Hospital Standards December 2017 English

Egyptian HealthCare
Accreditation Program
Standards for
Hospitals
Third Edition
December 2017
International Society for Quality in Health Care
Egyptian Executive Healthcare

Accreditation Committee
Standards for Hospitals
Third Edition 2017
Awarded by ISQua
following an independent assessment against ISQua’s
Principles for the Development of Health and Social
Care Standards,
4th Edition
The period of Accreditation for these Standards

is from
December 2017 until December 2021
President Head of the International Accreditation

Programme
Hospital Standards
Table of Content
Page
5 List of abbreviation/ code of standards
6 Introduction and Overview
10 Summary of changes
Patient Rights and Responsibilities, Organization Ethics (PR)
15 PR Individual Rights and Responsibilities
16 PR Consent
17 PR Organization Ethics
18 PR Research
Patient Access and Assessment of Patients (PA, AP)
20 PA Access and admission
20 PA Continuity of Care and Consultations
21 PA Transfer, Discharge, Referral
21 AP Assessments and Reassessment
23 AP Pain
23 AP Medical Staff Assessment and Documentation
24 AP Special Patient Populations
25 AP Baby Friendly Care and Pediatrics
25 AP Psychiatric
25 AP Addiction
26 AP Emotional and Behavioral Disorders
26 AP Psychosocial Assessment for Addiction and Behavioral Disorders
Providing Care, Diagnostic Services, Blood Bank and Transfusion Services, Invasive Procedures,
Patient and Family Education (PC, DS, BB, IP,PE)
28 PC General
29 PC Nutritional Care
30 PC Terminally Ill patients
30 PC Specialized Care Units
30 PC Restraint and Seclusion
31 PC Resuscitation
31 PC Emergency Care
32 DS Radiology
33 DS Laboratory and Pathology
35 DS Point of Care Testing
35 BB Blood Bank and Transfusion Services
36 IP Surgical and Invasive Procedures
37 IP Anesthesia and Moderate Sedation
37 IP Assessment prior to the administration of anesthesia or sedation
37 IP Monitoring During Anesthesia and /or sedation
38 IP Recovery Phase
38 PE Patient and Family Education
Medication Management (MM)
41 MM General
41 MM Patient Specific
Scoring of B& C standards: Met (M) = <20% deficiencies; Partially Met (P) = 20-<50% deficiencies;
Not Met (N ) = 50% and above deficiencies out of at least 10 observations distributed over m ore than one
relevant departm ents 2
41 MM Selection and Procurement
41 MM Storage
43 MM Prescribing/Ordering and Transcribing
44 MM Preparing and Dispensing
45 MM Administration
46 MM Monitoring
46 MM Evaluation
Patient Safety, Infection Control, and Environmental Safety (PS, IC, ES)
48 PS General Patient Safety
50 PS Medication Management Safety
52 PS Operative and Invasive Procedure Safety
Infection Control, Surveillance and Prevention

52 IC Program Plan and Management
55 IC Sterilization
56 IC Laundry and Linen
56 IC Surveillance and Monitoring
Facility and Environmental Safety

57 ES Planning and Implementation Activities
58 ES Safety and Security
59 ES Emergency/Disaster Management
59 ES Hazardous Materials and Waste
60 ES Fire Safety
61 ES Medical Equipment
63 ES Utility Systems
Information Management (IM)

66 IM Confidentiality and Security
66 IM Information Processes
67 IM Patient-Specific Information – Medical Record
Performance Improvement (PI)

71 PI Process and Design
72 PI Collecting and Measuring Activities
72 PI Clinical Care Monitoring
73 PI Managerial Monitoring
73 PI Analyzing Data
73 PI Comparative Activities, Benchmarking
74 PI Improving Activities
74 PI Risk Management
75 PI Significant events to be analyzed
Organization Management (OM, HR, NS, MS)

77 OM Governance – Governing Body
77 OM Leadership
78 OM Planning
78 OM Responsibilities
79 OM Directing of Departments and Services
Human Resources
80 HR Planning
81 HR Orientation
81 HR Competence Assessment, Training and Education
82 HR Health care Library
82 HR Staff Performance Evaluation
82 HR Occupational and Employee Health
83 NS Nursing Services
Medical Staff
83 MS Organized Medical Staff Structure
84 MS Appointment
84 MS Privileges
85 MS Competency for reassessment and Re-privileging
85 MS Peer Review
85 MS Continuing Education
85 MS Graduate Medical Education
CI Community Involvement
87 CI Community Involvement
87 CI Public Relations
88 List of Policies & Procedures

91 List of hospital required plans & Committees
92 Glossary
List of abbreviations / code of standards.
Code Meaning
PR Patient Rights and Responsibilities, Organization Ethics
PA Patient Access
AP Assessment of Patient
PC Providing Care
DS Diagnostic Services
BB Blood Bank and Transfusion Services
IP Invasive Procedures
PE Patient and Family Education
MM Medication Management
PS Patient Safety
IC Infection control, Surveillance and Prevention
ES Facilty and Environmental Safety
IM Information Management
PI Performance Improvement
OM Organization Management
HR Human Resources
NS Nursing Services
MS Medical Staff
CI Community Involvement
Introduction and Overview
The Egyptian HealthCare Accreditation program is designed to encourage all hospitals
and clinics to become accredited over time. There are three programs: Hospital,
Ambulatory, and Primary Healthcare Clinics/Family Health Units, each program with it’s
own manual. Clinics and ambulatory units associated with a hospital will be surveyed
under the hospital standards at the same time the hospital is surveyed.
Standards Structure:
The rating system is designed to maximize inter-rater reliability. The system uses A, B
and C labels. B and C standards require a specific number of observed deficiencies. To
provide transparency for scoring and enable frequent self assessment, the scoring has
been added to each standard in the manuals as shown below. The first column
indicates if this is an A, B or C standard. This is followed by a series of 4 boxes which
are used for scoring. The letters in the boxes are M for Met, P for Partially Met, N for
Not Met and NA for Not Applicable.
A standards M P N NA
The A standards are structures that include policy and procedures, plans, bylaws,
required committees and other specified items. “A” standards with numbered elements
(example PR.1 with elements 1 through 10) require all elements to be present in order
to be scored as Met. If one of the numbered elements were lacking or is inadequate
this standard will be scored as "Partially Met”, and if more than that were lacking the
standard will be scored "Not Met". Passing 85% of the A standards is required to
achieve the Foundation Level, which is level 1 of the Pyramid of Excellence in
Healthcare.
M P N NA
B & C standards
The B and C standards are implementation standards. These standards are scored
either based on the number of observations, documentation of deficiencies, or non
compliance with the standard. The scoring is M (Met) if there is less than 20% of
observations and/or documentation were deficient; P = (Partially Met) if 20 to less than
50% of observations and/or documentation were deficient; and N = (Not Met) if 50%
or more of observations and or documentation were deficient out of at least 10
observations distributed over more than one relevant departments/services.
The difference between the B and C standards is: (a) the increasing difficulty in the
implementation process of C standards, (b) achieving compliance with the C standards,
or (c) a standard that is not applicable on an initial survey which requires a 4 month
track record (example an annual report that requires 12 months to complete it).
Staging – Levels:
The design of the accreditation process is flexible. An organization may choose to seek
full accreditation or they may choose to achieve accreditation over a period of time by
making incremental improvements in the development and implementation of processes
and systems.
There are three levels of achievement: Foundation level – Level 1; Basic Quality – Level
2; and Accreditation. Refer to the pyramid diagram below for an illustration of the three
levels plus a flow of the process from baseline to the top of the pyramid representing
achievement of accreditation.
Pyramid of Excellence in HealthCare Accreditation
A+B+C
Egypt Standards
Accreditation
A+B
Basic Quality Level Standards
A
Standards
Foundation Level
Pre-survey Assessment
Application Validation
Application
Self Assessment
Accreditation Levels
Total
Foundation Level A 85% B 40% 40%
Basic Level A 90% B 60% C 20% 60%
Accreditation level l A 95% B 80% C 60% 80%
Scoring Standards – Summary
• A – structures – policy/procedures, plans, required committees (all or none

scoring)
 Met
• Present – all elements
 Partially Met
• One element is lacking or inadequate
 Not Met
• More than one elements is lacking or inadequate
• B & C – implementation - frequency based - observations of deficiencies
 Met
• <20% observed or documented deficiency
 Partially Met
• 20-<50% observed or documented deficiencies
 Not Met
• 50% and more observed or documented deficiencies
B versus C standards
B standards are to be implemented first (easier)

C standards are more difficult to implement or not needed for an initial survey
Accreditation Process:
The accreditation process begins with an initial self assessment. Assistance may be
requested for clarification of applicability of a standard or set of standards to the
organization. After completion and submission of the application form, a telephone
conference will be held to review and validate the application information. Prior to an
initial survey, a pre survey visit will be scheduled to validate the application information.
The pre survey team will also determine that the organization has met a sufficient
number of standards to minimally be able to achieve the Foundation level. A report of
deficiencies will be left with the organization to enable further preparation. A full survey
Team will be scheduled when the organization has at a minimum a 4 month track
record of achievement with these selected standards. The organization may choose to
be surveyed for only the first or first 2 levels or for a complete survey of all
accreditation standards. After the survey, a report will be given to the organization with
an outcome of the level achieved and a list of all Not Met and Partially Met standards.
The Not Met standards will require a written response to each “Need for Improvement”.
An on site resurvey could occur depending on the problem or lack of ability to correct
deficiencies.
In case of full accreditation a certificate will be given to the hospital. A mid cycle
(approximately 18 month) assessment process will occur. This assessment consists of a
combination of self assessment and an on site survey by a team. A full on-site survey
conducted by a team of surveyors will occur in the 3rd year.
However in case of achieving foundation or basic quality level a letter of recognition will
be given to the hospital and another on-site survey is required in a period between 6 to
18 months.
Summary of Changes to Hospital Accreditation Standards
Third Edition
General Rules: the scoring system of "A" standards have been changed to include
"Partially Met", standards with numbered elements (example PR.1 with elements 1
through 10) require all elements to be present in order to be scored as Met. If one of
the numbered elements were lacking or is inadequate this standard will be scored as
"Partially Met”, and if more than that were lacking the standard will be scored "Not
Met". Thus all "A" standards preceded "A" with multiple elements were deleted to avoid
repetition. The changing of scoring system of "A" standards was recommended by JCI
team in 2011 and requested frequently by stakeholders.
N.B. The standard's code number mentioned in this table is conforms to 2013 version
of the standards. The number could be changed in 2017 version due to deleting, adding
or dividing some few standards. All modification or improvements in standards'
statements are written in italic and bold.
Standard Change Explanation
PR.1 Deleted See general rule

PR.4 Moved down after PR.8 Because "responsibility" is added
PR.13 Add time frame Required by ISQua
PR.25 Re-classified as C Difficult in assessment and
implementation
PR.32& 33 Deleted in Egypt Autopsy is not allowed by law to
be done in hospitals
PR. Add a new standard Required by ISQua: The staff respect the
preferences and choices of patients
AP.1 See general rule

AP.6 Add a new sub-item Required by ISQua
PA.13& 16 Merged together They are relevant
PA.14 Requirement change Required by hospitals & quality
coordinators
PA.15& 17 Merged together they are relevant
AP.26 Statement is improved To clarify the meaning

AP.31 Add a requirement Required by ISQua
AP.32& 33 Merged together They are relevant
PC.2 Statement is improved To clarify the meaning

PC.6 Deleted It has no meaning
PC.9 Add a requirement Required by ISQua
PC.10 Deleted To avoid repetition as inter disciplinary and
collaborative care are included in PA 7 & 8
PC.13 Changed to policy and Required by ISQua
moved up before PC.12
PC.15 deleted Included in the above newly developed
policy
PC.35& 36 Merged together They are relevant
PC.49 Moved up before PC.48 Better arrangement
MM.24 moved to this section More relevant to resuscitation
IP.3 Deleted Required by surveyors

IP.5 Deleted Repetition, present in patient rights chapter
IP.6& 7 Deleted Repetition, present in PC chapter
IP.16 Deleted Required by surveyors
IP.21 Deleted It has no meaning

IP.24 &25 Improve the language To clarify the intent of each standards
IP.39& 40 Merged together They are relevant
PE.1& 2 Merged together they are relevant
MM.15 Add new implementation standard for it

MM.16 Add new implementation standard for it
MM.21 Change statement To clarify
MM.31 Moved to PS section More relevant to PS
MM.36& 37 Remove preparation To require only dispensing in the two
standards as preparation is included in
MM.40
PS.1 Deleted See general rule
IC.11 Deleted See general rule

IC.12 two sub-items are added Required by ISQua
IC.12.11 Separated as B standard As implementation of IC.11.1
ES.6 & 11 Merged together They are relevant

ES.9 & 10 Moved under safety plan As part of implementation of safety plan
ES.29 deleted Not possible right now in Egypt

ES.61 deleted See general rule
ES.68 Divided into 6 standards To ensure regular inspection, maintenance,
testing and repair of each one essential
utilities
IM.1 deleted To avoid repetition

IM.2 Add subdivision Required by ISQua and suggested by
surveyors
IM.4 Divided into two To separate unauthorized accessor use
from loss and destruction
IM.13 deleted Difficult at this stage of implementation of
the program
IM.24 deleted Repeated in MM & PS
PI A new standard is added Recommended by ISQua

(PI.7)
PI.1 Deleted Repeated in OM 16, 35, 38, 51.6
PI.3&4 Merged together They are relevant
PI.17 deleted Repeated in 6 standards in ES section
PI.39 Change requirement and Required by ISQua
move up with clinical
monitoring
PI.45 Moved to HR section More relevant to HR
PI.52 deleted Repeated in OM.10
PI.53 Change in requirements To be more clear and evidence based
PI.54 Change in requirements To be more clear and evidence based
PI.55 deleted As its integrated as a requirement in
modified PI.54
Two standards are added Required by ISQua
to risk management
OM Two new standards are Required by ISQua

added in governance
(OM.6&8 )
OM.5 Values are added as Recommended by ISQua
requirement
OM.12 Moved up
OM.16 Add sub-item Required by ISQua
OM.22 Moved to IM section More relevant to IM
OM.23 Add a requirement Required by ISQua
OM.25& 27 Merged together They are relevant
OM.29 Moved down to More relevant
responsibilities
OM.32 deleted Repeated in HR1 & OM53
OM.33 Integrated in OM.28 Relevant to some extent
OM.37 Clarify statement To measure one process
OM.54 Clarify statement To measure one process
HR.1 Add a requirement Required by ISQua

HR.13 deleted Included already in HR.12
HR.44 deleted No added value
HR.45 deleted No added value
HR.46& 47 integrated They are relevant
NS Add new standard Required by ISQua
MS.2 Modify statement To measure one process (N.B.

department/service periodical report is
required in OM.52 of 2017 edition.
MS.13 Deleted Included already in HR.12
MS.28 Deleted Included in HR (after moving PI.45 to HR)
CI.4& 5 Merged together They are relevant
Patient Rights and Responsibilities,
Organization Ethics
(PR)
Score Standard
Patient Rights and Responsibilities
A M P N NA PR. 1 Patient rights Policy and procedure includes at least the following:
PR 1.1 Rights as defined by laws and regulations
PR 1.2 Right to access care if provided by the organization
PR 1.3 Right to know the name of the treating, supervising and/or

responsible physician
PR 1.4 Right to care that respects the patient's personal values and beliefs
PR 1.5 Right to be informed and participate in decisions relating to their

care
PR 1.6 Right to refuse care and discontinue treatment
PR 1.7 Right to security, personal privacy, confidentiality and dignity
PR 1.8 Right to have pain assessed and treated
PR 1.9 Right to make a complaint or suggestion without fear of retribution
PR 1.10 Right to know the price of services and procedures
B M P N NA PR. 2 Patients are informed of their rights in a manner they can

understand.
B M P N NA PR. 3 Patients’ dignity, privacy and confidentiality are protected during all
assessments, care and treatments.
C M P N NA PR. 4 There is a process to respond to patients religious or spiritual needs
A M P N NA PR. 5 Policy and procedure defines patient and family responsibilities

including at least the following:
PR. 5.1 Patients and their families have the responsibility to comply with the
policies and procedures of the organization
PR. 5.2 Patients and their families have the responsibility to comply with
financial obligation according to law and regulation and
organization policy
Score Standard
PR. 5.3 Patients and their families have the responsibility to show respect to
other patients and healthcare workers
PR. 5.4 Patients and their families have the responsibility to follow the
recommended treatment plan
B M P N NA PR. 6 Patients are informed of their responsibilities. and agree to comply

with it
A M P N NA PR. 7 Patients' rights are maid visible to patients and staff.
A M P N NA PR. 8 Policy and procedure defines informing patients and families about
their rights and responsibilities related to refusing or discontinuing
treatment.
B M P N NA PR. 9 Patients and families are informed about the consequences of

refusing or discontinuing treatment.
B M P N NA PR. 10 Patients and families are informed about their responsibilities related
to refusing or discontinuing treatment.
B M P N NA PR. 11 Patients are informed about available care and treatment

alternatives.
A M P N NA PR. 12 Policy and procedure defines the process for patients to make oral or
anonymous written complaints or suggestions including tim efram e
for resolution of and response to com plaints.
B M P N NA PR. 13 Patients’ complaints and concerns are addressed and resolved timely
as per policy .
Consent
B M P N NA PR. 14 General consent for treatment is obtained when the patient is

admitted to seek service of the organization.
A M P N NA PR. 15 Policy and procedure guides the process of informed consent and
defines the length of time a signed consent is valid before a new
consent must be obtained.
A M P N NA PR. 16 The organization has a list of procedures or treatments for which

informed consent is required, including at least the following (as
applicable):
PR. 16.1 Surgery and invasive procedures
PR. 16.2 Anesthesia/moderate or deep sedation
PR. 16.3 Use of blood and blood products
Score Standard
PR. 16.4 High-risk procedures or treatments (including but not limited to

