyn, Romelia, Margilyn, Teresita

Venue: F-09 1st floor Building 500

1200-
Surveyors Working Lunch – Team Debriefing and Survey Planning
1300
FMS Document Review

Attendees: Dr. Ahmed Al-Kuwaiti, Prof. Ahmed

Ammar, Mr. Mohammed Abdulateef, Eng. Ali
1300- Individual Patient-Department / Individual Patient-Department / Al Ali, Hani Desouki, Hamad Shabeeb, Enas Al Individual Patient-Department / Service
1600 Service Quality Measurement Tracer Service Quality Measurement Tracer Shuwayer, Eng. Mohammed Fasiuddin. Quality Measurement Tracer
Elizabeth Rajan,Tahani Al Elaiwi, Manal
Abutwibah, Jehan Al Muhammadi

Venue: F-03 1st floor Building 500

1600–
Meeting with Survey Coordinator
1630
1630-
Surveyors Planning Meeting
1730

1
 Joint Commission International Accreditation Survey
13 – 17 September 2015
Day Two, Monday – 14 September 2015
Physician Dr. Bonny Chen Nurse Ms. Salma S. Jaffer Administrator Mr. Robert Christmas Clinician Mr. Elijah J. Gilreath
Time
Escort Dr. Mohye Al Wahhas Escort Ma. Ezabilita Cuizon Escort Ms. Tahani Al Elaiwi Escort Ms. Jenny Anne Serrano

Daily Debriefing
0800-
0900 Attendees: All Chairpersons, All Supervisors, Charge Nurses

Venue : Auditorium ground floor Building 500

Quality Program Interview
Attendees: Dr. Mohammed Al Jumaan, Dr. Mohammed Al Shahrani, Dr. Ahmed Al-Kuwaiti, Dr.
Abdullah Hosni, Dr. Nadia Ismail, Dr. Mariam Al Ali, Dr. Ashraf Attia, Susan Alyami, Dr.
0900-
Thennarasu, Khadija Al Hijab, Samia Al Nassri, Bashayer Al Shehail, Maryann Dassala, Vivien
1030
Go, Jenny Ann Serrano, Yolanda P. Mateo, Elizza Esmediana, Rosalyn P. Noche, Nouf Al
Individual Patient-Department / Individual Patient-Department / Sagabi, Rabab Emshamea,
Service Quality Measurement Tracer Service Quality Measurement Tracer Venue: F-03 1st floor Building 500
Facility Tour
Eng. Ali Al Ali, Hany Desouki, Eng. Fassihudin,
1030- Individual Patient-Department / Service
Eng. Larry Vargas, Eng. Glen Canlas, Enas
1200 Quality Measurement Tracer
Shuwayer, Nevele Martinez, Elizabeth Rajan,
Jehan Al Muhammadi Ms. Ruby Ocampo
1200-
Surveyors Working Lunch
1300
Medication Management System
Tracer
Attendees: Dr. Mohye Al Wahhas, Dr.
Mohammed Al-Shahrani, Dr. Waleed
1300- Bakr, Dr. Amani Al Nimr, Dr. Nadia Facility Tour
1500 Ismail, Bashayer Al Shehail, Mohammed
Alyami, Ms. Nada Al Amri, Julia Individual Patient-Department / Eng. Ali Al Ali, Hany Desouki, Eng. Fassihudin, Individual Patient-Department / Service
Cacayuran, Engr. Sunbul, Omar Basha Service Quality Measurement Trace Eng. Larry Vargas, Eng. Glen Canlas, Enas Quality Measurement Trace
Shuwayer, Nevele Martinez, Elizabeth Rajan,
Venue: F-05 1st Building 500 Jehan Al Muhammadi, Ms. Ruby Ocampo
Medical Student / Trainee Interview
1500-
1600 Attendees: Medical Students / Trainee
Venue: F-05 1st Building 500
1600-
Meeting with Survey Coordinator
1630
1630 –
Surveyors Planning Meeting
1730