Electro Convulsive Treatment, radiation therapy, chemotherapy)
PR. 16.5 Family planning interventions
PR. 16.6 Research
B M P N NA PR.17 Informed consent is obtained and documented as required by law

and regulation and also as required by hospital policy.
B M P N NA PR. 18 Informed consent includes the risks, benefits, and alternatives were
explained.
B M P N NA PR. 19 Consent given by someone other than the patient complies with laws
and regulation and is documented in the patient's medical record.
B M P N NA PR. 20 Consent forms are available in all applicable locations.
Organization Ethics
B M P N NA PR. 21 The organization advertises and markets honestly in accordance with

law and regulation and the ethical code of the Medical Syndicate.
A M P N NA PR. 22 The organization has a system to inform patients and families of all
services available and how gain to access these services.
A M P N NA PR. 23 The organization has a system to inform patients and families of any
expected costs.
C M P N NA PR. 24 Patients and families are informed of alternatives to the provided

services and are assisted in seeking other services as needed or
desired.
A M P N NA PR. 25 Policy defines the organization's responsibilities regarding patients’

belongings including at least the following:
PR. 25.1 Who is responsible
PR. 25.2 When responsibility for these belongings begin
PR. 25.3 How belongings will be protected
PR. 25.4 Valuables that the organization will not take responsibility for
B M P N NA PR. 26 Information about the organization's responsibility for belongings is

given to the patient or family.
B M P N NA PR. 27 Patients’ belongings are protected and returned.
Score Standard
A M P N NA PR. 28 There is a defined process for informing patients and families of the
outcome of care and treatment.
A M P N NA PR. 29 Policy and procedure defines how the organization informs patients
and families about choosing to donate organs and other tissues.
C M P N NA PR. 30 Patients and families are informed about how to donate organs and
other tissues according to law and regulation and hospital policy.
Research
B M P N NA PR. 31 An appropriate committee reviews and approves all research

protocols that involve human subjects as required by law and
regulation.
A M P N NA PR. 32 Research Policy and procedures is available and includes eligibility for
enrollment in research projects or protocols.
B M P N NA PR. 33 A signed patient consent for participation in research is placed in the

research file and in the medical record.
B M N NA PR. 34 Patient has the right to withdraw from a research protocol without
fear of retribution.
B M N NA PR. 35 Photographs and patient information included in the research are

guaranteed confidentiality and names and identifiers will not be
published.
Patient Access (PA)
Assessment of Patients (AP)
Score Standard
Score Standard
Access and Admission
B M P N NA PA. 1 Patients have access to services based on their health needs and
the mission and resources of the organization.
A M P N NA PA. 2 Policy and procedure defines access and admission to services

and include at least the following:
PA. 2.1 Process to screen patients to determine that the organization can
meet their health care needs
PA. 2.2 Admission of patients, including those from emergency services
PA. 2.3 The screening process to determine the priority of the patient's
medical and nursing care needs
PA. 2.4 Information to be given to the patient and family at the time of
admission
PA. 2.5 Management of patients when space is not available for the
desired service.
PA. 2.6 M anagem ent of patients w hose care needs cannot be

m et by the organization including care at presentation
site and processes for safe transfer out of the
organization (refer to PA12).
B M P N NA PA. 3 Patients are screened, admitted and receive access to services as
needed, and according to policy.
C M P N NA PA. 4 Waiting times for services meet the needs of the community
(Refer to standards CI.2 and PI.18)
Continuity of Care and Consultations
B M P N NA PA. 5 All diagnoses are recorded and updated in the patient record as
needed
A M P N NA PA. 6 Policy and procedure defines the coordination between multiple

disciplines (including nurses and physicians) and different clinical
settings across inpatient, outpatient and community services
C M P N NA PA. 7 All patient care between multiple disciplines (including nurses

and physicians) is collaborative and coordinated.
C M P N NA PA. 8 There is a process to ensure that patient care between

different clinical services and settings across inpatient, outpatient
and community services, if applicable , is coordinated
Score Standard
A M P N NA PA. 9 Policy and procedure defines the criteria for getting consultation
for patients including the time frame and the process, both
internally and externally, as needed
B M P N NA PA. 10 Consultations are obtained as per defined hospital criteria, and

are conducted in a timely manner.
C M P N NA PA. 11 Consultation results are documented in the medical record in a

timely manner, and with sufficient details to enable safe and
appropriate care of the patient.
Transfer, Discharge, Referral
A M P N NA PA. 12 Policy and procedure defines the process of transfer,

referral and discharge of patients including at least:
PA. 12.1 R esponsible staff for transfer, referral and discharge of

patients,
PA. 12.2 Criteria determ ine the appropriateness of transfers

w ithin and outside the organization,
PA.12.3 M aking links w ith referral agencies, if applicable, other

levels of health service and other organisations.
C M P N NA PA. 13 Planning for referral and discharge begins once diagnosis or
assessm ent is settled and when appropriate includes the
patient and family.
B M P N NA PA. 14 Patients are appropriately transferred, referred and discharged

based on the patients' needs for continuing care.
B M P N NA PA. 15 The reason for the transfer and referral is explained to the
patient and/or his family.
B M P N NA PA. 16 The reason for the transfer or referral is documented in the

medical record.
B M P N NA PA. 17 The complete and up to date patient medical record is

transferred with the patient to another clinical unit in the
organization.
B M P N NA PA. 18 A copy of relevant portions of the medical record is sent with

patients transferred to another facility (Refer to standard IM.33)
Assessments and Reassessment
A M P N NA AP. 1 The organization has defined who may screen and assess
patients.
Score Standard
A M P N NA AP. 2 Policy and procedure defines:
AP. 2.1 Scope and content of initial assessment by each discipline
AP. 2.2 Time frame for completion of initial assessments,
AP. 2.3 Frequency of reassessment of patients by diagnosis and/or level

or need
B M P N NA AP. 3 A nursing assessment is recorded in the patient's medical record

within the shift admitted,
A M P N NA AP. 4 Policy and procedure defines the screening criteria for further
assessment of all patients for the following:
AP. 4.1 Nutritional risk and needs
AP. 4.2 Functional/rehabilitation risk and needs
AP. 4.3 Social and psychological services and discharge needs
A M P N NA AP.5 Policy and procedure defines the screening criteria of patients

against abuse and neglect.
A M P N NA AP.6 Qualified individuals develop criteria to identify patients who

require further nutritional assessment.

require further functional assessment.

require further abuse and neglect assessment.
C M P N NA AP.9 All screens are completed and documented within 24 hours of

admission and as needed.
C M P N NA AP.10 Patient's health care needs are evaluated according to the

defined screening and assessment processes.
C M P N NA AP.11 Patients are referred for further assessment by the specific

service when defined criteria are met.
C M P N NA AP.12 Patients are screened for abuse and neglect using the defined
criteria, and are referred to the appropriate service(s) for follow
up.
B M P N NA AP.13 The findings of assessments performed outside the organization

are verified at admission.
Score Standard
B M P N NA AP.14 Nursing reassessments are documented each shift.
Pain
A M P N NA AP.15 Policy and procedure defines and guides screening, assessment,

reassessment and management of pain.
B M P N NA AP.16 All patients are screened for the presence of pain each shift or as
physician order.
B M P N NA AP.17 In case of pain; the type, site, and severity of pain is assessed
and documented in the patient file.
B M P N NA AP.18 Pain is managed and documented.
B M P N NA AP.19 Pain is reassessed and documented to determine the

effectiveness of treatment, as per hospital policy.
Medical Staff Assessments and Documentation
A M P N NA AP.20 Policy and procedure of the comprehensive history and physical

examination for inpatient admission includes at least the
following:
AP.20.1 Chief complaint
AP.20.2 Details of the present illness
AP.20.3 Previous hospital admissions and surgery
AP.20.4 Allergies
AP.20.5 Adverse drug reactions
AP.20.6 Medications the patient has been taking
AP.20.7 Psychosocial history, including emotional, behavior, and social

status
AP.20.8 Family history
AP.20.9 The required elements of the comprehensive physical

examination
AP.20.10 Conclusion or impressions drawn from the admission history and

physical examination, including diagnoses
AP.20.11 Initial investigations as needed
Score Standard
B M P N NA AP.21 History and physical examination is completed as per policy and

recorded in the patient's medical record within 24 hours of
admission.
B M P N NA AP.22 A history and physical examination completed prior to admission

may be used provided it is no more than 30 days old.
B M P N NA AP.23 On admission, the physician documents in the medical record

subsequent changes to the initial history and physical
ex am ination, based on reassessment of the patient , and
confirm that the history and physical is still accurate and current
A M P N NA AP.24 Policy and procedure defines the minimum frequency and

content of reassessment
B M P N NA AP.25 Physician's progress notes for acute care patients are

documented at least daily.
B M P N NA AP.26 If the organization provides care for chronic patients;

physician's progress notes are docum ented w ith the
frequency and content required by policy.
A M P N NA AP.27 Policy and procedure defines the minimum scope of assessment

(history and physical exam) for short-stay (less than 24 hours)
patients.
A M P N NA AP.28 Policy and procedure defines the minimum acceptable scope of

the history and physical examination for outpatient surgery and
invasive procedures.
A M P N NA AP.29 Policy and procedure defines the minimum content of outpatient

medical records for new and returning patients for medical
assessment.
B M P N NA AP.30 Short stay, day surgery and clinic outpatients are assessed
according to policies and procedures.
Special Patient Populations
A M P N NA AP.31 Policy and procedure defines the organization's vulnerable

patients, and the specific assessment required for each.
B M P N NA AP.32 Vulnerable children, disabled individuals, the elderly, psychiatric

patients (including addiction, behavioral disorders and forensics),
and others identified by the organization are assessed and
Score Standard
protected according to their needs.
Baby-Friendly Care and Pediatrics
B M P N NA AP.33 In organizations with mother-baby units, care is provided

according to UNICEF and the World Health Organization (WHO)
clinical guidelines.
B M P N NA AP.34 For pediatric patients, the history must include immunization

status.
B M P N NA AP.35 For pediatric patients, the history and physical examination must
include documentation on the growth and development status
Psychiatric
A M P N NA AP.36 All nurses have training and experience in psychiatric nursing.
A M P N NA AP.37 There are written admission and discharge criteria.
B M P N NA AP.38 When ECT is prescribed, it will be performed with an

anesthesiologist in attendance.
C M P N NA AP.39 Overnight visits to the home must have a physician order and be
limited to no more than 5 days.
C M P N NA AP.40 Overnight and home visits must have a documented date and
time of leave and return.
C M P N NA AP.41 Overnight and home visits must be monitored with follow up of

non-returning patients.
C M P N NA AP.42 Vocational and recreational activities are to be provided for

patients who are able to participate.
Addiction
B M P N NA AP.43 The history of drug use, including age of onset, duration,

intensity, patterns of use, drugs used, and consequences and
complications is assessed and documented.
B M P N NA AP.44 Types of previous treatment and responses to the treatment are

assessed and documented.
B M P N NA AP.45 History of mental, emotional, and behavioral problems, plus

results of previous treatments used are assessed and
Score Standard
documented.
B M P N NA AP.46 Treatment acceptance or motivation for treatment is assessed

and documented.
B M P N NA AP.47 Features of the environment that promote compliance and

wellness or obstacles to recovery are assessed and documented.
Emotional and Behavioral Disorders
B M P N NA AP.48 Current mental, emotional, behavioral functioning, including a

mental status examination are assessed and documented.
B M P N NA AP.49 A history of mental, emotional, behavioral, and substance use

problems; their co-occurrence; and treatment are assessed and
documented.
B M P N NA AP.50 Maladaptive or problem behaviors are assessed and documented.
B M P N NA AP.51 The patient’s work environment is assessed and documented.
B M P N NA AP.52 The social, peer-group, and environmental setting from which

the patient comes are assessed and documented.
Psychosocial Assessment for Addiction and Behavioral

Disorders
B M P N NA AP.53 Leisure and recreation activities and preferences are assessed

and documented.
B M P N NA AP.54 Childhood and family history for psychiatric disease is assessed

and documented.
B M P N NA AP.55 Military service history is assessed and documented.
B M P N NA AP.56 Financial status is assessed and documented.
B M P N NA AP.57 Sexual history, including abuse, either as abuser or abused is

B M P N NA AP.58 Physical abuse, either as abuser or abused is assessed and

documented.
B M P N NA AP.59 Current living situation and family circumstances are assessed

and documented.
B M P N NA AP.60 Social, ethnic, cultural, emotional, religious and health factors are
B M P N NA AP.61 Need for family participation in the patient's care is assessed and
Score Standard
documented.
Providing Care (PC)

Diagnostic Services (DS)
Blood Bank & Transfusion Services (BB)
Invasive Procedures (IP)
Patient Family Education (PE)
Score Standard
General
C M P N NA PC.1 Care delivery is uniform when similar care is needed.
C M P N NA PC.2 Care and treatm ents respect culturally and spiritually

needs of the patients.
C M P N NA PC.3 Patient and family (as appropriate) are involved in all care and
treatment decisions.
C M P N NA PC.4 The patient's care plan is documented and includes relevant

disciplines providing care.
C M P N NA PC.5 The care plan is based on assessments of patient conducted by

the various healthcare disciplines and providers.
C M P N NA PC.6 The care plan is developed with participation by the patient

and/or family
C M P N NA PC.7 Each patient's care plan includes identified needs, interventions

and desired outcomes with time frames.
C M P N NA PC.8 The care plan is updated as appropriate based on reassessment

of the patient.
C M P N NA PC.9 Care is delivered timely in accordance with the care plan.
A M P N NA PC.10 Policy and procedures defines how clinical practice

guidelines are developed, review ed and updated based
on current professional literature.
B M P N NA PC.11 Clinical practice guidelines are used when required by law and
regulation and w hen applicable to patient condition .
C M P N NA PC.12 Clinical practice guidelines developed by the organization are

reviewed at least every two years or w hen needed .
B M P N NA PC.13 Services and treatment are available with defined timeframes for
availability.
C M P N NA PC.14 Radiology, histo-pathology and other tests ordered include the

clinical reasons for the order on the request form.
C M P N NA PC.15 A histo-pathology request form accompanies the specimen.
Score Standard
C M P N NA PC.16 Reporting of clinical critical values is done as per policy.
Nutritional Care
A M P N NA PC.17 Policy and procedure defines the role of relevant care givers in
assessment, follow up and monitoring of patients according to
their nutritional needs
B M P N NA PC.18 Each patient has a complete order for food or other nutrients
based on assessed nutritional status or need.
A M P N NA PC.19 Policy and procedure of food services include at least the

following:
PC.19.1 A list of all special diets is available and accommodated.
PC.19.2 Ordering of food that is appropriate to the patient’s clinical
condition
PC.19.3 Schedule for meals and timings of distribution of meals.
PC.19.4 Food storage
PC.19.5 Food preparation
B M P N NA PC.20 Food is appropriate to the patient's clinical condition and needs
B M P N NA PC.21 There is a schedule for meals and a process to ensure timely

distribution of meals.
B M P N NA PC.22 Patients assessed as being at nutritional risk receive nutritional

therapy as indicated.
B M P N NA PC.23 Food and nutrition products are stored under proper conditions
of sanitation, temperature and ventilation.
B M P N NA PC.24 Food and nutrition products are prepared under proper

conditions of sanitation, temperature and ventilation.
A M P N NA PC.25 Policy and procedure describes how to manage and store food
brought in by family members.
C M P N NA PC.26 Food brought in from outside the organization is managed

according to policy and procedure.
A M P N NA PC.27 Policy and procedure governs the preparation, storage and
Score Standard
administration of feeding tube nutritional therapy.
B M P N NA PC.28 Administration of feeding tube nutritional therapy is performed

according to policy and procedure.
Terminally Ill Patients
A M P N NA PC.29 Policy and procedure guides the management of terminally ill

patients and includes at least the following:
PC.29.1 Management of symptoms, including pain
PC.29.2 Provision of patient and family support for psychosocial and

spiritual needs
C M P N NA PC.30 Management of the needs and preferences of the terminally ill

patient are implemented and documented.
Specialized Care Units
A M P N NA PC.31 There is a designated Medical Director for Specialized Care Units

with defined responsibilities.
A M P N NA PC.32 There are established physiologic based admission criteria for

the intensive care and specialized units and /or specific
conditions defined by appropriate individuals in the hospital
B M P N NA PC.33 Patients admitted to intensive and specialized units meet the

defined physiologic based criteria.
C M P N NA PC.34 Patients who no longer meet the criteria are discharged from the
unit.
Restraint and Seclusion
A M P N NA PC.35 Policy and procedure defines the appropriate and safe use of
restraint and seclusion and includes at least the following:
PC.35.1 Protection of patient's rights, dignity and well being during use
PC.35.2 The least restrictive methods are to be used as appropriate
PC.35.3 Safe and effective application and removal by qualified staff
PC.35.4 Monitoring and reassessment during use
B M P N NA PC.36 The use of restraints or seclusion is according to defined criteria.
B M P N NA PC.37 There is a physician order for the use of restraints and seclusion.
Score Standard
B M P N NA PC.38 For medical-surgical reasons, the restraint order is renewed at

least every 24 hours based on continuing need.
B M P N NA PC.39 For psychiatric reasons, the restraint/seclusion order is renewed,

as per policy, at least every 6 hours based on continuing need.
B M P N NA PC.40 Patients in restraints for medical-surgical reasons are monitored

at least every 2 hours and documented.
B M P N NA PC.41 Patients in restraints and seclusion for psychiatric reasons are

monitored no less than every 30 minutes and documented.
B M P N NA PC.42 The termination of restraints and seclusion is according to

defined criteria.
Resuscitation
A M P N NA PC.43 Policy and procedure defines the response to medical

emergencies in the organization for both adult and pediatric
patients.
A M P N NA PC.44 Emergency equipment and supplies as required by law and

regulation and organization policy are available, where needed
and are age appropriate
B M P N NA PC.45 Resuscitation is performed as per policy and procedure.
B M P N NA PC.46 Emergency medications in crash carts and em ergency bags

are replaced immediately after use.
B M P N NA PC.47 Supplies in crash carts and em ergency bags are replaced

immediately after use.
B M P N NA PC.48 All equipment and supplies are checked and documented daily
for their availability and that there are no expired items.
Emergency Care
B M P N NA PC.49 Emergency services are provided and operated according to

applicable laws and regulations.
B M P N NA PC.50 Qualified staff is available 24 hours a day.
A M P N NA PC.51 Criteria are developed to determine priority of care.
B M P N NA PC.52 Patients with emergent and urgent needs are given priority for
assessment and treatment as per the defined criteria.
B M P N NA PC.53 Clinical guidelines/protocols for emergency care are used for at
Score Standard
least the following:
PC.53.1 Emergency stabilization and treatment of chest pain
PC.53.2 Emergency stabilization and treatment of shock
PC.53.3 Emergency stabilization and treatment of poly-trauma
PC.53.4 Emergency stabilization and treatment of altered level of

consciousness
B M P N NA PC.54 In specialized hospital; clinical guidelines/ protocols for

em ergency care are used w ithin the hospital scope of
services.
B M P N NA PC.55 Emergency care is provided and documented according to

guidelines and protocols.
Radiology
B M P N NA DS.1 Radiology services are provided and operated according to

applicable laws and regulation and as per hospital policy.
A M P N NA DS.2. Procedure manuals or guidelines for all tests and equipment are
available
B M P N NA DS.3 Radiology procedure guidelines are followed.
B M P N NA DS. 4 All radiological procedures are conducted as per physician order.
A M P N NA DS. 5 There is a quality control program covering the inspection,

maintenance, and calibration of all equipment
B M P N NA DS. 6 All diagnostic equipment is regularly inspected, maintained, and

calibrated, and appropriate records are maintained.
B M P N NA DS.7 Radiology services are available 24 hours per day, seven days
per week.
A M P N NA DS.8 Special techniques or procedures that must be performed under

physician supervision are listed.
B M P N NA DS.9 There is a final interpretation by a radiologist for all films and

diagnostic tests.
A M P N NA DS.10 The organization defines the timeframes for availability of

reports for interpretation of radiology tests and procedures,
including both emergency (STAT) and routine reports by types
of tests are defined.
Score Standard
B M P N NA DS.11 Radiology reports are available by the defined reporting times.
C M P N NA DS.12 All tests and procedures are documented.
B M P N NA DS.13 All copies of radiology reports are available in the department.
A M P N NA DS. 14 There is a radiation safety program.
B M P N NA DS.15 A radiation safety program is in place, followed, and

documented.
B M P N NA DS.16 Risks to the Radiation safety program are reported to

Environmental Safety or other appropriate designated
committee.
B M P N NA DS. 17 Reporting of critical test results is done as per policy

requirements (Refer to standard PS.3.4)
Laboratory and Pathology
B M P N NA DS.18 Laboratory and pathology services are provided and operated

according to applicable laws and regulations and as per hospital
policy.
B M P N NA DS.19 There is 24 hour supervision of laboratory functions by a

qualified individual.
A M P N NA DS.20 Policy and procedure for receiving the lab tests orders,
collecting, identifying, processing, and disposing of specimens
B M P N NA DS. 21 Laboratory policies for receiving the lab tests orders, collecting,
identifying, processing, and disposing of specimens are
implemented.
A M P N NA DS. 22 Policy and procedure cover inspection, maintenance, calibration,

and testing of all equipment
B M P N NA DS. 23 All laboratory equipment are regularly inspected, maintained,

and calibrated, and appropriate records are maintained.
A M P N NA DS. 24 Procedure manuals or guidelines for all tests and equipment are
available
B M P N NA DS. 25 Laboratory Procedure guidelines are followed
A M P N NA DS. 26 There is a Quality control program for all laboratory equipment
B M P N NA DS. 27 Quality control program is implemented
Score Standard
A M P N NA DS.28 There is a current list of essential reagents and supplies.
A M P N NA DS. 29 Policy and procedure cover management of reagents and

supplies, including availability, storage, labeling and testing for
accuracy
B M P N NA DS.30 All reagents and solutions are available, stored, completely and
accurately labeled, and tested for accuracy as per hospital policy
B M P N NA DS.31 Twenty-four hour per day laboratory coverage is provided to

meet routine and emergency needs of patients.
A M P N NA DS.32 There is a written list of laboratory tests that are performed in

the organization.
C M P N NA DS.33 Referral laboratory services are available through formal

contracts for tests not performed in the organization.
A M P N NA DS.34 The referral laboratory is licensed by MOH.
B M P N NA DS.35 All laboratory test results and reports have identified reference
(normal) ranges, specific for age and sex, if applicable.
C M P N NA DS.36 Reference ranges are reviewed and updated as needed.
A M P N NA DS.37 Report times for routine and emergency (STAT) results by type
of test are defined.
C M P N NA DS.38 Laboratory tests are reported within the defined timeframe, as

per hospital policy.
B M P N NA DS.39 Laboratory tests requiring professional interpretation are

reviewed and signed by the laboratory physician.
B M P N NA DS.40 All laboratory results are available in the laboratory, reviewed

and signed by a laboratory supervisor daily.
B M P N NA DS.41 Cytology services are performed according to written procedure,

and are supervised by a pathologist.
B M P N NA DS.42 Final pathology reports contain gross and microscopic

description and diagnosis as relevant to the specimen.
A M P N NA DS. 43 There is a Laboratory and pathology safety program
B M P N NA DS. 44 Laboratory and pathology safety program is in place, followed

and documented
B M P N NA DS.45 Laboratory and pathology safety program findings are reported
Score Standard
to Environmental Safety or other appropriate committee.
B M P N NA DS. 46 Reporting of critical test results is done as per policy

requirements (Refer to standard PS.3.4)
Point of Care Testing
A M P N NA DS.47 Policy and procedure specifies:
DS.47.1 Which tests can be performed in the organization outside of the

laboratory
DS. 47.2 Which individuals may perform the test
DS. 47.3 The training/competence required of staff who perform the point
of care tests
DS. 47.4 Monitoring for calibration of equipment and controls are

overseen by the laboratory
B M P N NA DS.48 Point of care testing is performed as specified.
Blood Bank and Transfusion Services
B M P N NA BB.1 Blood bank and transfusion services are provided and operated
according to applicable laws and regulations and as per hospital
policy.
A M P N NA BB.2 Policy and procedure for the organization's blood bank and
transfusion services describes the following:
BB.2.1 Selection of blood donors in accordance with the national

selection criteria.
BB.2.2 Procedures to be followed for all blood bank tests including

screening of specified communicable diseases, blood type and
Rh.
B M P N NA BB.3 Policy and procedure for selection of blood donors & screening
of specified communicable diseases, blood type and Rh is
implemented.
A M P N NA BB.4 Policy and procedure for safe collection, handling and storage of
blood and blood products.
B M P N NA BB.5 Policy and procedure for safe collection and handling is

implemented.
Score Standard
B M P N NA BB.6 Storage and labeling of all blood and blood products in the blood
bank meet the national requirements.
B M P N NA BB.7 Blood is stored outside the blood bank prior to administration

according to law and regulation and hospital policy.
B M P N NA BB.8 All blood products entering/in the organization are labeled with
at least the identification number, name of the product, required
storage condition, production date, expiration date, and name of
the blood bank.
B M P N NA BB.9 A record is kept to ensure complete tracing of a unit of blood

and blood products from drawing until final disposition.
A M P N NA BB.10 Policy and procedure defines safe administration and monitoring

of blood transfusions.
B M P N NA BB.11 Administration and monitoring of blood transfusions is

performed according to the policy and procedure.
Surgical and Invasive Procedures
A M P N NA IP.1 Policy and procedure defines the process of preoperative,

operative and postoperative patient surgical care
B M P N NA IP.2 The history, physical examination, (including a pre-procedural

diagnosis) and results of the necessary diagnostic tests are
documented in the patient's medical record prior to the
surgery/invasive procedure.
B M P N NA IP.3 In life-threatening emergencies, minimally the preoperative

diagnosis and plan for surgery is recorded in the medical record
prior to surgery.
B M P N NA IP.4 Informed consent must be documented in the patient's medical

record prior to surgery except in life-threatening emergencies.
B M P N NA IP.5 The surgical record includes the time of start and finish of
surgery.
B M P N NA IP.6 Operative or procedure reports are documented in the patient's

record immediately after surgery and invasive procedures.
B M P N NA IP.7 The operative or procedure report includes the pre and post-
operative/procedure diagnosis difference, if applicable.
B M P N NA IP.8 The operative/procedure report includes the name of the

surgeon(s)/physicians and assistants.
Score Standard
B M P N NA IP.9 The operative/procedure report includes the

operation/procedure performed.
B M P N NA IP.10 The operative/procedure report includes the findings and any

complications, if applicable, during surgery and invasive
procedures.
B M P N NA IP.11 The operative/procedure report includes the specimens

removed.
B M P N NA IP.12 The operative/procedure report is signed by the surgeon or

performing physician.
B M P N NA IP.13 Surgically removed tissue is sent for pathologic examination

unless on a list of exempt tissues approved by the Medical Staff.
Anesthesia and Moderate Sedation
A M P N NA IP.14 Policy and procedure of anesthesia care including pre–

anesthesia assessment, monitoring during anesthesia and post
anesthesia care of patients
Assessment prior to the administration of anesthesia or

sedation
B M P N NA IP.15 Prior to administration of any pre-anesthesia/sedation

medication, an informed consent for the use of
anesthesia/sedation must be obtained by an anesthesiologist
and documented in the medical record.
B M P N NA IP.16 A pre anesthesia/sedation assessment is completed and

documented by a qualified anesthesiologist.
B M P N NA IP.17 Anesthesia/sedation care (type and method of administration),

which includes moderate and deep sedation, is planned and the
planned anesthesia/sedation is documented in the patient's
record by an anesthesiologist
B M P N NA IP.18 The patient is reassessed immediately prior to induction of

anesthesia and sedation by an anesthesiologist, the pre-
induction assessment is documented in the anesthesia record.
Monitoring During Anesthesia and/or Sedation
B M P N NA IP.19 The patient's physiologic status is continuously monitored during

anesthesia or sedation administration
B M P N NA IP.20 The results of the m onitoring are docum ented in the

patient's m edical record including pulse rate and rhythm,
Score Standard
blood pressure, respiratory rate and oxygen saturation.
B M P N NA IP.21 The anesthesia/sedation record includes medications

administered, including dose and time of administration.
B M P N NA IP.22 The anesthesia/sedation record includes fluids administered.
B M P N NA IP.23 The anesthesia/sedation record includes blood or blood products

administered.
B M P N NA IP.24 The anesthesia/sedation record includes actual

anesthesia/sedation used.
B M P N NA IP.25 The anesthesia/sedation record includes any unusual events or

complications of anesthesia/sedation, if it occurred .
B M P N NA IP.26 The anesthesia/sedation record includes the condition of the

patient at the end of anesthesia/sedation.
B M P N NA IP.27 The anesthesia/sedation record includes the time of start and

finish of anesthesia/sedation.
B M P N NA IP.28 The anesthesia record includes the name and signature of the
anesthesiologist or qualified physician.
Recovery Phase
B M P N NA IP.29 The patient is monitored during the post-anesthesia/sedation

recovery period.
B M P N NA IP.30 The results of monitoring during recovery are documented in the

patient's medical record.
B M P N NA IP.31 The time of arrival and discharge from the recovery area are
recorded.
B M P N NA IP.32 Patients are recovered from anesthesia/sedation in an area that

has equipment required by law and regulation.
B M P N NA IP.33 Qualified nurses are present at all times during the recovery
phase.
B M P N NA IP.34 A qualified physician makes the decision to discharge the patient

from post-anesthesia/sedation care and signed the discharge
order.
Patient and Family Education
A M P N NA PE.1 Policy and procedure for patient and family education including:
Score Standard
PE.1.1 screening criteria for educational needs (including family)
PE.1.2 the responsible disciplines involved in patient education
A M P N NA PE.2 Policy and procedure guides patient and family education on:
PE.2.1 Diagnosis and condition
PE.2.2 Diagnostic tests and treatments
PE.2.3 Medication and potential side effects
PE.2.4 Nutrition
PE.2.5 Food and drug interactions
PE.2.6 Physical rehabilitation and use of medical equipment,
PE.2.7 information on risk reduction: diet, exercise, smoking cessation,

and other health-related practices,
PE.2.8 Guidance to community resources available to the patient, as

appropriate
PE.2.9 availability of special education classes
PE.2.10 Discharge instruction
B M P N NA PE.3 Physicians, nurses and other disciplines as applicable, participate

in on-going patient and family education
B M P N NA PE.4 There is documented evidence that patients and families have

been educated regarding relevant issues to their condition and
treatment.
C M P N NA PE.5 Patients and families are provided education consistent with

their values and level of learning, and also in a language and
format that they understand.
B M P N NA PE.6 Patients and families are provided sufficient opportunities to ask

questions and to have their questions answered in a manner
that they understand.
C M P N NA PE.7 Patient’s understanding of the discharge instructions and follow

up steps is documented.
Medication Management (MM)
Score Standard
General
B M P N NA MM.1 Pharmacy and medication use practices comply with law

and regulation, and organization policy.
A M P N NA MM.2 A licensed pharmacist is on duty at all times for

supervising all pharmaceutical services.
A M P N NA MM.3 There is an interdisciplinary drug and therapeutic

committee with established terms of reference.
B M P N NA MM.4 The drug and therapeutic committee meetings occur

monthly and documented.
Patient Specific
B M P N NA MM.5 Patient specific information is available for all relevant care

givers as appropriate
Selection and Procurement
B M P N NA MM.6 Medications are selected and Procured according to law

and regulation and policy and procedure.
A M P N NA MM.7 Policy and procedure defines the selection and

procurement of medications, including when the pharmacy
is closed, and how to access medications and information
when the pharmacy is closed.
A M P N NA MM.8 The Essential Drug List (EDL) or organization developed

medication list (formulary) is approved by the Drug and
Therapeutic Committee and Medical staff Com m ittee
and medications are listed by their generic names.
B M P N NA MM.9 The medication list includes all needed therapeutic groups

of drugs.
B M P N NA MM.10 The medication list is available for all care givers in all
clinical areas.
C M P N NA MM.11 The medication list is current and updated at least
Score Standard
annually.
A M P N NA MM.12 There is a list of the high risk and look-alike, sound-alike

medications.
A M P N NA MM.13 Policy and procedures defines how sample medications are

stored, inventoried, dispensed and safely used both in
outpatient and inpatient areas.
C M P N NA MM.14 Sample medications in the organization are appropriate for

the patients being served.
Storage
A M P N NA MM.15 Policy and procedure defines the appropriate storage of

medications
B M P N NA MM.16 The storage of medications follows policy and procedures.
A M P N NA MM.17 Policy and procedure defines the appropriate storage of

therapeutic parenteral nutrition (TPN).
B M P N NA MM.18 The storage of therapeutic parenteral nutrition (TPN)

follows policy and procedures.
B M P N NA MM.19 There are defined processes to prevent errors with high

risk, concentrated, look-alike and sound-alike medications.
B M P N NA MM.20 Temperature control for all medications and contrast

agents meet requirements of law and regulation and as
per manufacturer recommendations and guidelines.
B M P N NA MM.21 Medication refrigerator temperatures are monitored and

documented according to policy.
A M P N NA MM.22 Policy and procedure defines the storage, distribution and

control of narcotics in compliance with law and
regulations.
B M P N NA MM.23 The policy and procedure of storage, distribution

and control of narcotics is im plem ented.
C M P N NA MM.24 Medications including emergency medications and sample

medications must be secure at all times.
B M P N NA MM.25 Emergency medications must be securely stored, but must

also be readily available at all times.
B M P N NA MM.26 Expired medications are removed from the clinical units
Score Standard
and pharmacy.
B M P N NA MM.27 Medications that are no longer in active use is removed

from the clinical units and returned to the pharmacy as
per policy
B M P N NA MM.28 All medication areas are checked by pharmacist at least on

a monthly basis, and these checks are documented.
Prescribing/Ordering and Transcribing
A M P N NA MM.29 The organization identifies those qualified individuals, by

job title , permitted to prescribe or order medications, as
per law and regulations and hospital policy.
A M P N NA MM.30 Policy and procedure defines safe prescribing/ordering of

medications in the organization
A M P N NA MM.31 Policy and procedure defines safe prescribing/ordering and

transcribing includes at least the following:
MM.31.1 Where medication orders are uniformly written in the

medical record
MM.31.2 Definition of elements of a complete order
MM.31.3 Legibility requirement and steps to take when medication

orders are not legible
MM.31.4 As needed orders (PRN) must include reasons for

administration
MM.31.5 Other types of orders that are acceptable (range, sliding

scale, etc.)
MM.31.6 Therapeutic parenteral nutrition (TPN)
MM.31.7 Actions to take if prescriptions/orders are incomplete,

illegible, unclear, or potentially unsafe
MM.31.8 Requirements for prescriber's signature (date and time, if

applicable).
B M P N NA MM.32 Medication verbal orders are implemented as per policy,

(refer to PS.3) .
A M P N NA MM.33 Policy and procedure defines the use of dose based
Score Standard
calculations, at least for pediatrics, chemotherapy, and
compromised patients.
A M P N NA MM.34 Policy and procedure defines the use, review and updating
of preprinted order sets.
C M P N NA MM.35 Medication prescriptions/orders are complete, legible and

follow medication policy requirements.
Preparing and Dispensing
A M P N NA MM.36 There is a list of qualified individuals, by job titles , as per

requirements of law and regulations and hospital policy,
permitted to dispense medications.
A M P N NA MM.37 Policy and procedure defines the dispensing of

medications.
B M P N NA MM.38 There is a uniform medication and dispensing process to

ensure the medication is dispensed safely, including:
MM. 38.1 Right drug
MM. 38.2 Right dose
MM. 38.3 Right route of administration
MM. 38.4 Right time
MM. 38.5 Right patient
B M P N NA MM.39 There is a mechanism to review each prescription/order

before dispensing.
A M P N NA MM.40 Policy and procedure defines who can prepare medications

(compounding and admixing) and the equipment and
conditions required.
C M P N NA MM.41 All medications dispensed from the pharmacy are labeled

with at least the following:
MM.41.1 The patient's name
MM.41.2 The name of the drug and its concentration/strength
MM.41.3 The expiration date
MM.41.4 Written instructions for use/administration
Score Standard
A M P N NA MM.42 Policy and procedure governs the preparation and

distribution of therapeutic parenteral nutrition (TPN).
B M P N NA MM.43 Preparation and dispensing of medications and TPN follow

policy and procedures.
C M P N NA MM.44 Information is accessible for medical staff, nurses and

patients on the medications use, administration, and side
effects, including potential adverse reactions.
C M P N NA MM.45 The organization has a medication recall system.
C M P N NA MM.46 Sample medications are dispensed by qualified staff and

are labeled the same as for dispensing from pharmacy.
Administration
A M P N NA MM.47 The organization identifies those qualified individuals, by

job titles, permitted to administer medications with or
without supervision.
A M P N NA MM.48 Policy and procedure defines safe and accurate

administration of medications including:
MM. 48.1 The seven rights
MM. 48.2 Patient education regarding potential side effects
MM. 48.3 Self-administration and storage of self-administered

medications
MM. 48.4 Pediatric emergency medication dosing
MM. 48.5 Therapeutic parenteral nutrition (TPN)
B M P N NA MM.49 Administration of medications and therapeutic parenteral

nutrition (TPN) follows policy and procedures.
B M P N NA MM.50 Each medication dose administered is documented.
A M P N NA MM.51 Policy and procedure governs the medications that are

allowed to be brought from home or by the family includes
at least the following:
MM. 51.1 When to accept medications brought from home or by

family
Score Standard
MM. 51.2 Process to assure safety of the brought medications
MM. 51.3 Accuracy of use
MM. 51.4 Proper storage of the medications
MM. 51.5 Appropriate administration of the medications
B M P N NA MM.52 Policy and procedure that governs the medications that

are allowed to be brought from home or by the family is
implemented
Monitoring
B M P N NA MM.53 Pharmacists are actively involved in the development,

implementation and monitoring of all aspects of the
medication management system.
A M P N NA MM.54 Policy and procedure defines the monitoring of the

response to medications including:
MM.54.1 the first dose of a new m edication,
MM.54.2 High risk m edications (including TPN).
B M P N NA MM.55 Monitoring and documentation of medications are

performed as required by policy and procedures.
B M P N NA MM.56 Antibiotics are monitored for appropriate use.
A M P N NA MM.57 Medication error and adverse drug reactions (ADR's) are

defined.
A M P N NA MM.58 There is a system for reporting medication errors and

adverse drug reactions.
C M P N NA MM.59 Medication errors and adverse drug reactions are reported

in a timely manner using the established process.
Evaluation
C M P N NA MM.60 Aggregate data about medication errors and adverse drug

reactions are analyzed to identify patterns and trends.
C M P N NA MM.61 The organization uses medication error and adverse drug

reaction reporting information to improve medication use
processes.
Patient Safety (PS)
Infection Control (IC)
Environmental Safety (ES)
Score Standard
General Patient Safety
A M P N NA PS. 1 The patient’s safety policy defines Egyptian and WHO

Patient Safety recommendations and solutions that include
PS.1.1 Accurate standardized patient identification in all service

areas
PS.1.2 Standardized process for dealing with verbal or telephone

orders.
PS.1.3 Handling critical values/tests
PS. 1.4 Hand hygiene throughout the organization (Refer to

standard IC.12.2)
PS. 1.5 Prevention of catheter and tubing mis-connections
PS. 1.6 Prevention of patient's risk of falling
PS. 1.7 Prevention of patient's risk of developing pressure ulcers
PS. 1.8 A standardized approach to hand over communications
A M P N NA PS.2 Policy and procedure defines the use of verbal and/or telephone orders
including:
PS.2.1 When verbal and telephone orders may be used
PS.2.2 Who can receive a verbal/telephone order
PS.2.3 The process to receive and document the order
A M P N NA PS. 3 The policy and procedure for handling critical values/tests

includes al least the following:
PS. 3.1 List of the lab tests that have critical values/test results and
the critical values/test results are defined for each test.
PS. 3.2 List of the radiology tests that have critical values/test
Score Standard
results and the critical values/test results are defined for
each test.
PS. 3.3 List of the clinical findings that have critical values results
and the critical values are defined for each clinical finding
PS. 3.4 Process of communication of the critical values/test results

including the timing of reporting
B M P N NA PS.4 The organization and staff are educated regarding the

Egyptian and WHO Patient Safety recommendations and
solutions In addition to hospital policy.
B M P N NA PS.5 The patient safety standards and solutions are posted in all
applicable areas.
B M P N NA PS.6 At least two (2) ways are used to identify a patient when
giving medicines, blood, or blood products; taking blood
samples and other specimens for clinical testing; or
providing any other treatments or procedures.
B M P N NA PS.7 Current published and generally accepted hand hygiene

guidelines, laws and regulations are implemented to
prevent healthcare-associated infections.
B M P N NA PS.8 Single use injection devices are discarded after one time
use to prevent healthcare-associated infections.
B M P N NA PS.9 A process for taking verbal or telephone orders and for the
reporting of critical test results, that requires a verification
by write down and "read-back" of the complete order or
test result by the person receiving the information is
implemented
B M P N NA PS.10 Systems are implemented to prevent catheter and tubing

mis-connections.
B M P N NA PS.11 Each patient's risk of falling, including the potential risk

associated with the patient's medication regimen is
assessed and periodically reassessed.
B M P N NA PS.12 Action is taken to decrease or eliminate any identified risks

of falling.
B M P N NA PS.13 Each patient's risk of developing pressure ulcers is assessed

and documented.
B M P N NA PS.14 Action is taken to decrease or eliminate any identified risks
Score Standard
of developing pressure ulcers.
B M P N NA PS.15 Preventive maintenance and testing of critical alarm

systems is implemented and documented.
B M P N NA PS.16 Alarms are tested and activated with appropriate settings

and are sufficiently audible with respect to distances and
competing noise within the unit.
B M P N NA PS.17 A standardized approach to hand over communications,

including an opportunity to ask and respond to questions is
implemented.
Medication Management Safety
A M P N NA PS.18 Policy & Procedures For Medication Management Safety

include at least the following:
PS.18.1 Abbreviations not to be used throughout the organization