2
 Joint Commission International Accreditation Survey
13 – 17 September 2015

Day Three, Tuesday – 15 September 2015

Physician Dr. Bonny Chen, Nurse Ms. Salma S. Jaffer Administrator Mr. Robert Christmas Clinician Mr. Elijah J. Gilreath
Time Dr. Mohammad Al
Escort Escort Ms. Vivien Go Escort Ms. Jehan Al Muhammadi Escort Ms. Analyn Palacios
Shahrani
Daily Debriefing
0800-
Attendees: All Chairpersons, All Supervisors, Charge Nurses
0900
Venue : Auditorium ground floor Building 500
Supply-Chain Management and Evidence-
Based Purchasing Interview and Tracer
Attendees: Dr. Khalid Al-Otaibi, Dr. Mohye Al
0900- Individual Patient-Department / Individual Patient-Department / Wahhas, Dr. M. Al Jumaan, Ms. Sausan Saleh, Individual Patient-Department / Service
1030 Service Quality Measurement Tracer Service Quality Measurement Tracer Mr. Ibrahim Abdulatif Al Qasimi, Ph. Nadia Quality Measurement Tracer
Ismail, Ph. Abdullah Al Asmari, Mr. Jamal Al
Sulayman, , Mr. Mousab Adiel
Venue: F-04 1st floor Building 500
Human Subjects Research Leadership
Infection Control System Tracer
Interview
Attendees: Dr. Mohammed Al Shahrani,
Attendees: Dr. Khalid Al Otaibi, Prof.
Dr. Marwan Al Wazeh, Dr. Huda Bukhari,
Akram Al Kadra, Dr. Mona Ismail, Dr. A.
Dr. Ahlam Al Ghamdi, Dr. Amani Al Nimr,
1030- Aljoudi, Dr. Hossam Aljehani, Dr. Turki
Mr. Saif Al Awad, Ms. Mervat Ghazi, Ms. Individual Patient Tracer
1200 Abu Olait, Dr. Fahad Al Khamis, Prof.
Nevele Martinez, Ms. Susan Alyami, Ms.
Mohd Fakhri Abdulmohsen, Dr. Ali
Rosalyn Noche, Ms. Samia Al Nassri,
Alamri, Dr. Nadia Ismail, Mr. Vijaya
Ms. Ruby Ocampo
Kumar
Venue: F-03 1st floor Building 500
Venue: F-05 1st floor Building 500
1200-
Surveyors Working Lunch
1300
Closed Patient Medical Record Review
Closed Patient Medical Record Review
Mary Ann Dasalla, Elizza Esmediana
1300-
Jenny Ann Serrano, Victoria Ramos, Gina
1500 Attendees: Dr. Ashraf Attia, Abdul Majeed, Khadija Al Hijab, Vivien Go, Ma. Ezabelita
M. Ebeo
Acebes, Yolanda Mateo
Venue: F-03 1st floor Building 500
Venue: F-04 1st floor Building 500
1500-
Individual Patient Tracer Individual Patient Tracer Individual Patient Tracer Individual Patient Tracer
1600
1600-
Meeting with Survey Coordinator
1630
1630 –
Surveyors Planning Meeting
1730

3

Physician Dr. Bonny Chen,
Time
Escort Dr. Ashraf Attia
0800- 0900 Attendees: All Chairpersons, All Supervisors, Charge Nurses
Venue : Auditorium ground floor Building 500
Staff and Medical Professional Education
Qualifications Session
Medical Staff
Attendees: Dr. Khalid Al Otaibi, Dr. Abdullah
Aljoudi, Dr. Hanan Al Ghamdi, Ms. Leilani
0900-1030
Ysmael, Ms. Reem Al Jaber, Ms. Nadia Al
Assiri
Venue: F-09 1st floor Building 500
Medical Professional Education Leadership
Interview
Attendees: Dr. Khalid Al Otaibi, Dr. Mohye Al
Wahhas, Dr. Mohammed Al Jumaan, Dr. Raed
Bukhari, Dr. Abdullah Aljoudi, Prof. Maha
1030-1200
Abdulhadi, Dr. Ayman Talib, Dr. Mona Al
Sheikh, Dr. Khalid Kamaleddin, Dr. Abdullah Al
Hweish, Dr. Sahar Natur, Ms. Nada Al Amri,
Leilani Ysmael, Katarina Alvarado, Jessie Asilo
Venue: F-03 1st floor Building 500
1200- 1300
1300-1430
Individual Patient Tracer Activity
1500-1600
Joint Commission International Accreditation Survey
13 – 17 September 2015
Day Four, Wednesday – 16 September 2015
Nurse Ms. Salma S. Jaffer Administrator Mr. Robert Christmas Clinician Mr. Elijah J. Gilreath
Escort Ms. Mary Ann Dasalla Escort Ms. Nevele Martinez Escort Ma. Ezabilita Cuizon
Daily Debriefing
Facility Management and Safety (FMS)
Staff and Medical Professional
Tracer
Education Qualifications Session
Attendees: Dr. Ahmed Al-Kuwaiti, Prof.
Nursing Staff
Ahmed Ammar, Mr. Mohammed Abdulateef,
Attendees: Mr. Hussain AlZugerty, Ms.
Eng. Ali Al Ali, Hani Desouki, Hamad
Sausan Saleh, Ms. Mervat Ghazi, Ms. Individual Patient-Department /
Shabeeb, Enas Al Shuwayer, Eng.
Haifa Al Ikwan, Ms. Analyn Palacios, Service Quality Measurement Tracer
Mohammed Fasiuddin, Elizabeth
Ms. Ghadah Al Ghammas,
Rajan,Tahani Al Elaiwi, Jehan Al
Muhammadi, Manal Abutwibah, Ms. Ruby
Ocampo
Venue: F-03 1st floor Building 500
Venue: F-04 1st floor Building 500
Individual Patient Tracer Activity Individual Patient Tracer Activity Individual Patient Tracer Activity
Surveyors Working Lunch
Staff and Medical Professional Education
Qualifications Session
Other Professional Staff
Attendees: Ms. Reem Al Jaber, Ms. Nadia
Individual Patient Tracer Activity Al Assiri, Ms. Ghadah Al Ghammas, Ms. Individual Patient Tracer Activity
Lama Al Subaie, Ms. Maysoum Abo-Foul
Venue: F-04 1st floor Building 500
Undetermined Tracer