(Refer to standard PS.21)
PS.18.2 Documentation and communication of patient's current

medications & discharge medication
PS.18.3 Labeling of medications, medication containers and other

solutions
PS.18.4 Prevent errors from high risk medications
PS.18.5 prevent errors from look-alike, sound-alike medications
A M P N NA PS.19 The Policy to prevent errors from high risk medications

defines:
PS.19.1 The list of high risk medications including concentrated

electrolytes
PS.19.2 Labeling and storage of high risk medications
PS.19.3 Dispensing and preparation of the high risk medications
PS.19.4 Frequency of reviewing and updating of the list
A M P N NA PS.20 The Policy to prevent errors from look-alike, sound-alike

medications defines the following:
PS.20.1 The list of look-alike ,sound-alike medications,
PS.20.2 Labeling and storage of look-alike ,sound-alike medication
Score Standard
PS.20.3 Dispensing and preparation of the look-alike ,sound-alike

medication
PS.20.4 Frequency of reviewing and updating of the list
B M P N NA PS.21 Abbreviations not to be used throughout the organization

are :
U/ IU
Q.D., QD, q. d. qd
Q.O.D., QOD, q. o. d., qod
MS, MSO4
MgSO4
Trailing zero
No leading zero
Dose x frequency x duration
B M P N NA PS.22 Look-alike and sound-alike medications are identified,

stored and dispensed to assure that risk is minimized
B M P N NA PS.23 Concentrated electrolytes; including, but not limited to,

potassium chloride (2 meq/L or greater concentration),
potassium phosphate, sodium chloride (>0.9%
concentration), magnesium sulfate (50% or greater
concentration) and concentrated medications are removed
from all patient care areas, whenever possible.
B M P N NA PS.24 Concentrated medications not removed are segregated

from other medications with additional warnings to remind
staff to dilute before use
B M P N NA PS .25 All medications, medication containers (e.g., syringes,

medicine cups, basins), or other solutions on and off the
sterile field in pre-operative and other procedural settings
are labeled.
B M P N NA PS.26 A process is implemented to obtain and document a

complete list of the patient's current medications upon
admission to the organization and with the involvement of
the patient.
Score Standard
B M P N NA PS.27 A complete list of the patient's medications to be taken

after discharge is provided to the patient.
B M P N NA PS.28 The discharge medication list is communicated to the next

provider of service when the patient is referred or
transferred outside the organization.
Operative and Invasive Procedure Safety
A M P N NA PS.29 Policy & Procedures for operative and invasive procedures

safety includes at least the following:
PS.29.1 Accurate documented patient identification preoperatively,

and just before surgery (time out)
PS.29.2 Process for verification of all documents and equipments

needed for surgery or invasive procedures preoperatively
PS.29.3 Marking of site of surgery preoperative
PS.29.4 Verification of accurate counting of sponges, needles and

instruments pre and post procedure
B M P N NA PS.30 A process or checklist is developed and used to verify that

all documents and equipment needed for surgery or
invasive procedures are on hand, correct and functioning
properly before the start of the surgical or invasive
procedure.
B M P N NA PS.31 There is a documented process of accurate pt. identification

preoperatively and just before starting a surgical or invasive
procedure (time out), to ensure the correct patient,
procedure, and body part
B M P N NA PS.32 The precise site where the surgery or invasive procedure

will be performed is clearly marked by the physician with
the involvement of the patient.
B M P N NA PS.33 There is a documented process to verify an accurate

accounting of sponges, needles and instruments pre and
post procedure.
Score Standard
Program Plan and Management
A M P N NA IC.1 A qualified physician and a qualified nurse jointly oversee

the infection control activities of the organization / hospital.
A M P N NA IC.2 There is a continuous program to reduce the risks of

organization acquired infections that describes the scope,
objectives and surveillance methods.
B M P N NA IC.3 The infection control program covers patients, staff, and

visitors.
A M P N NA IC.4 The infection control program is based on current scientific

knowledge, accepted practice guidelines, and applicable
laws and regulations.
B M P N NA IC.5 All areas of the organization are included in the infection

control program.
C M P N NA IC.6 The infection control program is evaluated, updated at least

annually, and reported to the governing board at least
annually.
B M P N NA IC.7 There is an established functioning infection control

committee that meets at least monthly.
A M P N NA IC.8 All relevant disciplines are represented on the infection

control committee.
A M P N NA IC.9 There are clear terms of reference for the infection control
committee that include the following:
IC.9.1 Coordination of infection control activities
IC.9.2 Development, implementation, monitoring and revision and

updates to the infection control program
IC.9.3 Approval of all relevant infection control policies and

procedures.
IC.9.4 Selecting, approving and monitoring of the surveillance

activities
IC.9.5 Reviewing, aggregating, and analyzing infection control

data
IC.9.6 Taking or recommending action (including education) when
Score Standard
infection prevention and control issues are identified
IC.9.7 Reviewing the effectiveness of the actions taken
A M P N NA IC.10 The organization identifies those procedures and processes

associated with increased risk of infection.
A M P N NA IC.11 IC Policies and procedures that describe infection control

practices include at least the following:
IC.11.1 Selection and uses of antiseptics and disinfectants
IC.11.2 Hand hygiene and washing techniques
IC.11.3 All cleaning activities, including environment, equipment,

supplies, furniture, etc.
IC.11.4 Types of isolation with standard precautions (contact,

droplet and airborne)
IC.11.5 Precautions for Immune-compromised patients
IC.11.6 Precautions for Haemorrhagic patients
IC.11.7 Handling and disposal of sharps/needles and bio-hazardous

materials
IC.11.8 Identification and management of organization-acquired

infections.
IC.11.9 Reporting of patients with communicable diseases as

required by law and regulation (Refer to standard IC.47)
IC.11.10 Management and reporting of outbreaks of infections (Refer

to standard ES.27)
IC.11.11 Staff vaccination
IC.11.12 Use of antibiotics
B M P N NA IC.12 Antiseptics and disinfectants are available and used

correctly when required as per policy
B M P N NA IC.13 Gloves, gowns, masks, soap, and washing detergents are

available and used correctly when required.
B M P N NA IC.14 Hand hygiene , washing techniques are used correctly in

the organization
B M P N NA IC.15 All cleaning activities are implemented as per policy
Score Standard
B M P N NA IC.16 Policies and procedures of Identification and management

of organization-acquired infections are implemented
B M P N NA IC.17 IC precautions for immune-compromised and hemorrhagic

patients are implemented
B M P N NA IC.18 Handling and disposal of sharps/needles and bio-hazardous

materials follow the policy
B M P N NA IC.19 Isolation and standard precautions are implemented as per

policy
B M P N NA IC.20 National guidelines for the care of infectious patients are

followed when there is no isolation room available.
B M P N NA IC.21 Approved policies and procedures are disseminated to all

departments, and relevant staff is educated and trained
regarding infection prevention and control process.
C M P N NA IC.22 Infection control policies and procedures are reviewed and

updated by the infection control committee at least every
three years, and more frequently as needed.
Sterilization
A M P N NA IC.23 The organization has a central sterilization processing and

supply department or defined area.
B M P N NA IC.24 The functions of cleaning, processing, and sterile storage

and distribution are physically separated.
A M P N NA IC.25 In all areas where instruments are cleaned there must be

airflow that prevents cross-contamination and prevents
contaminated material from exiting the area
A M P N NA IC.26 There is at least one functioning sterilizer.
B M P N NA IC.27 There is documented evidence that complete sterilization

has been accomplished.
A M P N NA IC.28 There is a procedure that guides each sterilization

technique or device used, and includes the manufacturer's
recommendations.
A M P N NA IC.29 Policy and procedure describes the processes of sterilization

including at least the following:
IC.29.1 Receiving and cleaning of used items and disinfection.
Score Standard
IC.29.2 Preparation, processing and labeling of sterile packs
IC.29.3 Storage of sterile supplies
IC.29.4 Inventory levels
IC.29.5 Expiration dates for sterilized items
IC 29.6 Use of emergency flash sterilization
B M P N NA IC.30 Policies and procedures are uniformly applied implemented,

and monitored for compliance.
A M P N NA IC.31 There is a policy and procedure for reprocessing guided by

the laws and regulations and manufacturers requirements
B M P N NA IC.32 Emergency flash sterilization policy and procedure is

implemented
B M P N NA IC.33 Reprocessing follows law and regulations and hospital

policy.
B M P N NA IC.34 Quality control processes are implemented using indicators

as recommended by the manufacturer.
B M P N NA IC.35 Results of sterilizer quality control tests are reported to the

infection control committee at least quarterly.
Laundry and Linen
A M P N NA IC.36 Policy and procedure defines laundry and linen services and
includes at least the following:
IC.36.1 Collection and storage of contaminated linen, including

linens with bio-hazardous contamination and exposure
IC.36.2 Cleaning of contaminated linen, including linens with bio-

hazardous contamination
IC.36.3 Storage and distribution of clean linen
IC.36.4 Quality control program, including water temperatures
A M P N NA IC.37 Policy and procedure for laundry and linen services are
approved by the infection control committee.
B M P N NA IC.38 Laundry and linen policy and procedures are implemented.
B M P N NA IC.39 Contaminated linen is covered and is separated from clean
Score Standard
linen.
A M P N NA IC.40 There is at least one functioning washing machine.
Surveillance and Monitoring
A M P N NA IC.41 The organization has an infection control surveillance policy

and procedure which includes all areas of the organization
(Refer to standards IC.2)
B M P N NA IC.42 The Infection Control surveillance and data collection policy

has been implemented, and results are disseminated to the
organization staff.
C M P N NA IC.43 The surveillance data of organization acquired infections

and the effectiveness of the program, are regularly
aggregated and analyzed
B M P N NA IC.44 Results of the surveillance program are reported at a

minimum quarterly to the Infection Control Committee and
to the Leadership
C M P N NA IC.45 The results, when relevant, are utilized for improving the
quality of care.
C M P N NA IC.46 Results of the surveillance activities analysis are compared

with internal and external benchmarks, if available.
B M P N NA IC.47 Communicable diseases are reported to the appropriate

agencies as required by law and regulation, (referee to
standard IC.11.9).
C M P N NA IC.48 Organization acquired infection resulting in an adverse

outcome of a patient or employee, is thoroughly
investigated utilizing a process of intense analysis.
Facility and Environmental Safety
Planning and Implementation Activities
B M P N NA ES.1 The organization follows laws, regulations, and facility

inspection requirements that relate to management of the
physical environment.
A M P N NA ES.2 A designated qualified individual has responsibility for

oversight of the facility maintenance and environmental
safety.
A M P N NA ES.3 An interdisciplinary Environment of Care committee has
Score Standard
responsibility for monitoring and assuring compliance with
facility requirements.
B M P N NA ES.4 The Environment of Care committee meets at least

monthly.
C M P N NA ES.5 The Environment of Care committee has an ongoing

process for addressing and resolving identified environment
of care risks and issues.
C M P N NA ES.6 Services are physically accessible for patients and families

including the elderly and physically challenged.
B M P N NA ES.7 The organization has a documented, current, and accurate

inspection of the physical facilities.
B M P N NA ES.8 Clinical and diagnostic services have adequate space and

equipment's according to the requirements of law and
regulation and scope of services provided.
C M P N NA ES.9 The physical location of the emergency room must support

ES.9.1 Designated access for ambulance, car, and walk-in patients
ES.9.2 Signage both within and outside the organization that

provide clear directions
ES.9.3 A designated registration area
ES.9.4 A designated triage area
Safety and Security
A M P N NA ES.10 There is a safety and security plan that addresses the

objectives, scope, strategy/methodology, and evaluation.
A M P N NA ES.11 The safety and security plan includes monitoring of at least

one performance improvement activity regarding actual or
potential risk(s).
B M P N NA ES.12 Interdisciplinary hazardous surveillance rounds are

conducted in patient care areas no less than twice a year
and in non-clinical areas no less than annually.
B M P N NA ES.13 Identified risks and hazards are eliminated when possible.
B M P N NA ES.14 There are measures to protect against infant/child

abduction and to protect patients, visitors, and staff from
Score Standard
harm, including assault, violence and aggression.
B M P N NA ES.15 All organization staff can be identified at all times.
B M P N NA ES.16 Individuals without identification are investigated.
B M P N NA ES.17 Remote or isolated areas of the facility are monitored.
B M P N NA ES.18 Action is taken to correct identified deficiencies in safety

and security.
C M P N NA ES.19 The safety and security plan is monitored with collection,

aggregation, and analysis of data to identify areas for
improvement.
C M P N NA ES.20 Corrective action(s), monitoring and analysis of the

safety and security plan are submitted to Leadership at
least every 12 months.
C M P N NA ES.21 The safety and security plan is reviewed annually and

updated as needed.
Emergency/Disaster Management
A M P N NA ES.22 There is an emergency/disaster management plan for

internal and external emergencies that addresses the
A M P N NA ES.23 The emergency/disaster management plan includes

monitoring of at least one performance improvement
activity per year regarding actual or potential risk(s).
A M P N NA ES.24 The plan for response to emergencies/disasters includes a

personnel recall system; alternate care sites, if needed; and
alternate sources of medical supplies, utilities, and
communication.
B M P N NA ES.25 The organization has tested the emergency/disaster plan at

least annually.
A M P N NA ES.26 There is an emergency/disaster management plan to

respond to likely community emergencies, epidemics,
natural or other disasters.
B M P N NA ES.27 The plan for response to external emergencies/disasters is

developed according to government guidelines relating to
the responsibility of the organization in the event of an
external emergency.
Score Standard
C M P N NA ES.28 The emergency/disaster management plan is monitored

with collection, aggregation, and analysis of data to identify
areas for improvement.

emergency/disaster management plan are submitted to
leadership at least once every 12 months.
C M P N NA ES.30 The emergency/disaster management plan is reviewed

annually and updated as needed.
Hazardous Materials and Waste
A M P N NA ES.31 There is a hazardous materials and waste management

plan for the use, handling, storage, and disposal of
hazardous materials and waste that addresses at least the
following:
ES.31.1 Safety and security requirements for handling and storage
ES.31.2 Requirements for personal protective equipment
ES.31.3 Procedures and interventions to take following spills and

accidental contact or exposures
ES.31.4 Disposal in accordance with applicable laws and regulation
ES.31.5 Labeling of hazardous materials and waste
ES.31.6 Monitoring data on incidents to allow corrective action
A M P N NA ES.32 The hazardous materials and waste plan addresses the

A M P N NA ES.33 The hazardous materials and waste plan includes

monitoring of at least one performance improvement
activity per year regarding actual or potential risk(s).
A M P N NA ES.34 There is current inventory of the types and locations of

hazardous materials and waste including the interventions
to take in the case of a splash or spill (material safety data
sheets)
B M P N NA ES.35 The hazardous materials and waste management plan is
Score Standard
implemented.
C M P N NA ES.36 The hazardous materials and waste management plan is

monitored with collection, aggregation, and analysis of data
to identify risk and areas for improvement.

hazardous materials and waste management plan are
submitted to Leadership at least every 12 months.
C M P N NA ES.38 The hazardous materials and waste management plan is

reviewed annually and updated as needed.
Fire Safety
A M P N NA ES.39 There is a fire and smoke safety plan that addresses

prevention, early detection, response, and safe exit when
required by fire or other emergencies that addresses at
ES.39.1 Frequency of inspecting fire detection and suppression

systems, including documentation of the inspections
ES.39.2 Maintenance and testing of fire protection and abatement

systems in all areas
ES.39.3 Documentation requirements for staff training in fire

response and evacuation
ES.39.4 The assessment of fire risks when construction is present in

or adjacent to the facility
A M P N NA ES.40 The fire safety plan addresses the objectives, scope,

strategy/methodology, and evaluation.
A M P N NA ES.41 The fire safety plan includes monitoring of at least one

performance improvement activity annually regarding actual
or potential risk(s).
B M P N NA ES.42 Fire drills are conducted at least quarterly in different

clinical areas and different shifts, including at least one
unannounced annually.
B M P N NA ES.43 The facility partial evacuation plan is tested annually.
B M P N NA ES.44 The fire and smoke safety plan is implemented with
Score Standard
documentation of all inspections, maintenance, testing, and
training.
B M P N NA ES.45 The law prohibiting smoking in the organization is enforced.
C M P N NA ES.46 The fire and smoke safety plan is monitored with collection,
aggregation, and analysis of data to identify risks and areas
for improvement.
C M P N NA ES.47 Corrective action(s), monitoring and analysis of the fire

and smoke safety plan are submitted to Leadership at least
every 12 months.
C M P N NA ES.48 The fire and smoke safety plan is reviewed annually and
updated as needed.
Medical Equipment
A M P N NA ES.49 There is a plan for selecting, inspecting, maintaining,

testing, and safe usage of medical equipment that
addresses at least the following:
ES.49.1 Inventory of all medical equipment

ES.49.2 Schedule for inspection and preventive maintenance
according to manufacturer's recommendations and
frequency of repair and breakdown
ES.49.3 Testing of all new equipment before use and repeat testing,
as part of the preventive maintenance
ES.49.4 Testing of alarm systems including clinical alarm
ES.49.5 Qualified individuals who can provide these services
ES.49.6 Data monitoring for frequency of repair or equipment failure
ES.49.7 Ensure only trained and competent people handle
specialized equipment.
A M P N NA ES.50 The medical equipment plan addresses the objectives,

scope, strategy/methodology, and evaluation.
A M P N NA ES.51 The medical equipment plan includes monitoring of at least

one performance improvement activity annually regarding
actual or potential risk(s).
A M P N NA ES.52 There is a current list of all equipment in the organization.
Score Standard
B M P N NA ES.53 All diagnostic equipment is calibrated, and maintenance

records are maintained.
B M P N NA ES.54 Water and machinery used in chronic renal dialysis are

tested regularly as per manufacturer recommendations and
hospital policy.
B M P N NA ES.55 Temperature control for all refrigerators and freezers meet

requirements of law and regulation, hospital policy and
manufacturer recommendations for safe and appropriate
storage of products stored in the refrigerators and freezers.
A M P N NA ES.56 Policy and procedure defines the monitoring of refrigerators

and freezers available in the organization.
B M P N NA ES.57 There is documented evidence of appropriate temperature

storage for all refrigerators and freezers if used, but no less
than every 24 hours.
B M P N NA ES.58 Alarm system(s) are tested minimally at the frequency

recommended by the manufacturer.
C M P N NA ES.59 The medical equipment plan is monitored with collection,

for improvement.

medical equipment plan are submitted to Leadership at
least every 12 months.
C M P N NA ES.61 The medical equipment plan is reviewed annually and

updated as needed.
Utility Systems
A M P N NA ES.62 There is a plan for regular inspection, maintenance, testing

and repair of essential utilities addresses at least the
following:
ES.62.1 Electricity, including stand-by generators

ES.62.2 Water
ES.62.3 Heating, ventilation, and air conditioning, including air flow
in negative and positive pressure rooms, appropriate
temperature, humidity, and eliminates odors
ES.62.4 Medical gases
Score Standard
ES.62.5 Communications systems
ES.62.6 Waste disposal
ES.62.7 Regular inspections
ES.62.8 Regular testing
ES.62.9 Regularly scheduled maintenance
ES.62.10 Correction of identified risks and deficiencies
A M P N NA ES.63 The utility systems plan addresses the objectives, scope,

strategy/methodology, and evaluation.
A M P N NA ES.64 The utility systems plan includes monitoring of at least one

performance improvement activity per year regarding actual
or potential risk(s).
B M P N NA ES.65 Regular inspection, maintenance, testing and repair of

electricity, including stand-by generators are done
B M P N NA ES.66 Regular inspection and testing of water are done

heating, ventilation, and air conditioning, air flow in
negative and positive pressure rooms, appropriate
temperature and humidity are done.

medical gases are done.

communication system are done.
B M P N NA ES.70 Waste disposal policy is implemented
C M P N NA ES.71 The utility systems plan is monitored with collection,

for improvement.

utility systems plan are submitted to Leadership at least
every 12 months.
C M P N NA ES.73 The utility systems plan is reviewed annually and updated

as needed.
Information Management (IM)
Score Standard
Confidentiality and Security
A M P N NA IM.1 Policy and procedure defines the confidentiality and

security of data and information and protection from
loss or damage that addresses at least the following:
IM.1.1 Who may have access to the patient's record to ensure

confidentiality of patient information
IM.1.2 The circumstances under which access is granted
IM.1.3 Determination of who can access what type of data and

information for decision making
IM .1.4 Procedure if privacy or security of inform ation

has been breached/ broken
B M P N NA IM.2 All staff and physicians sign a confidentiality agreement,

and are held in compliance with that agreement.
B M P N NA IM.3 Medical records and information are protected from loss,

destruction, tampering.
B M P N NA IM .4 M edical records and inform ation are protected
Score Standard
from unauthorized access or use.
B M P N NA IM.5 Medical records, data and information are destroyed as

defined by law, regulation and policy.
Information Processes
A M P N NA IM.6 Policy and procedure defines the requirements for

developing, approving and revising policies and
procedures at least every two years.
C M P N NA IM.7 Policy and procedure of developing, approving and

revising policies and procedures is implemented
A M P N NA IM.8 The organization has an Information plan to meet

information needs based on at least the following:
IM.8.1 The identified information needs of clinical and

managerial leaders of the organization
IM.8.2 The size and the types of services provided by the

organization
C M P N NA IM.9 The Information plan is implemented
C M P N NA IM.10 Clinical and managerial staff participate in selecting,

integrating, and using information management
technology
A M P N NA IM.11 The organization has a policy on the retention time of

records, data, and information that is consistent with
law and regulation.
B M P N NA IM.12 The organization commits to the retention policy
C M P N NA IM.13 Standardized diagnosis codes, procedure codes, symbols

and definitions are used.
Patient-Specific Information - Medical Record
B M P N NA IM.14 There is a medical record with a unique identifier for

each patient evaluated and treated.
B M P N NA IM.15 Each closed medical record contains sufficient

information to:
IM.15.1 Identify the patient, including name, address, and date

of birth
Score Standard
IM.15.2 Promote continuity of care
IM.15.3 Support the diagnosis (or diagnoses)
IM.15.4 Justify the treatment
IM.15.5 Document the course and results of treatment
A M P N NA IM.16 Policy and procedure defines a uniform/consistent

structure of the medical record including:
IM.16.1 The order of filing of the notes and reports
IM.16.2 Uniform location of medication and other orders
B M P N NA IM.17 Each page of the medical record contains the patient's

name and unique identifier.
A M P N NA IM.18 The organization has defined who is authorized to make

entries in the medical record.
B M P N NA IM.19 Nurses document directly in the patient's medical record.
B M P N NA IM.20 Entries in the medical record are dated (date and time of
the entry)
C M P N NA IM.21 The author of all entries in the medical record can be

clearly identified by name and title.
C M P N NA IM.22 Entries in the medical record are legible.
C M P N NA IM.23 Verbal/telephone orders are signed within the time

frame that does not exceed 24 hours.
B M P N NA IM.24 Diagnostic and therapeutic orders are signed by the

ordering practitioner.
C M P N NA IM.25 Results of diagnostic tests are documented in the

patient's medical record.
B M P N NA IM.26 Treatments are documented and signed by the person

providing the treatment.
B M P N NA IM.27 The medical record of patients receiving emergency care

includes at least the following:
IM.27.1 Time of arrival and time of discharge
IM.27.2 Conclusions at termination of treatment
Score Standard
IM.27.3 Patient's condition at discharge
IM.27.4 Patient's disposition at discharge
IM.27.5 Follow-up care instructions
IM.27.6 discharge order by the treating physician
C M P N NA IM.28 There is a process to ensure that medical records of

discharged patients are completed within 30 days.
B M P N NA IM.29 The patient's medical record must be available when

needed to care providers.
B M P N NA IM.30 The closed medical record must contain a discharge

summary.
B M P N NA IM.31 The discharge summary must include the following:
IM.31.1 The reason for admission
IM.31.2 Any diagnoses made
IM.31.3 Investigations
IM.31.4 Significant findings
IM.31.5 Procedures performed
IM.31.6 Medications and/or other treatments
IM.31.7 Patient's condition and disposition at discharge
IM.31.8 Discharge instructions, including diet, medications and

follow-up instructions
IM.31.9 The name of the physician who discharged the patient
B M P N NA IM.32 A copy of the discharge instructions and discharge

summary is given to the patient on discharge.
B M P N NA IM.33 The referral/transfer sheet is sent with the patient when

referred to another facility.
B M P N NA IM.34 The referral/transfer sheet contains at least the

following:
IM.34.1 Reason for referral/transfer
IM.34.2 Assessments information done in the hospital,
Score Standard
IM.34.3 Medications given, and treatments provided
IM.34.4 Transportation means and required monitoring
IM.34.5 Condition on referral/transfer
IM.34.6 Destination on referral/transfer
B M P N NA IM.35 A copy of the referral sheet is retained in the patient's

medical record.
A M P N NA IM.36 The organization has a policy for review of medical

records at least quarterly that includes the following:
IM.36.1 Review of a representative sample of all services
IM.36.2 Review of a representative sample of all disciplines/staff
IM.36.3 Involvement of representatives of all disciplines who

make entries in the medical record
IM.36.4 Review of the completeness and legibility of entries
C M P N NA IM.37 The policy for reviewing medical records is implemented

B M P N NA IM.38 Nurses participate in Medical Record Review activities
Performance Improvement (PI)

Score Standard
Process and Design
A M P N NA PI.1 There is a performance improvement, patient safety and

risk management plan that defines at least the following:
PI.1.1 The required membership of the performance
improvement, patient safety and risk management
committee(s)
PI.1.2 Authority of the committee
PI.1.3 Criteria for establishing priorities
PI.1.4 A description of the methodology to be used

PI.1.5 Information flow and reporting frequency
A M P N NA PI.2 There is a performance improvement, patient safety and

risk management committee(s) w ith a designated
chairperson(s).
A M P N NA PI.3 The membership is multidisciplinary and includes members
of the medical and nursing staff, other department
representatives, and the performance improvement
coordinator/ m anager .
Score Standard
A M P N NA PI.4 There are terms of reference for the committee (s), which
include the following:
PI.4.1 Ensuring that all required or designated departments
participate
PI.4.2 Establishing organization-wide priorities for improvement
PI.4.3 Ensuring that all required measurements are monitored,

including the frequency of data collection
PI.4.4 Reviewing the analysis of aggregate data
PI.4.5 Taking action in response to identified performance

improvement or patient safety issues
PI.4.6 Reporting information both to leaders and to appropriate

staff members
B M P N NA PI.5 The performance improvement, patient safety and risk
management committee(s) meets at least monthly.
B M P N NA PI.6 The performance improvement, patient safety and risk
management plan(s) is/are implemented organization
wide.
A M P N NA PI.7 There is an assigned, qualified performance improvement
coordinator/ m anager .
B M P N NA PI.8 The performance improvement coordinator/ m anager is a
member of all relevant committees.
A M P N NA PI.9 There is a written job description for the performance
improvement coordinator/ m anager .
B M P N NA PI.10 Medical staff participates in performance improvement
activities.
B M P N NA PI.11 Nursing Staff participate in performance improvement
activities.
B M P N NA PI.12 Other staff participates in performance improvement
activities.
Collecting and Measuring Activities
C M P N NA PI.13 Performance indicators are identified and monitored for all

significant processes.
C M P N NA PI.14 Indicators have a definition and specified frequency of

data collection and analysis.
Score Standard
Clinical Care Monitoring includes at least one

appropriate and relevant indicator to monitor each of the
following:
B M P N NA PI.15 Waiting times in the relevant service areas
B M P N NA PI.16 Patient assessment is complete, accurate and timely.
B M P N NA PI.17 Surgical and invasive procedures.
B M P N NA PI.18 Use of anesthesia and moderate and deep sedation.
B M P N NA PI.19 Use of medications.
B M P N NA PI.20 Use of blood and blood products.
B M P N NA PI.21 Medical records, including availability and content.
B M P N NA PI.22 Infection control, surveillance and reporting.
C M P N NA PI.23 Medication errors and adverse outcomes.
C M P N NA PI.24 Use of restraints and seclusion.
B M P N NA PI.25 Patient safety requirements
C M P N NA PI.26 Clinical effectiveness.
Managerial Monitoring includes at least one

appropriate and relevant indicator to monitor each of the
following:
B M P N NA PI.27 Compliance with law and regulations.
B M P N NA PI.28 Patient and family expectations and satisfaction.
B M P N NA PI.29 Patient complaints.
B M P N NA PI.30 Staff expectations and satisfaction.
Score Standard
C M P N NA PI.31 Staff complaints
B M P N NA PI.32 Patient demographics, diagnoses and procedures.
B M P N NA PI.33 Procurement of routinely required supplies and

medications essential to meet patient needs.
B M P N NA PI.34 Financial management.
B M P N NA PI.35 Risk management.
C M P N NA PI.36 Staff and professional performance.
C M P N NA PI.37 Utilization management.
Analyzing Data
A M P N NA PI.38 Individuals with appropriate experience, knowledge, and
skills systematically aggregate and analyze data in the
organization.
B M P N NA PI.39 Data review is timely and appropriate.
B M P N NA PI.40 Data is aggregated, trended over time and analyzed.
C M P N NA PI.41 Statistical tools and techniques suitable to the process or

outcome under study are used.
C M P N NA PI.42 Data are transformed into useful information using

appropriate graphical and reporting methodology.
Comparative Activities, Benchmarking
C M P N NA PI.43 The organization uses internal and external reference

databases, as available, for comparative purposes.
Improving Activities
B M P N NA PI.44 Action to correct problems is timely and appropriate.
C M P N NA PI.45 Changes to improve are planned and reevaluated.
Score Standard
B M P N NA PI.46 The organization documents the improvements.
C M P N NA PI.47 Identified changes for improvement are implemented and

integrated into applicable care processes.
C M P N NA PI.48 Data are available to demonstrate that improvement is
sustained.
Risk Management
A M P N NA PI.49 There is a risk management program/plan that includes at

PI.49.1 Scope and objectives
PI.49.2 R isk identification.
PI.49.3 R isk priotrization.
PI.49.4 R isk reporting.
PI.49.5 R isk m anagem ent.
A M P N NA PI.50 Policy and procedure defines an incident-reporting system

that includes at least the following:
PI.50.1 List of reportable incidents and near misses
PI.50.2 Persons responsible for initiating reports
PI.50.3 How, when, and by whom incidents are reported and

investigated
PI.50.4 Incidents required im m ediate notification to
m anagem ent.
PI.50.5 Incidents classification, analysis and results

reporting.
PI.50.6 Indication for conducting intensive analysis and its
process.
B M P N NA PI.51 Risk management program/plan and policies are
implemented
C M P N NA PI.52 A risk register is developed and updated, as
needed, for identified risks.
Score Standard
C M P N NA PI.53 The hospital uses a proactive risk reduction tool for

at least one high risk processes.
Analysis are perform ed and corrective action
im plem ented in response to the follow ing:
B M P N NA PI.54 Patient elopement or attempted elopement
B M P N NA PI.55 Patient suicide, attempted suicide and violence.
B M P N NA PI.56 Unexpected morbidity and mortality including those due to

organization acquired infections.
B M P N NA PI.57 Confirmed transfusion reactions.
B M P N NA PI.58 Significant anesthesia and sedation events that cause

harm or have the potential to cause harm to a patient
C M P N NA PI.59 Significant differences between pre- and post-operative
diagnoses, including surgical pathology findings.
C M P N NA PI.60 Significant adverse drug reactions that cause harm or
have the potential to cause harm to a patient
C M P N NA PI.61 Significant medication errors that cause harm or have the
potential to cause harm to a patient
Organization Management Governance
and Leadership (OM)
Human Resources (HR)
Nursing Services (NS)
Medical Staff (MS)
Score Standard
Governance - Governing Body
Score Standard
A MPN NA OM.1 The organization's governance structure is defined.
A MPN NA OM.2 The organizational structure indicates clear lines of authority.
A MPN NA OM.3 Governance responsibilities and accountabilities are defined.
A MPN NA OM.4 Those responsible for governing and managing are identified
by title and preferably name.
A M P N NA OM.5 The organization has a mission statement approved by the
governing body.
C M P N NA OM.6 The m ission statem ent developed by the governing body
w ith participation of the staff and com m unity if possible
A M P N NA OM.7 The mission statement is visible in a public area(s).
A M P N NA OM.8 The organization has defined the code of behavior/ ethics for
all staff, including m edical ethics and confidentiality.
A M P N NA OM.9 The organization's strategic plan is approved by the governing
body.
C M P N NA OM.10 The governing body allocates the financial resources required
to meet the organization's strategic plan .
B M P N NA OM.11 The governing body supports performance improvement,
patient safety and risk management efforts.
C M P N NA OM.12 The governing body supports involvement with the community
and other identified customers.
C M P N NA OM.13 The community and other identified customers are informed of
the results of the current accreditation status or performance
improvement activities.
C M P N NA OM.14 Processes provide communication and cooperation between
governance and management.
C M P N NA OM.15 The Governing Board performs an annual review of achieved
goals
Leadership
A M P N NA OM.16 A full-time qualified director appointed by the governing body
is assigned to manage the organization in accordance with
applicable laws and regulations.
C M P N NA OM.17 The organization director has appropriate training and/or
experience in health management as defined in the job
description.
A M P N NA OM.18 The director has a clear written job description that defines at
OM.18.1 Ensuring that the organization complies with all laws and
regulations
OM.18.2 Providing oversight of day-to-day operations
OM.18.3 Ensuring clear and accurate posting of the organization's
services and hours of operation to the community
OM.18.4 Ensuring that policies and procedures are developed and
approved, according to hospital policy.
OM.18.5 Ensuring that there is a functional, organization-wide program
for performance improvement, patient safety and risk
management with appropriate resources
Score Standard
OM.18.6 Providing oversight of human, financial, and physical resources
OM.18.7 Ensuring appropriate response to reports from any inspecting
or regulatory agencies, including accreditation
OM.18.8 Ensure efficient m anagem ent of m oney (funds) to achieve
the objectives of the organization
B M P N NA OM.19 There is a clear process for coordination and communication
between the director and the staff.
A M P N NA OM.20 The nurse director is a member of the leadership team of the
organization.
B M P N NA OM.21 The nurse director attends the leadership staff meetings.
B M P N NA OM.22 The nurse director and other nursing leaders participate with
the hospital leaders in the development, ongoing review and
implementation of all relevant organization programs, policies
and plans.
B M P N NA OM.23 Nurses participate in all relevant committees, including, but not
limited to, the following:
OM.23.1 Infection control
OM.23.2 Performance improvement, patient safety and risk
management
OM.23.3 Drug and therapeutics committee
Planning
C M P N NA OM.24 Strategic planning is relevant to organization's m ission
and identifies goals, measurable objectives, with defined time
lines.
C M P N NA OM.25 Strategic plan's objectives are reviewed for progress at least
annually.
C M P N NA OM.26 Strategic planning includes participation by staff and the
community to meets the community healthcare needs.
C M P N NA OM.27 Planning for addition of new and closing of existing services
considers community needs, environmental and financial
factors.
C M P N NA OM.28 Leaders plan and budget for the upgrading or replacing of
systems, or buildings needed for the continued operation of
safe and effective facility.
C M P N NA OM.29 Leaders annually assess the operational plans of the services
provided to determine required facility and equipment needs.
C M P N NA OM.30 Leaders, in collaboration w ith staff, design and implement
processes that support continuity and coordination of care and
risk reduction
Responsibilities
Leaders provide appropriate facilities and time for staff
B M P N NA OM.31
education and training.
C M P N NA OM.32 Leaders ensure the organization meets the conditions of facility
inspection reports.
Score Standard
C M P N NA OM33 Leaders create a safe and "blame-free" process for reporting
errors, near misses, and complaints.
C M P N NA OM.34 Leadership annually reports to the hospital's governance or
authority on system errors and actions taken to improve
safety.
C M P N NA OM.35 Leaders use organization's information for decision making
B M P N NA OM.36 Leaders ensure required policies, procedures and plans have
been developed and dissem inated .
C M P N NA OM.37 Leaders ensure that services are developed and delivered in
accordance w ith policies and procedures .
C M P N NA OM.38 Leaders provide for adequate space, equipment and resources
of needed services based on law s and regulations .
B M P N NA OM.39 Leaders select equipment and supplies based on criteria that
include quality and cost effectiveness with input from the
users/staff.
B M P N NA OM.40 Leaders ensure that quality control monitoring is implemented
and action is taken when necessary.
A M P N NA OM.41 The organization has a mechanism to obtain or provide
ambulance services.
B M P N NA OM.42 When the organization owns and operates an ambulance
service, the ambulance service meets all requirements of laws
and regulations.
B M P N NA OM.43 Leaders approve contracts for clinical and managerial services.
C M P N NA OM.44 Contracted services must provide documentation for oversight
by leaders.
C M P N NA OM.45 Contracted service personnel comply with relevant hospital's
policies and procedures.
C M P N NA OM.46 Leaders utilize available community resources to provide health
promotion and education to the community.
B M P N NA OM.47 The community is clearly and accurately informed of the
current organization's services and operating hours.
Directing of Departments and Services
A M P N NA OM.48 A designated qualified individual is assigned to supervise each
department and service.
A M P N NA OM.49 The responsibilities of the designated supervisor of each
department and service are defined in writing and include at
OM.49.1 Provides a written description of the services provided by the
department (scope of service)
OM.49.2 Ensures coordination and integration of these services with
other departments when relevant
OM.49.3 Recommends space, staffing, and other resources needed to
fulfill the department's responsibility
OM.49.4 Defines the education, skills, and education needed by each
category of employee in the department
Score Standard
OM.49.5 Ensures that there is a department specific orientation and
continuing education program for the department's employees
OM.49.6 Ensures the department is involved in the performance
improvement, patient safety and risk management program (s)
OM.49.7 Ensures the department's/service's performance is monitored
and reported annually to Leadership
B M P N NA OM.50 Department and service heads carry out their responsibilities.
A M P N NA OM.51 Each department has a written staffing plan that defines the
following:
OM.51.1 The minimum number of staff needed to fulfill the
department's responsibilities
OM.51.2 The types of staff needed
OM.51.3 The required license, certification or registration, education,
skills, knowledge, and experience required for needed
positions
C M P N NA OM52 Each department or service submits a periodical report related
to outcomes of care.
Human Resources
Planning
A M P N NA HR.1 There is a staffing plan for the organization that matches the
strategic and operational plans.
C M P N NA HR.2 The staffing plan is periodically reviewed and updated as
required, but at least annually.
C M P N NA HR.3 The staffing plan addresses the assignment of staff as per skill
level and number of staff identified as needed at each skill
level.
C M P N NA HR.4 Nursing assignments are made based on the individual nurse's
competence for the defined job.
C M P N NA HR.5 Licensed pharmacists are available to meet the needs of the

organization.
C M P N NA HR.6 Support personnel to meet the needs of the organization.
A M P N NA HR.7 Each employee has a current job description.
A M P N NA HR.8 The job description includes the required license, certification

or registration, education, training, skills, experience and the
terms of reference of each position.
B M P N NA HR.9 There is documentation in each employee's file that the

current job description has been discussed with and signed by
the employee.
Score Standard
C M P N NA HR.10 There is a recruitment process that is uniformly applied.
C M P N NA HR.11 Appropriate leaders participate in the recruitment process.
C M P N NA HR.12 There is a process for verifying credentials and evaluating the

qualifications of new and current staff that is uniformly
applied.
B M P N NA HR.13 There is a process for appointing new staff members that is
uniformly applied.
A M P N NA HR.14 A personnel file is maintained for each employee.
B M P N NA HR.15 Each personnel file must contain, when applicable to that

employee, the following elements:
HR.15.1 Copies of verified diploma, license, certification, registration
HR.15.2 Education, training and work history
HR.15.3 Current job description