1600-1630 Meeting with Survey Coordinator

1630–1730 Surveyors Planning Meeting

4
 Joint Commission International Accreditation Survey
13 – 17 September 2015
Day Five, Thursday – 17 September 2015

Physician Dr. Bonny Chen Nurse Ms. Salma S. Jaffer Administrator Mr. Robert Christmas Clinician Mr. Elijah J. Gilreath
Time
Escort Yolanda Mateo Escort Ms. Mary Ann Dasalla Escort Ms. Tahani Al Elaiwi Escort Ms. Jenny Anne Serrano

Daily Debriefing
0800- Attendees: All Chairpersons, All Supervisors, Charge Nurses
0900
Venue : Auditorium ground floor Building 500

0900-
Individual Patient Tracer Activity Individual Patient Tracer Activity Individual Patient Tracer Activity Individual Patient Tracer Activity
1030
Leadership for Quality and Patient Safety Interview (Part 2)
Ethical Frame Work and Culture of Safety
System Themes Identified
Attendees: Dr. Khalid Al Otaibi, Dr. Mohye Al Wahhas, Dr. M. Al Shahrani, Dr. M. Al Jumaan, Dr. Ahmed Al-Kuwaiti, Ms. Nada Alamri, Ms Sausan Saleh, Dr. Raed Bukhari, Dr. A.
1030-
Aljoudi, Dr. Yasser Al Jehani, Dr. Haifa Al-Turki, Dr. Walid Bakr, Dr. Mohammad Hussain Al Qahtani, Dr. Dakheel Al-Dakheel, Prof. Akram Al-Khadra, Dr. Abdullah Al-Huweish, Dr.
1200
Hanan Al-Ghamdi, Ph. Abdullah Al Asmari, Ph. Nadia Ismail, Ms. Susan Alyami, Ms. Khadija Al Hijab, Dr. Thenarrasu, Muhil Sakthivel, Yolanda P. Mateo, Analyn Palacios, Romelia
Dalacat, Elizza Esmediana, Rosalyn P. Noche

Venue: F-03 1st floor Building 500

1200-
Surveyors Working Lunch and Integration of Findings and Report Preparation
1500

Leadership Exit Report

1500- Attendees: Dr. Khalid Al Otaibi, Dr. Mohye Al Wahhas, Dr. M. Al Shahrani, Dr. M Al Jumaan, Dr. Ahmed Al-Kuwaiti, Ms. Nada Alamri, Ms Sausan Saleh, Dr. Raed Bukhari, Prof. Akram
1530 Al-Khadra, Dr. Abdullah Al-Huweish, Dr. Hanan Al-Ghamdi, Ph. Nadia Ismail, Mr. Mohammed Abdulateef, Mr. Saif Al Awad, Prof. Maha Abdulhadi

Venue: F-03 1st floor Building 500

Exit Findings Presentation

1530-
Attendees: All Staff
1600
Venue : Auditorium ground floor Building 500