HR.15.4 Documented evidence of orientation to the organization, the
assigned department, and the specific job
HR.15.5 Evidence of initial evaluation of the employee's ability to
perform the assigned job
HR.15.6 Ongoing In-service education received
HR.15.7 Copies of annual evaluations
HR.15.8 Other documents as required by law and regulation and the
organization
Orientation
A M P N NA HR.16 There is a formal orientation program for all employees,
volunteers and contract workers.
B M P N NA HR.17 Orientation to the organization is provided by appropriate
designated staff and leaders.
B M P N NA HR.18 Hospital Orientation includes review of the organization
mission, structure, policies, including environment of care,
infection control, and performance improvement, patient
safety, risk management.
B M P N NA HR.19 Orientation to the assigned department includes the review of
relevant policies and procedures and skills needed.
B M P N NA HR.20 Orientation to the specific job within the department is
provided.
B M P N NA HR.21 There is documented evidence that each employee was
oriented to the hospital/organization, department and specific
job.
Competence Assessment, Training and Education
C M P N NA HR.22 Each employee's competence for required skills is assessed at
Score Standard
time of hire, and any time there is a change in job and at least
annually.
A M P N NA HR.23 There is a continuing education and training program for all
employees, and applicable physicians.
C M P N NA HR.24 The continuing education programs based on services
provided, new information, and evaluation of the employees'
needs.
B M P N NA HR.25 Education and training is provided and documented for patient
assessment as relevant to the position or job.
B M P N NA HR.26 Education and training is provided and documented for
infection control policy and procedures as relevant to the
position or job.
environmental safety and environment of care plans relevant
to the position or job.
occupational health hazards and safety procedures, including
the use of personal protective equipment and prevention of
needle sticks and exposures.
information management, including medical records
requirements as appropriate to responsibilities or job
description.
B M P N NA HR.30 Education and training is provided and documented for pain
assessment and treatment.
restraint use and seclusion.
B M P N NA HR.32 Education and training is provided and documented to
psychiatric staff in physical holding techniques and take down
procedures.
B M P N NA HR.33 Education and training is provided and documented to relevant
staffs who participate in moderate sedation.
B M P N NA HR.34 Education and training is provided and documented to relevant
staff for the clinical guidelines used in the organization.
B M P N NA HR.35 Education and training is provided and documented for basic
cardiopulmonary resuscitation training at least every two years
for all staff that provides direct patient care.
B M P N NA HR.36 Education and training is provided and documented for quality
concept, performance improvement, patient safety, and risk
management.
B M P N NA HR.37 Education and training is provided and documented on patient
rights and the complaint process.
C M P N NA HR.38 Education and training is provided and documented about
patient satisfaction.
interpersonal communication between patients and other staff.
Score Standard
B M P N NA HR.40 Education and training is provided and documented on the
abuse and neglect criteria.
C M P N NA HR.41 Education and training is provided and documented on the
cultural beliefs, needs and activities of different groups served
B M P N NA HR.42 Education and training is provided and documented for staff to
operate and to maintain medical equipment and utility
systems, appropriate to their job requirements.
Healthcare Library
A M P N NA HR.43 Medical and nursing information is accessible 24 hours to all
staff.
Staff Performance Evaluation
A M P N NA HR.44 Policy and procedure defines the process for performance
review of employees.
C M P N NA HR.45 The process for performance review of each category of

employee is uniformly applied.
C M P N NA HR.46 The performance review is based upon the employee's job

functions as described in the job description.
C M P N NA PI.47 The performance of individual staff is reviewed when indicated
by the findings of quality improvement activities, and
appropriate education and training provided.
B M P N NA HR.48 Performance reviews are done at least annually for each
employee.
Occupational and Employee Health
A M P N NA HR.49 The employee health program has a designated person to
manage the program.
A M P N NA HR.50 The organization has an employee health program that is
provided for all employees.
B M P N NA HR.51 The employee health program conforms to laws and
regulations.
A M P N NA HR.52 The organization has completed and documented an
occupational hazard/risk assessment.
B M P N NA HR.53 Action is taken on identified hazards including needle sticks
and exposures to decrease risk.
A M P N NA HR.54 Policy and procedure defines the extent and frequency of the
employee health and physical assessment, testing, actions to
be taken including the reporting of occupational hazards for
staff.
B M P N NA HR.55 Each new employee has a complete pre-employment
evaluation as relevant to the occupational hazards for each
department and job, as required by law and regulation and by
organization policy.
B M P N NA HR.56 When screening results or investigations are positive, action is
taken as per policy; the employee is made aware of these
Score Standard
results and provided with counseling and intervention as might
be needed.
B M P N NA HR.57 There is a process for communication between responsible
personnel for Infection Control and Employee Health.
Nursing Services
B M P N NA NS.1 legal requirements governing the professional regulation of
nurses and allied health professionals are followed
A M P N NA NS.2 The nurse director is a licensed nurse qualified by education
and managerial experience, as required by the job description.
A M P N NA NS.3 The nurse director has terms of reference defined in a job
description.
C M P N NA NS.4 The nurse director is responsible for implementing written
nursing standards of practice.
B M P N NA NS.5 The nursing department develops and implements written
policies and procedures guiding nursing care.
B M P N NA NS.6 The nurse director ensures that schedules and assigned tasks
to the staff are completed.
B M P N NA NS.7 The nurse director ensures that all nurse trainees are
supervised by a qualified member of the nursing staff.
Medical Staff
Organized Medical Staff Structure
A M P N NA MS.1 There is an organized medical staff to provide oversight to
ensure uniform quality of care, treatment and services.
A M P N NA MS.2 The medical staff committee reports regularly to the governing
body.
A M P N NA MS.3 There is a structured, functioning medical staff committee with
defined, documented duties.
A M P N NA MS.4 Medical staff bylaws address the following:
MS.4.1 The structure of the entire medical staff
MS.4.2 The structure and function of the medical staff committee
MS.4.3 The appointment process including the process for validating
required licensure, education, registration and/or certification
of all medical staff, other staff and visiting consultants and
professors
MS.4.4 The privileging process
MS.4.5 The revision and/or renewal of privileges
MS.4.6 The process to identify those members who may provide care
without supervision
MS.4.7 The process and criteria for suspension
MS.4.8 The mechanism for a fair hearing and appeal process
MS.4.9 The process for peer review and criteria for external peer
review
A M P N NA MS.5 The medical staff bylaws are in accordance with law and
regulations, and approved by the governing body.
B M P N NA MS.6 The medical staff includes licensed physicians and dentists and
Score Standard
may include other licensed individuals permitted by law and
regulation to provide patient care services independently in the
organization.
B M P N NA MS.7 All medical staff members with clinical privileges are subject to
medical staff bylaws.
A M P N NA MS.8 Each medical department has a designated head.
A M P N NA MS.9 The head of the department is certified in an appropriate
specialty and/or has appropriate documented experience as
required by the job description.
Appointment
A M P N NA MS.10 There is a file/record for every medical staff member.
B M P N NA MS.11 The file/record for every medical staff member contains a copy
of all documents related to license, education, experience, and
certification.
B M P N NA MS.12 Appointment of medical staff members is done according to
the medical staff bylaws, law and regulation.
B M P N NA MS.13 Medical staff appointments are approved by the governing
body.
Privileges
B M P N NA MS.14 All medical staff members have current and specific delineated
clinical privileges or/and job descriptions approved by the
medical staff committee.
B M P N NA MS.15 Privileges or job description indicate if the physician can admit,
consult and treat patients, and defines the scope of patient
care services and types of procedures they may provide in the
organization.
C M P N NA MS.16 Privileges are determined based on documented competency.
C M P N NA MS.17 Privileges are reviewed and renewed at least every three
years.
C M P N NA MS.18 There is an effective mechanism to enable appropriate staff to
determine if a physician is approved to admit, consult and
treat patients, the scope of care and types of procedures.
C M P N NA MS.19 Physicians and other individuals with privileges do not practice
outside the scope of their privileges.
C M P N NA MS.20 The mechanism for a fair hearing and appeal process when
adverse decisions are made to appointment and privileges is
implemented.
Competency for Reassessment and Re-privileging
C M P N NA MS.21 The performance of individual medical staff members is
reviewed and documented at least annually to determine
continued competence to provide patient care services.
C M P N NA MS.22 Performance and quality data used to determine competency
includes medical record review for completeness and
timeliness.
Score Standard
includes utilization practice.
includes complications, outcomes of care, mortality and
morbidity.
includes blood utilization.
includes medication use.
Peer Review
B M P N NA MS.27 There is an ongoing process of peer review.
A M P N NA MS.28 There are criteria/indicators for designating how peer review is
performed and documented.
A M P N NA MS.29 There are criteria for when cases are referred for external peer
review.
B M P N NA MS.30 Internal and external peer review is done as per established
criteria.
C M P N NA MS.31 The data and information from peer review is used for
competency assessment and considered at the times of re-
appointment and re- privileging.
Continuing Education
B M P N NA MS.32 The organization has functioning continuous medical education
activities.
B M P N NA MS.33 Medical staff members participate in continuing medical
education, related to their practices and as designated as
appropriate.
C M P N NA MS.34 Medical education and training is documented.
Graduate Medical Education
B M P N NA MS.35 In organizations participating in professional graduate
education programs, physicians in training are supervised by a
qualified medical staff member in carrying out their patient
care responsibilities.
A M P N NA MS.36 Policy and procedure define the scope of house officer and
resident assessment and treatment of patients.
B M P N NA MS.37 House officers and residents practice within their scope/job
description.
C M P N NA MS.38 House officers and residents are oriented to and comply with
medical staff rules and regulations and policies and procedures
of the organization.
C M P N NA MS.39 There is a mechanism for communication between the
committee/person who coordinates training activities and the
medical staff committee.
Community Involvement (CI)
Score Standard
Community Involvement
A M P N NA CI.1 There is a designated person to coordinate community
involvement.
C M P N NA CI.2 Information and concerns are gathered from the community at
least every 2 years regarding at least the following:
CI.2.1 Waiting times for services
CI.2.2 Environmental problems
CI.2.3 Healthcare needs
CI.2.4 Healthcare education needs
C M P N NA CI.3 The community and other identified customers participate in the
planning and assessment of the delivery of the health service.
C M P N NA CI.4 Community representatives and the organization work
collaboratively to identify community health needs and seek
solutions.
C M P N NA CI.5 Community representatives and the organization work
collaboratively to identify community health education needs
and to provide education to the community as is needed.
B M P N NA CI.6 The organization provides education to the community on the
following, as appropriate:
CI.6.1 Preventative care and immunizations
CI.6.2 Smoking cessation
CI.6.3 Nutrition
CI.6.4 Exercise and fitness
CI.6.5 Sexual and reproductive health
CI.6.6 Mental health including depression and addiction
A M P N NA CI.7 Educational opportunities for the community are posted.
C M P N NA CI.8 Training tools and information provided for community
education are varied to meet the learning needs and educational
level of the community.
C M P N NA CI.9 The community education activities are evaluated at least
annually.
C M P N NA CI.10 Accredited organizations assist other neighboring healthcare
facilities to understand and achieve accreditation.
Public Relations
A M P N NA CI.11 There is a designated person to coordinate and manage public
relations.
A M P N NA CI.12 Policy and procedure guides the public relations process for
dealing with at least the following:
CI.12.1 Community satisfaction
CI.12.2 External business customers
CI.12.3 Aggressive persons
Score Standard
CI.12.4 Media
A M P N NA CI.13 There is a defined process to document and manage community
and external customer complaints.
C M P N NA CI.14 Complaints from the community and external customers are
addressed and efforts are made to resolve the issues.
List of Required Polices and Procedures

Serial Chapter Standard Standard
No. No
1. Individual Rights PR 1. Policies and procedures define patents right.
2. Individual Rights PR 5. Policies and procedures define patents responsibilities
Individual Rights PR 8. Policies and procedures define informing patients about their rights in
3.
refusing treatment.
Individual Rights PR 12. Policies and procedures define the process for patients to make oral or
4.
anonymous complaints
5. Consent PR 15. Policies and procedures guides the process of informed consent
6. Organization Ethics PR 25 Policies and procedures define patient responsibilities
Organization Ethics PR 29. Policy and procedure defines how the organization informs patients about
7.
organs donation
8. Organization Ethics PR 30. Policy and procedure defines the process of an autopsy.
Research PR 32. Policy and procedures is available and includes eligibility for enrollment in
9.
research projects or protocols.
10.
11. Access and Admission PA 2. Policy and procedure defines access and admission to services
12. Access and Admission PA 6. Policy and procedure ensures coordination and continuity of care
Continuity of care PA 9. Policy and procedure defines the criteria for when and how to get
13.
consultation for patients.
Transfer, Discharge, PA 12. Policy and procedure defines the process of transfer, referral and discharge of
14.
Referral patients
Assessments and AP 1. Policy and procedure defines screen and assessment of patients
15.
Reassessment
Assessments and AP 2. Policy and procedure define scope and content of initial assessment by each
16. Reassessment discipline, time fare for completion of assessment and frequency of
reassessment by diagnosis/level/need
Assessments and AP 4. Policy and procedure defines the screening criteria for further assessment
17.
Reassessment
Assessments and AP 5. Policy and procedure defines the screening criteria of patients against abuse
18.
eassessment and neglect.
Pain AP 15. Policy and procedure defines and guide assessment, reassessment and
19.
management of pain.
Medical Staff AP 20. Policy and procedure defines the minimum scope of the comprehensive H&P
20.
Assessment for inpatient
Medical Staff AP 24 Policy and procedure defines the minimum frequency and content of
21.
Assessment reassessment
Medical Staff AP 27. Policy and procedure defines the minimum acceptable scope of H&P for
22.
Assessment short stay
Medical Staff AP 28. Policy and procedure defines the minimum acceptable scope of H&P for
23.
Assessments outpatient surgery
Medical Staff AP 29. Policy and procedure defines the minimum content of outpatient medical
24.
Assessment record
Specific Patient AP 31. Policy and procedure defines the organization’s vulnerable patients
25.
Population
No. No
General PC 10. Policy and procedures defines how clinical practice guidelines are developed,
26.
reviewed and updated based on current professional literature.
Nutritional Care PC 17. Policy and procedure defines the role of relevant care givers in assessment
27.
OF patients according to their nutritional needs
28. Nutritional Care PC 19. Policy and procedure of food services
Nutritional Care PC 25. Policy and procedure describes how to manage food brought in by family
29.
members.
Nutritional Care PC 27. Policy and procedure governs preparation,& administration of feeding tube
30.
nutritional therapy.
31. Terminally Ill Patients PC 29. Policy and procedure guides the management of terminally ill patients
Restraint and Seclusion PC 35 Policy and procedure defines the appropriate and safe use of restraint and
32.
seclusion
Resuscitation PC 43 Policy and procedure defines the response to medical emergencies in the
33.
organization
34. Radiology DC 2. Policy and procedure guides Radiology

Laboratory & DC 20. Policy and procedure for laboratory services
35.
Pathology
Laboratory & DC 22. Policy and procedure cover inspection, maintenance, calibration, and
36.
Pathology testing of all equipment
Laboratory & DC 29. Policy and procedure cover management of reagents and supplies
37.
Pathology
38. Point of Care Testing DC 47. Policy and procedure specifies Point of Care Testing services
Blood Bank and Transfusion BB 2. Policy and procedure for the organization’s blood bank and transfusion
39.
services
Blood Bank and Transfusion BB 4. Policy and procedure for safe collection, handling and storage of blood
40.
and blood products.
Blood Bank and Transfusion BB 10. Policy and procedure defines the administration and monitoring of blood
41.
transfusions
Surgical and Invasive IP 1. Policy and procedure defines safe practices before, during and after surgery
42.
Procedures
Anesthesia and Moderate IP 14. Policy and procedure of anesthesia care including pre–anesthesia assessment,
43.
Sedation monitoring during anesthesia and post anesthesia care of patients
Patient and Family PE 1. Policy and procedure for pt and family education including educational needs
44.
Education and involved disciplines
Patient and Family PE 2. Policy and procedure guides patient and family education
45.
Education
46. Selection and Procurement MM 7. Policy and procedure defines the selection and procurement of medications
47. Storage MM 15. Policy and procedure defines the appropriate storage of medications
Storage MM 17. Policy and procedure defines the appropriate storage of therapeutic
48.
parenteral nutrition (TPN).
49. Storage MM 22. Policy and procedure defines the distribution and control of narcotics
50. Ordering and Transcribing MM 30. Policy and procedure defines safe prescribing/ordering and transcribing
51. Ordering and Transcribing MM 27. Policy and procedure defines the use of verbal orders
52. Ordering and Transcribing MM 33. Policy and procedure defines the use of dose based calculations.
Ordering and Transcribing MM 34. Policy and procedure defines the use, review and updating of preprinted
53.
order sets.
54. Preparing and Dispensing MM 37. Policy and procedure defines safe preparation and dispensing of medications.
No. No
55. Preparing and Dispensing MM 40. Policy and procedure defines who can prepare medications
Preparing and Dispensing MM 42. Policy and procedure governs the preparation and distribution of therapeutic
56.
parenteral nutrition
57. Administration MM 48. Policy and procedure defines safe and accurate administration of medications
Administration MM 51. Policy and procedure governs the medications that are allowed to be brought
58.
from home or by the family
59. Monitoring MM 54. Policy and procedure defines the monitoring of the response to medications.
60. General Patient Safety PS 2. Policy and procedure defines the use of verbal and/or telephone orders
Medication Management PS 18. Policy & Procedures For Medication Management Safety
61.
Safety
Operative and Invasive PS 29. Policy & Procedures for operative and invasive procedures safety
62.
Procedure Safety
63. Infection Control IC 11. Policy and procedure describes infection control practices
64. Infection Control IC 28. Policy and procedure guides each sterilization technique or device used
65. Infection Control IC 29. Policy and procedure describes sterilization processes
66. Laundry and Linen IC 36. Policy and procedure defines laundry and linen services
Laundry and Linen IC 37. Policy and procedure for laundry and linen services are approved by the
67.
infection control.
Surveillance and Monitoring IC 41. policy and procedure for infection control surveillance includes all area of
68.
organization
69. Medical equipment ES 56. Policy and procedure defines the monitoring of refrigerators and freezers.
Confidentiality and Security IM 1. Policy and procedure defines the confidentiality and security of data and
70.
information
Information Processes IM 6. Policy and procedure defines the requirements for developing, approving and
71.
revising policies and procedures.
Information Processes IM 11. The organization has a policy on the retention time of records, data, and
72.
information.
Information Processes IM 16. Policy and procedure defines a uniform/consistent structure of the medical
73.
record
74. Information Processes IM 36. The organization has a policy for review of medical records at least quarterly
75. Risk Management PI 50. Policy and procedure defines an incident-reporting system
Risk Management PI 54. Policy and procedure defines the criteria for intensive analysis when
76.
unexpected events
Staff Performance HR 44. Policy and procedure defines the process for performance review of
77.
Evaluation employees.
Occupational and Employee HR 54. Policy and procedure defines the extent and frequency of the health and
78. Health physical assessment,
Organized Medical Staff MS.4 Medical staff bylaws

79.
Structure
Graduate Medical Education MS 36. Policy and procedure define the scope of student, house officer and resident
80.
assessment and treatment of patients.
81. Public Relations CI 12. Policy and procedure guides the public relations process
Required Hospital Plans
Chapter Std. # Standard

Infection Control IC.2 Infection Control Program (Plan)
Safety & Security ES.11 Safety and Security plan
Emergency Management ES.22 Emergency Management plan
Hazardous Materials & ES.31 Hazardous Materials and Waste Management plan
Waste
Fire Safety ES.39 Fire and Smoke Safety plan
Medical Equipment ES.49 Medical Equipment plan
Utility Systems ES.62 Utilities Management plan
Information Processes IM.8 Plan to meet information needs
Performance Improvement PI.1 Performance Improvement, Patient Safety & Risk Management
plan
Organization Mgmt. OM.9 Organization’s Strategic Plan
Directing of Departments OM.51 Department Staffing plan
Human Resources HR.1 Organization Staffing plan
Required Hospital Committees
Chapter Std. # Standard

Medication Management MM.3 Interdisciplinary Drug and Therapeutic Committee
Infection Control IC.7 Infection Control Committee
Facility & Environmental ES.3 Interdisciplinary Environment of Care Committee.
Safety
Performance Improvement PI.2 Performance Improvement, Patient Safety and Risk
Management Committee(s)
Medical Staff MS.3 Medical Staff Committee
Glossary
abatement systems
Related to fire safety: fire extinguishers of all types.
abuse**
The intentional mal-treatment of an individual, which may cause injury, physical and/or psychological.
See also neglect.
mental abuse Includes humiliation, harassment, and threats of punishment or deprivation.
physical abuse Includes hitting, slapping, pinching, or kicking. Also includes controlling behavior
through corporal punishment.
sexual abuse Includes sexual harassment, sexual coercion, and sexual assault.
access*
The ability of patients or potential patients to obtain required or available care and services within an
appropriate time, when needed.
accreditation
1. A process in which an organization outside the health care organization assesses the organization to
determine if it meets a level of performance to the set of standards designed to improve quality of
care.
2. The outcome of the review by the accrediting organization. Also, the decision that an eligible
organization meets the applicable set of standards.
accreditation framework
Structures and processes in an organization that are necessary for an accrediting organization to
 Consistently and reliably evaluate applicant organizations against standards;
 Recruit and send out trained surveyors;
 Reach consistent and progressive accreditation decisions; and
 Carry-out related policies and procedures.
accreditation process
A process whereby the organization is required to demonstrate the provision of safe, high quality of care,
as determined by compliance with the standards, evaluated by surveyors on-site of the organizations.
accreditation survey
An evaluation of an organization to assess its compliance with applicable standards and to determine its
accreditation status, which includes
 Evaluation of documents provided by organization staff that show compliance;
 Verbal information about the implementation of standards or examples of their implementation
that enables compliance to be determined;
 On-site observations by surveyors; and
 Education about standards compliance and performance improvement.
advance directive**
A document or documentation allowing a person to give directions about future medical care or to
appoint another person(s) to make medical decisions if the person loses decision-making capacity.
Advance directives may include living wills, powers of attorney, do-not-resuscitate (DNR) orders, right to
die, or similar documents, which expresses the patient’s preferences.
adverse drug reaction (ADR)**

Unintended, undesirable, or unexpected effects of prescribed medications, or of medical errors that
require discontinuing a medication or modifying the dose; require initial or prolonged hospitalization;
result in disability; require treatment with a prescription medication; result in cognitive deterioration or
impairment; are life threatening; result in death; or result in congenital anomalies.
adverse events*
Events that that have an unplanned negative effect on clients, groups, staff, or the organization.
ambulatory health care**

All types of health services provided to individuals on an outpatient basis. Ambulatory care services are
provided in many settings, ranging from primary care centers, freestanding ambulatory surgical facilities.
anesthesia and sedation**

The administration to an individual, in any setting, for any purpose, by any route, moderate or deep
sedation as well as general, spinal, or other major regional anesthesia. There are four levels of sedation
and anesthesia:
minimal sedation
A drug-induced state during which patients respond normally to verbal commands. Although
cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are not
affected.
moderate sedation/analgesia (“conscious sedation”)

A drug-induced depression of consciousness during which patients respond purposefully to verbal
commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful
stimulus is not considered a purposeful response. No interventions are needed to maintain a patent
airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
deep sedation/analgesia
A drug-induced depression of consciousness during which patients cannot be easily aroused, but
respond purposefully after repeated or painful stimulation. The ability to independently maintain
ventilatory function may be impaired. Patients may need help in maintaining a patent airway, and
spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
anesthesia
Consists of general anesthesia and spinal or major regional anesthesia. It does not include local
anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients cannot
be aroused, even by painful stimulation. The ability to independently maintain ventilatory function is
often impaired. Patients often need help in maintaining a patent airway, and positive pressure
ventilation may be needed because of depressed spontaneous ventilation or drug-induced depression
of neuromuscular function. Cardiovascular function may be impaired.
anesthetizing locations
Any area used for the administration of anesthetic agents, including moderate sedation.
appeal process
See fair hearing and appeal process.
ASA (American Society of Anesthesiologists)

The ASA developed scoring levels of physical status classification of patients having surgery or high risk
invasive procedures:
ASA 1: A healthy patient (has no disease)
ASA 2: Mild systemic disease (e.g., hypertension, diabetes, asthma controlled on meds, mild
obesity, pregnancy)
ASA 3: Severe systemic disease, no incapacitation that interferes with function (e.g., morbid
obesity, COPD, angina, post-MI, poorly controlled hypertension, active asthma)
ASA 4: Incapacitating systemic disease that is a constant threat to life (e.g., unstable angina,
CHF, hepatic or renal failure, debilitating respiratory disease)
ASA 5: A moribund patient not expected to survive for 24 hours with or without surgery or an
invasive procedure
assessment*
Process by which the characteristics and needs of patients, clients, groups or situations are evaluated or
determined so that they can be addressed. The assessments form the basis of the patient’s care plan
with actions.
authenticate**
To verify that an entry into the medical record is complete, accurate, and final.
authority
The power to enforce. Power to influence or persuade.
behavior management and treatment**

The use of basic behavioral or learning-based techniques designed to help the patient develop socially
appropriate and safe replacement behavior. Characteristics of a behavior management and treatment
program are that all the direct care staff are trained in the application of the program; it is a written,
planned program; it is applied at all times the patient is under the supervision of direct care staff; it is
individualized; and it is distinct from routine interactions with the patient.
behavioral health**
A board array of mental health, chemical dependency, habilitation, and rehabilitation services provided in
inpatient and outpatient settings.
benchmarking*
Comparing the results of an organization’s evaluations to the results of other programs or organizations,
and examining processes against those of others recognized as excellent, as a means of making
improvements.
blame free
In investigating sentinel events, the investigation focuses on system and/or process failures and not on
any particular individual – not to look for someone to blame.
blood products
Products such as albumin, gamma globulin, or Rh immune globulin whose use is considered significantly
lower in risk that that of blood.
capabilities
Abilities, resources, assets, and strengths of groups or individuals to deal with situations and meet their
needs.
capital cost
The cost of investing in the development of new or improved facilities, services, or equipment. Does not
include operational costs.
care plan (plan of care)

A written plan that identifies the individual patient’s care needs, lists the strategy to meet those needs,
documents treatment goals and objectives, outlines the criteria for ending interventions, and documents
the individual’s progress in meeting specified goals and objectives. It is based on data gathered during
patient assessment. The format of the plan in some organizations may be guided by specific policies and
procedures, protocols, practice guidelines, clinical paths, care maps, or a combination of these. The plan
of care may include prevention, care, treatment, habilitation, and rehabilitation.
certification
1. The procedure and action by which an authorized organization evaluates and certifies that an
individual, institution, or program meets requirements. Certification differs from accreditation in that
certification can also be applied to individuals (for example, a medical specialist).
2. The process by which an agency or association formally recognizes that an individual has met
predetermined qualifications specified by that agency or association.
citation
A need for improvement mentioned in an official report, such as from a regulatory agency.
clinical pathology
Services relating to solving clinical problems, especially using laboratory methods in clinical diagnosis.
Includes clinical chemistry, bacteriology and mycology, parasitology, virology, clinical microscopy,
hematology, coagulation immunohematology, immunology, serology, and radio bioassay.
clinical practice guidelines/pathways

See practice guidelines
clinical trial
Therapy testing in three or sometimes four stages depending on the purpose, size, and scope of the test.
Phase I trials evaluate the safety of diagnostic, therapeutic, or prophylactic drugs, devices, or
techniques to determine the safe dosage range (if appropriate). They involve a small number of
healthy subjects. The trial usually lasts about one year.
Phase II trials are usually controlled to assess the effectiveness and dosage (if appropriate) of the
drugs, devices, or techniques. These studies involve several hundred volunteers, including a limited
number of patients with the target disease or disorder. The trial usually lasts about two years.
Phase III trials verify the effectiveness of the drugs, devices, or techniques determined in Phase II
studies. Phase II patients are monitored to identify any adverse reactions from long-term use. These
studies involve groups of patients large enough to identify clinically significant responses. The trial
usually lasts about three years.
Phase IV trials study the drugs, devices, or techniques that have been approved for general sale.
These studies are often conducted to obtain more data about a product’s safety and efficacy.
committee
A multidisciplinary group working as a team to address, analyzes, and resolves issues for which they were
formed.
community**
The individuals, families, groups, agencies, facilities, or organizations that interact with one another,
cooperate in common activities, solve mutual concerns, usually within the geographic area served by an
organization.
competence or competency
A determination of staff’ job knowledge, skills, and capacity to meet defined expectations**. Knowledge
is the understanding of facts and procedures. Skill is the ability to perform specific actions. For example,
a competent cardiologist knows about the physiology and pathology of the heart and how to detect
rhythm abnormalities by reading an electrocardiogram. Behaviors, such as the ability to work in teams,
are frequently considered as a part of competence.
complete order
A complete medication order contains the following: medication name, dose, frequency, and the route to
be administered.
complaint*
Expression of a problem, an issue, or dissatisfaction with services that may be verbal or in writing.
confidentiality
1. The safekeeping of data and information collected so as to restrict access to only individuals who
have a need, a reason, and permission for such access.
2. An individual’s right to personal and informational privacy, including the medical record.
consent*
Voluntary agreement or approval given by a patient and/or family member or a surrogate.
continuity of care (continuing care)

Coordinated care and services provided over time; among practitioners in various settings, programs or
services; level of medical, psychological, or nursing care; or spiritual and social care or service. This
applies within an organization or across multiple organizations.
contracted services
1. Services provided through a written agreement with another organization, agency, or individual. The
agreement specifies the services or personnel to be provided and the fees to provide these services
or personnel**.
2. Formal agreement that stipulates the terms and conditions for services that are obtained from, or
provided to, another organization. The contract and the contracted services are monitored and
coordinated by the organization and comply with the standards of the government and the
organization.
coordination of care
1. The process of coordinating care, treatment, and services provided by the organization, including
referral to appropriate community resources to meet the ongoing identified needs of the individuals,
to ensure implementation of the care plan, and to avoid unnecessary duplication of services**.
2. The process of working together effectively with collaboration among providers, organizations and
services to meet needs of patients in and outside the organization, ensure implementation of the care
plan, and to avoid duplication, gaps, or breaks.*
credentialing**
The process of obtaining, verifying, assessing, and attesting the qualifications of a physician. The
process determines if an individual can provide patient care services in or for a health care organization.
The process of periodically checking the physician’s qualifications are called re-credentialing.
credentials
Evidence of competence, current and relevant licensure, education, training, and experience. Other
criteria may be added by a health care organization. See also competence; credentialing.
criteria
Expected level(s) of achievement or specifications against which performance or quality may be
compared. Specific steps to be taken or activities to be done, to reach a decision or a standard*.
critical value/test (results)

Critical results (or panic values) are results that are abnormal to a degree that it may indicate a life-
threatening situation requiring an urgent response. Example in radiology: pneumothorax, unanticipated
pneumo-peritoneum, and intracranial midline shift; example in laboratory tests may be a blood sugar of
600.
data
Representation of facts, concepts, or instructions in a formalized manner suitable for communication,
interpretation, or processing by humans or by automatic means. Data before it is analyzed is called raw
data.
decisions
The act of reaching a conclusion or making up one’s mind
delivery (of care or service)*

It is the provision of care or service, usually in line with a care plan.
discharge
1. To release the patient from the hospital to home.
2. To release the individual from the emergency room to the hospital inpatient setting.
discharge planning
A formalized plan of follow-up care is determined and, if necessary, arranged for the patient.
discharge summary
A section of a patient record that summarizes the reasons for admission; significant findings; diagnosis’s;
any procedures performed; medications and other treatments provided; the patient’s condition at the
time of discharge; and discharge medications and follow-up instructions.
disciplines
Reference to the various members of the healthcare team. Disciplines can include but are not limited to
dietician, social worker, nurses, physicians, etc. A discipline is a job category.
dispensing
To distribute; to give; as, the pharmacist dispenses medications according to the physicians orders.
double check
A careful reinspection or reexamination to assure accuracy or proper condition; verification.
drug allergies
A state of hypersensitivity induced by a particular drug resulting in harmful immunologic reactions, such
as penicillin drug allergy.
education*
Systematic instruction and learning activities to develop or bring about change in knowledge, attitudes,
values or skills.
effectiveness*
The degree to which services, interventions or actions are provided in accordance with current best
practice to meet goals and achieve optimal results.
efficiency**
The relationship between the outcomes (results of care) and the resources used to deliver care (with
minimal waste, re-work, and effort). Increasing efficiency involve achieving the same outputs with fewer
resources or more outputs with the same amount of resources.
electroconvulsive therapy (ECT)

A form of therapy that uses electricity to induce a convulsive response.
emergency plan**
The organization’s written document that describes the process it would implement for managing the
consequences of natural disasters or other emergencies that could disrupt the organization’s ability to
provide care, treatment, and services. The plan identifies specific procedures that describe:
1. activities to be carried out to lessen the severity and impact of any potential emergency
2. activities to be carried out to build capacity and identify resources that may be used if an emergency
occurs
3. response to the emergency
4. recovery strategies from the emergency
5. corrective actions to be taken, if necessary, after the emergency ends
6. who will be responsible for the activities before, during, and after the emergency
environmental tours
Activities routinely used by the organization to determine the presence of unsafe environmental
conditions and whether the organization’s current processes for managing environmental safety risks are
being practiced correctly and are effective.
ethics*
Standards of conduct that are morally correct.
evaluation*
Assessment of the degree of success in meeting the goals and expected results (outcomes) of the
organization, services, programs or clients.
evidence*
Data and information used to make decisions. Evidence can be derived from research, experiential
learning, indicator data, and evaluations. Evidence is used in a systematic way to evaluate options and
make decisions.
evidence (scientific)–based medicine

Making medical decisions based on the best external evidence combined with the physician’s clinical
expertise and the patient’s desires. The approach requires understanding conflicting results and assessing
the quality and strength of evidence. Finally, physicians must know how this applies to patients and
health care policy.
external
Refers to outside of the organization, such as comparing data with other organizations or contributing to
Egypt’s required database.
family or responsible person

The person(s) with a significant role in the patient’s life. This may include a person(s) not legally related
to the patient. This person(s) is often referred to as a surrogate decision maker if authorized to make
care decisions for a patient if the patient loses decision-making ability.
fair hearing and appeal process

 A fair hearing and appeal process is for addressing adverse decisions regarding denial, reduction,
suspension, or removal of privileges that relate to quality of care, treatment, and services issues.
 This process is designed to allow the affected physician a fair opportunity to defend himself or
herself regarding the adverse decision to an unbiased hearing body of the medical staff, and an
opportunity to appeal the decision of the hearing body to the governing body.
 The process must have fair and just set of procedures guiding exactly what the physician can do to
have an opportunity to be heard by a panel of his or her peers and appeal opportunity to the
governing body.
fire safety plan
The organization’s written document that describes the processes in place for preventing fire and
managing the consequences of fire. The plan identifies activities, including the education of staff,
selected and implemented by the organization to assess and control the risks of fire, smoke, and other
byproducts of combustion that could occur during the organization’s provision or care, treatment, and
services.
formulary
A list of medications available within the organization with associated information related to medication
use and approved by the appropriate medical staff groups/committees. Essential Drug List (EDL) is a
similar list of medications..
functional status
Ability of an individual to take care of self, physically and emotionally as appropriate to their age group.
Functional status may be divided into social, physical, and psychological functions. Functional status may
be assessed by asking questions during periodic health examinations or using formal screening
instruments. See also measure.
goals*
Broad statements that describe the outcomes an organization is seeking and provide direction for day-to-
day decisions and activities. The goals support the mission of the organization.
governing body
Collectively the individuals, group, or agency that has ultimate authority, responsibility, and accountability
for the overall strategic direction, methods of operations (management and planning), establishment of
policies, and maintenance of the quality of care of the organization.
guidelines
See practice guidelines
hand-over communication
An exchange of information about a patient from one care provider to another. The primary objective is
to provide accurate, clear, and complete information, using interactive communication about the patient’s
(1) care, treatment, services, (2) current condition, and (3) any recent or anticipated changes. Must
allow for the opportunity to ask and respond to questions and minimize interruptions. The hand-over
communication may be nurse to nurse, physician to physician, nurse to physician, physician to nurse,
between disciplines.
hazardous materials and waste plan

The organization’s written document that describes the process it would implement for managing the
hazardous materials and waste from source to disposal. The plan describes activities selected and
implemented by the organization to assess and control occupational and environmental hazards of
materials and waste (anything that can cause harm, injury, ill-health or damage) that require special
handling. Hazardous materials include radioactive or chemical materials. Hazardous wastes include
biologic waste that can transmit disease (for example, blood, and tissues), radioactive materials, toxic
chemicals, and infectious waste, such as used needles, used bandages, and fluid-soaked items.
health care professional

1. Any person who has completed a recognized course of study and is skilled in a field of health. This
includes a physician, dentist, nurse, or other healthcare professional. Health professionals are often
licensed by a government agency or certified by a professional organization.
2. Medical, nursing or allied health professional staff that provide clinical treatment and care to patients,
having membership of the appropriate professional body and, where required, having completed and
maintained registration or certification from a legal authority*.
hygiene*
The practice that serves to keep people and environments clean and prevent infection.
human resources/human resource file

The individuals working within an organization. May also refer to a department within an organization
that serves as a resource to the individuals working within the organization. Goal is to ensure
staff/personnel requirements, staffing, and education/training to meet patients and staff needs of the
organization. Human resource file are those files maintained on each individual within the organization.
The file may include hiring information, performance appraisals, job description, competency
assessments, and orientation information.
immediate post-operative/invasive procedure report

A brief summary, documented in the medical record, noting the surgery/procedure performed, post
operative/post procedure diagnosis, assistant surgeon,if any, estimated blood loss, and any specimens
obtained. To be completed immediately after the procedure before the patient goes to the next level of
care or at the conclusion of the emergency that delayed the writing of the report.
incidents*
Events that are unusual, unexpected, may have an element of risk, or that may have a negative effect on
patients, groups, staff, or the organization.
indicator
1. A measure of the performance of functions, systems, or processes over time.
2. A statistical value that indicates the condition or direction of the performance of a process or
achievement of an outcome over time.
3. A measurable variable (or characteristic) used to determine the degree to which a standard is met or
quality goal is achieved. (For example, proportion of nurses who correctly take vital signs on patients
admitted to the medical unit.)
4. Performance measurement tool, screen or flag that is used as a guide to monitor, evaluate, and
improve the quality of services. Indicators relate to structure, process, and outcomes and are
usually expressed as ratios with a numerator and denominator*.
infection
The transmission of a pathogenic microorganism,
endemic infection: The usual level or presence of an agent or disease in a defined population
during a defined period.
epidemic infection: A higher than expected level of infection by a common agent in a defined
population during a defined period.
healthcare associated infection (HAI): An infection acquired while receiving care, treatment,
and services in the organization. Common infections are urinary infections, surgical wound
infections, pneumonia, and blood stream infections.
infection control program**

Organized system of services designed to meet the needs of the organization in relation to the
surveillance, prevention, and control of infection which impacts patients, staff, physicians, and/or visitors.
information*
Data that is organized, interpreted and used. Information may be in written, electronic, audio, video or
photograph form.
information management.
1. The creation, use, sharing, and disposal of data or information across an organization. This practice is
critical to the effective and efficient operation of organization activities. It includes the role of
management to produce and control the use of data and information in work activities, information
resources management, information technology, and information services.
2. Systems for planning, organizing, analyzing and controlling data and information, including both
computer-based and manual systems*.
informed consent
Agreement or permission signed by the patient indicating that the patient has been informed of the
nature, risks, and alternatives of a medical procedure or treatment before the physician begins any such
course. The physician has a duty to inform his or her patients about whatever risks or injury might be
incurred from a proposed treatment, test, or research.
in-service education
Organized education, usually provided in the workplace, designed to enhance the knowledge and skills of
staff members or teach them new skills relevant to their jobs and disciplines.
interdisciplinary**
Communication; discussion; planning; evaluation; and care, treatment, and service activities that occur
formally and informally between and among team members who are representatives of multiple
disciplines. Every patient may not have the same number of disciplines involved in the care process.
invasive procedure
A procedure involving puncture or incision of the skin, or insertion of an instrument or foreign material
into the body.
inventory level
The quantity of goods and materials on hand. Maintaining a specified number of goods and materials in
stock.
ISQua accreditation
A public recognition by ISQua of the achievement of the ISQua international standards by a healthcare
external evaluation or standards setting body, demonstrated through an independent external peer
assessment of that body’s organizational performance, standards, training or education programs in
relation to the standards. There are four types of accreditation – organization accreditation, standards
accreditation, surveyor/assessor training program accreditation and education and learning program
education.
ISQua Accreditation Federation*

An international non-governmental, voluntary, professional federation of healthcare external evaluation
and standards setting organizations and interested associates, as a committee/special interest group of
ISQua.
job description
A document describing the functions of a position. The job description also includes qualifications,
education, experience, duties, responsibilities, and conditions required to perform the job.
leaders**
Individuals who set expectations, develop plans, and implement procedures. These activities are
designed to assess and improve the quality of an organization’s governance, management, and clinical
and support functions and processes. Leaders include the owners, members of the governing body, the
chief executive officer and other senior managers, nursing executives and other senior nurses, and the
leaders of the medical staff, as they apply to the organization’s structure.
leadership*
Ability to provide direction and cope with change. It involves establishing a vision, developing strategies
for producing the changes needed to implement the vision; aligning people; and motivating and inspiring
people to overcome obstacles.
legibility
Possible to read or decipher. The writing is clearly written so that every letter or number cannot be
misinterpreted. It is legible when any ONE individual can read the hand written documentation or
physician order.
levels of care
A classification of health care service levels. They are divided by the kind of care given, the number of
people served, and the people providing the care. Levels of care classified by the acuity of the patient or
intensity of the services provided are emergency, specialized (intensive care, psychiatric, obstetrics), and
general medical/surgical
licensure
1. A legal right granted by a government agency in compliance with a statute for an occupation (for
example, medicine, dentistry, nursing) or the operation of an activity (for example, acute care in a
hospital). Licensure of a physician is the legal permission granted by a government to take personal
and unsupervised responsibility for diagnosing and treating patients**.
2. The process by which a government agency grants permission to qualified persons to engage in a
given occupation or to an institution to engage in a given business*.
management*
Setting targets or goals for the future through planning and budgeting, establishing processes for
achieving those targets and allocating resources to accomplish those plans. Ensuring that plans are
achieved by organizing, staffing, controlling and problem-solving.
measure
To collect quantifiable data about a function, system, process, or outcomes/results of an activity(s).
medical equipment plan

The organization’s written document that describes the processes it has implemented for managing the
selection, care, and maintenance of its medical equipment. The plan describes activities selected and
implemented to access and control the clinical and physical risks of fixed or portable non-drug item or
equipment used for the diagnosis, treatment, monitoring, and direct care of patients.
medical record review**

The process of measuring, assessing, and improving the quality of the medical record documentation -
the degree to which the documentation is accurate, complete, readable, and performed in a timely
manner.
medical staff bylaws

Regulations and/or rules adopted by the medical staff and the governing body of the organization for
governance, defining rights and obligations of various officers, persons, or groups within the medical
staff’s structure.
medical setting
Any place that medical and health care is provided.
medication**
Any prescription medications; sample medications; herbal remedies; vitamins; over-the-counter drugs;
vaccines; diagnostic and contrast agent used on or administered to persons to diagnose, treat, or prevent
disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral
nutrition; blood products; and intravenous solutions with electrolytes and/or drugs.
medication error**
Any preventable event that may cause inappropriate medication use or endangers patient safety.
Examples are wrong patient, drug, dose, time, and route; incorrect ordering, dispensing, or transcribing;
missed or delayed treatments. Any professional/discipline/staff who handle medications can be involved
in the error.
mission statement
A written phrase that states what the organization does and why it exists. The creation of a mission
statement precedes the formation of goals and objectives.
monitoring
1. The review of information on a regular basis. The purpose of monitoring is to identify the changes in
a situation. For example, the clinic reports every month the cases of meningitis occurring in the
community at risk.
2. The ongoing evaluation of the patient to whom a medication was administered, to determine the
effectiveness and efficacy of the medication therapy and prevent the occurrence of any serious
adverse outcomes.
multidisciplinary
A group of staff members, representing a range of professions, disciplines, and service areas work
together as one functioning group.
“near miss”*
It is a situation in which an adverse event almost happens.
need*
Physical, mental, emotional, social or spiritual requirement for well-being. Needs may or may not be
perceived or expressed by those in need. They must be distinguished from demands, which are
expressed desires, not necessarily needs.
neglect
Withholding or inadequately providing food and hydration (without physician, patient, or surrogate
approval), clothing, medical care, and good hygiene. It also includes placing the person in unsafe or
unsupervised conditions.
nutrition care
Interventions and counseling to promote appropriate nutrition intake. This activity is based on nutrition
assessment and information about food, other sources of nutrients, and meal preparation. It considers
the patient’s cultural background and socioeconomic status.
nutrition screening**
A process used to indicate the need for a nutritional assessment to determine whether a patient is
malnourished or at risk for malnourishment.
objectives*
A target that must be reached if the organization is to achieve its goals. It is the translation of the goals
into specific, concrete terms against which results can be measured.
organization chart
A graphic representation of reporting relationships in an organization.
orientation*
The process by which staff become familiar with all aspects of the work environment and their
responsibilities.
outcome
The effect(s) that an intervention has on a specific health problem. It reflects the purpose of the
intervention. For example, the outcome(s) of a rural health education program on safe drinking water
could be fewer diarrhea episodes in children under five or decreased child mortality by diarrhea.
palliative services
Treatments and support services intended to lessen the pain and suffering rather than to cure illness.
Palliative therapy may include surgery or radiotherapy undertaken to reduce or shrink tumors
compressing vital structures and thereby improve the quality of life. Palliative services include attending
to the patient’s psychological and spiritual needs and supporting the dying patient and his or her family.
patient care process

The act of providing accommodations, comfort, care, and treatment to an individual in the organization.
This implies responsibility for safety, including the environment, treatment, services, habilitation,
rehabilitation, or other programs requested by the organization for the individual.
patient record/medical record/clinical record

A written account of a variety of patient health information, such as assessment findings, treatment
details, plan of care, progress notes, and discharge summary. This record is created by physicians,
nurses, and other health care professionals.
peer review*
A process whereby the performance of an organization, individuals or groups are evaluated by members
of similar organizations or the same profession or discipline and status as those delivering the services
performance improvement**
The continuous study and adaptation of an organization’s functions and processes to increase the
probability of achieving desired outcomes and to better meet the needs of patients and other users of
services.
performance review
The continuous process by which a manager and a staff member review the staff member’s performance
according to the job description, set performance goals, and evaluate progress towards these goals.
personnel record (file)*

Collection of information about a staff member covering personnel issues such as licensure, certification,
leave, references, performance reviews, qualifications, registration, and employment terms (job
description).
plan**
A detailed method, formulated beforehand, that identifies needs, lists strategies to meet those needs,
and sets goals and objectives. The format of the plan may include narratives, policies and procedures,
protocols, practice guidelines, or a combination of these.
point of care testing

Testing performed at sites outside the laboratory, usually at or near where care is delivered. Testing are
procedures, such as hema-stick for occult blood, glucose meters, urine dipsticks, etc.
policy*
Written statement(s) which act as guidelines and reflect the position and values of the organization on a
given subject
practice guidelines
1. A set plan for care of the typical patient in the typical situation. It is developed through a formal
process that uses the best scientific evidence of effectiveness with expert opinion. Synonyms:
algorithm, clinical criteria, guideline, parameter, practice parameter, preferred practice pattern,
protocol, review criteria.
2. Statements that help practitioners and patients choose appropriate health care for specific clinical
conditions (for example, recommendations on the case management of diarrhea in children under the
age of five years). The practitioner is guided through all steps of consultation (questions to ask,
physical signs to look for, lab exams to prescribe, assessment of the situation, and treatment to
prescribe).
3. An agreed-upon treatment regime that includes all elements of care.
practitioner**
Any individual who is qualified to practice a health care profession (physician, nurse) and is engaged in
the provision of care and services. Practitioners are often required to be licensed as defined by law.
PRN
Frequently used to denote “whenever necessary”. Example: Administer medication for headache PRN.
pre-printed order set

It is a set of physician orders containing medications (for pain, nausea, fever, etc), tests (laboratory,
radiology, cardiology), and care (place on cardiac monitor, start IV, etc) for which the physician selects to
be implemented. These order sets are printed and available in such locations as the recovery room and
intensive care areas or for certain types of conditions, such as vaginal delivery. These order sets are
approved by the individual physician or by the related medical staff department and the Drug and
Therapeutic Committee.
preventive services
Interventions to promote health and prevent disease. This includes identification of and counseling on
risk factors (for example, smoking, lack of physical activity), screening to detect disease (for example,
breast cancer, sexually transmitted diseases), immunizations, and chemoprophylaxis (for example,
hormone replacement therapy).
privileging**
The process whereby specific scope and content of patient care services (clinical privileges) are
authorized for a practitioner by the organization, based on evaluation of the physician’s credentials and
performance.
procedures*
Written sets of instructions conveying the approved and recommended steps for a particular act or series
of acts to meet a series of tasks.
process
A series of actions (or interrelated activities and communications) that transform the inputs (resources)
into outputs (accomplished services). For example, a rural health education program will require that
staff develop an education strategy, develop educational materials, and deliver the education sessions.
protocol
A plan or set of steps, to be followed in a study, an investigation, or an intervention. One example is
clinical protocols used in the care of trauma patients. See also practice guidelines.
qualified individual
1. An individual or staff member who can participate in one or all of the organization’s care activities or
services. Qualification is determined by the following: education, training, experience, competence,
applicable licensure, law or regulation, registration, or certification. Examples include physician,
nurse, administrator, psychiatrist, therapist, dietician, medical technologist, physical therapist,
psychiatric nurse, radiologic technologist, psychologist, and social worker.
2. Having the credentials for, being professionally and legally prepared and authorized to perform
specific acts (such as infection control)*.
qualitative*
Data and information written with descriptions and narratives, a method that investigates the experience
of users through observation and interviews.
quality activities*
Activities which measure performance, identify opportunities for improvement in the delivery of services,
and include corrective action(s) and follow-up.
quality assessment*
Planned and systematic collection and analysis of data about a service usually focused on service content
and delivery specifications and patient outcomes.
quality control
1. A process that consists of measuring performance, comparing performance against goals, and acting
on the differences when performance falls short of defined goals**.
2. The monitoring of output to check if it conforms to specifications or requirements and action taken to
correct the output. It ensures safety, transfer of accurate information, accuracy of procedures and
reproducibility*.
quality of care**
The degree to which health services for individuals and populations increase the likelihood of desired
health outcomes and are consistent with current professional knowledge. Dimensions of performance
include the following: patient perspective issues; safety of the care environment; and accessibility,
appropriateness, continuity, effectiveness, efficacy, efficiency, and timeliness of care.
quantitative
Data and information that is written in numbers and statistics, a method that investigates observable
facts with measures.
range orders**
Orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or
individual’s status.
read-back
Read-back is a process. The process is that the qualified person taking the physician order or the critical
values/test results writes down the order or the critical value/test results in the medical record, and then
reads it back exactly as it was written down to the person who initiated it.
reassessment**
Ongoing data collection, which begins on initial assessment, comparing the most recent data with the
data collected at easier assessments and reassessments.
recall system
To call back medications or supplies or materials. A system defined that alerts appropriate individuals
when a company is calling back a product due to a defect in manufacturing or contamination.
referral**
The sending of an individual (1) from one physician to an another physician(s) or specialist; (2) from one
setting or service to another or other resource, either for consultation or care that the referring source is
not prepared or qualified to provide.
rehabilitation services
The use of medical, social, educational, and vocational measures together for training or retraining
individuals disabled by disease or injury. The goal is to enable patients to achieve their highest possible
level of functional ability.
reliability*
Extent to which results are consistent through repeated measures by different measurers, or at different
times by the same measurer, when what is measured has not changed in the interval between
measurements.
reprocessing
All operations performed to render a contaminated reusable or single-use (disposable) device ready again
for patient use. The steps may include cleaning and disinfection/sterilization. The manufacturer of
reusable devices and single use devices that are marketed as non-sterile should provide validated
reprocessing instructions in the labeling.
research
1. The use of individuals in the systematic study, observation, or evaluation of factors on preventing,
assessing, treating, and understanding an illness.
2. Contribution to an existing body of knowledge through investigation, aimed at the discovery and
interpretation of facts*.
restraint
Any method (chemical or physical) of restraining a patient’s freedom of movement, including
seclusion, physical activity, or normal access to his or her body that (1) is not usual and customary
part of a medical diagnostic or treatment procedure to which the patient or his or her legal
representative has consented; (2) is not indicated to treat the patient’s medical condition or
symptoms; or (3) does not promote the patient’s independent functioning.
physical restraint: Any method of physically restricting a person’s patient’s independent
functioning, freedom of movement, physical activity, or normal access to his or her body.
chemical restraint: The use of psychotropic medication to subdue, inhibit, confine or control
behavior.
resuscitative services
Medications, supplies, personnel, and processes used to resuscitate an individual.
rights*
Something that can be claimed as justly, fairly, legally, or morally one’s own. A formal description of the
services that patients can expect and demand from an organization.
risk*
Chance or possibility of danger, loss or injury. This can relate to the health and well-being of patients,
staff and the public, property, reputation, environment, organizational functioning, financial stability,
market share and other things of value.
risk assessment, proactive

An assessment that examines a process in detail including sequencing of events; assesses actual and
potential risk, failure, or points of vulnerability; and, through a logical process, prioritizes areas for
improvement based on the actual or potential patient care impact (criticality).
risk management
1. Clinical and administrative activities to identify, evaluate, and take action to reduce the risk of injury.
This risk could apply to patients, staff, visitors, and the organization itself.
2. A systematic process of identifying, assessing and taking action to prevent or manage clinical,
administrative, property and occupational health and safety risks in the organization*.
safety**
The degree to which the potential risk and unintended results of an intervention (for example, use of a
drug or a procedure) and in the care environment are reduced or avoided for a patient and other
persons, including health care providers.
safety/security plan
The organization’s written document that describes the processes implemented for managing the safety
and the security of patient, staff and visitors within the organization. The plan describes activities
selected and implemented by the organization to assess and control the impact of environmental risk,
and to improve general environmental safety and security.
sample drugs
These are medications that are given directly to the physician(s) by the drug vendors which may or may
not be on the medication list, but should be appropriate to the patient population of the organization.
seclusion
A locked room to place a psychiatric patient for aggressive behavior that is appropriately prepared to be
safe for the patient. Safe means that risks for suicide were not accessible. Room must allow for
continuous observation by either by a window or a camera.
scope (care or services)*

The range and type of services offered by the organization and any conditions or limits to service
coverage.
scope of practice
The range of activities performed by a practitioner (physician, nurse) in the organization. The scope is
determined by training, tradition, law or regulation, or the organization.
screening criteria
A set of standardized objective criteria applied to patient groups on which to base a preliminary judgment
that further evaluation is warranted, such as the need for a nutritional evaluation based on nutritional
screening or functional evaluation based on functional screening.
secure/security
Protection from loss, destruction, tampering, or unauthorized access or use.
sedation
See anesthesia and sedation.
sentinel event
An unexpected occurrence involving death or serious physical or psychological injury, or the risk of
reoccurrence which would carry a significant chance of a serious adverse outcome. Serious injury
specifically includes loss of limb or function.
services*
Products of the organization delivered to patients, or units of the organization that deliver products to
patients.
short stay
Patients who usually stay less than one 24 hour period.
sliding scale
A set of instructions for adjusting insulin on the basis of blood glucose test results, meals, or activity
levels.
staff
Individuals, such as employees, contractors, or temporary personnel who provide services needed in the
organization.
stakeholder
Individuals, organizations or groups that have an interest in services offered by the healthcare
organization.
standard
1. For purposes of accreditation, a set of expectations predetermined by a competent authority. A
standard describes the acceptable level of performance of an organization or individual. It relates to
structures in place, conduct of a process, or measurable outcome achieved.
2. An expected level of performance that, if attained, would lead to the highest levels of quality in a
system. For example, every health provider must wash his or her hands after examining a patient.
3. A desired and achievable level of performance against which actual performance is measured*.
standards-based evaluation
An assessment process that determines an organization’s or practitioner’s compliance with pre-
established standards. See also accreditation.
strategic plan
A formalized plan that establishes the organization’s overall goals and that seeks to position the
organization in terms of its environment.
suppression system
Related to fire safety: system that puts out fires, such as the sprinkler system and the foam system over
the stove in the kitchen.
surrogate decision maker

Someone appointed to act on behalf of another. Surrogates make decisions only when an individual is
without capacity or has given permission to involve others.
surveillance
The ongoing systematic collection and analysis of data and the provision of information which leads to
action being taken to prevent and control a disease, usually one of an infectious nature.
survey*
External peer review which measures the performance of the organization against the agreed set of
standards.
surveyor
A physician or nurse, who meets the surveyor selection criteria, assesses and evaluates standards
compliance, and provides education and consultation regarding standards compliance to organizations.
sustainability*
The provision by a health system of infrastructure such as workforce, facilities and equipment, innovation
and responsiveness to emerging needs, e.g. research, monitors.
system
A series of inputs that result in an output. The admission through to discharge of a patient is an example
of a system. A system may consist of a series of processes.
telemedicine
The use of medical information exchanged from one site to another via electronic communications for the
health and education of the patient or provider, and for the purpose of improving patient care.
terminally ill care

Consist of services provided and coordinated by an interdisciplinary team to meet the needs of terminally
ill patients with a limited life span. This includes management of pain and other physical symptoms,
meeting the psychosocial and spiritual needs of the patient and family members, including extended family members.
timeliness
The time between the occurrence of an event and the availability of data about the event. Timeliness is
related to the use of the data.
titrating orders**
Orders in which the dose is either progressively increased or decreased in response to the individual’s
status.
TPN (Therapeutic Parenteral Nutrition)**

Nutrients that are provided intravenously, bypassing the digestive tract, which may contain protein,
sugar, fat, and added vitamins and minerals as needed by the patient. TPN is a solution mixed by a
pharmacist according to a physician order, given intravenously for a patient in poor nutritional status.
tracer (individual patient)

A methodology used to follow the actual care, treatment, and services offered by an organization to the
patient.
tracer (system tracer)

A methodology used to examine a specific system and the processes involved within a specific system
such as the medication system, infection prevention and control system.
transcribe (transcribing)
Copy from one document and rewrite the information into a different location in the medical record, such
as transcribing the physician’s order into the medication record.
transfer**
The formal shifting of responsibility for the care of a patient from (1) one care unit to another, (2) one
clinical service to another, (3) one qualified practitioner to another, or (4) one organization to another
organization.
triage
A system of establishing the order in which acts are to be carried out in an emergency, prioritize patients
by their problems, symptoms determining the order of being seen by the physician.
tube feeding
Nutrition provided to the gastrointestinal tract by a tube through the mouth or catheter through an
alternate route, such as gastrostomy tube.
uniform (uniformly)
Applied in the same way (consistently and in a standardized manner) when the same care, treatment,
and/or services are provided, regardless of the location.
utility systems plan

The organization’s written document that describes the processes implemented for managing the utility
systems in the organization. The plan describes activities selected and implemented by the organization
to assess and control the risks of utility systems of buildings that support the provision of care,
treatment, and services. Organization-wide systems and equipment that support the following: electrical
distribution; emergency power; water; vertical and horizontal transport; heating, ventilating, and air
conditioning; plumbing, boiler, and steam; piped gases; vacuum systems; or communication systems,
including data-exchange systems. Also include systems for life support; surveillance, prevention, and
control of infection; and environment support.
utilization
The use, patterns of use, or rates of use of a specified health care service. Overuse occurs when a health
care service is provided under circumstances in which its potential for harm exceeds the possible
benefits. Underuse is the failure to use a necessary health care service when it would have produced a
favorable outcome for a patient. Misuse occurs when an appropriate service has been selected but a
preventable complication occurs. All three reflect a problem in quality of health care. They can increase
mortality risk and diminish quality of life. See also utilization management.
utilization management**
The planning, organization, direction, and control of resources. How this relates to patient care by a
health care organization is significant.
validity*
Extent to which a measure truly measures only what it is intended to measure.
values*
Principles, beliefs or statements of philosophy that guide behavior and that may involve social or ethical
issues.
variation
The differences in results obtained in measuring the same event more than once. The sources of
variations can be grouped into two major classes: common causes and special causes. Too much
variation often leads to waste and loss, such as the occurrence of undesirable patient health outcomes
and increased cost of health services.
vision*
Description of what the organization would like to be.
*Definitions taken from the ISQua Glossary, copyright November 2006

**Definitions taken from the JCAHO, Comprehensive Accreditation Manual for Hospitals
The Official Handbook, 2006
7/2007

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Egyptian HealthCare

Egyptian Executive Healthcare

The period of Accreditation for these Standards

President Head of the International Accreditation

Infection Control, Surveillance and Prevention

Facility and Environmental Safety

Information Management (IM)

Performance Improvement (PI)

Organization Management (OM, HR, NS, MS)

88 List of Policies & Procedures

Pyramid of Excellence in HealthCare Accreditation

• A – structures – policy/procedures, plans, required committees (all or none

• B & C – implementation - frequency based - observations of deficiencies

B standards are to be implemented first (easier)

Standard Change Explanation

PR.1 Deleted See general rule

AP.1 See general rule

AP.26 Statement is improved To clarify the meaning

PC.2 Statement is improved To clarify the meaning

IP.3 Deleted Required by surveyors

IP.21 Deleted It has no meaning

PE.1& 2 Merged together they are relevant

MM.15 Add new implementation standard for it

PS.1 Deleted See general rule

IC.11 Deleted See general rule

ES.6 & 11 Merged together They are relevant

ES.29 deleted Not possible right now in Egypt

IM.1 deleted To avoid repetition

PI A new standard is added Recommended by ISQua

OM Two new standards are Required by ISQua

HR.1 Add a requirement Required by ISQua

NS Add new standard Required by ISQua

MS.2 Modify statement To measure one process (N.B.

Patient Rights and Responsibilities

PR 1.1 Rights as defined by laws and regulations

PR 1.2 Right to access care if provided by the organization

PR 1.3 Right to know the name of the treating, supervising and/or

PR 1.5 Right to be informed and participate in decisions relating to their

PR 1.6 Right to refuse care and discontinue treatment

PR 1.7 Right to security, personal privacy, confidentiality and dignity

PR 1.8 Right to have pain assessed and treated

PR 1.9 Right to make a complaint or suggestion without fear of retribution

PR 1.10 Right to know the price of services and procedures

B M P N NA PR. 2 Patients are informed of their rights in a manner they can

C M P N NA PR. 4 There is a process to respond to patients religious or spiritual needs

A M P N NA PR. 5 Policy and procedure defines patient and family responsibilities

B M P N NA PR. 6 Patients are informed of their responsibilities. and agree to comply

A M P N NA PR. 7 Patients' rights are maid visible to patients and staff.

B M P N NA PR. 9 Patients and families are informed about the consequences of

B M P N NA PR. 11 Patients are informed about available care and treatment

B M P N NA PR. 14 General consent for treatment is obtained when the patient is

A M P N NA PR. 16 The organization has a list of procedures or treatments for which

PR. 16.1 Surgery and invasive procedures

PR. 16.2 Anesthesia/moderate or deep sedation

PR. 16.3 Use of blood and blood products

PR. 16.4 High-risk procedures or treatments (including but not limited to

PR. 16.5 Family planning interventions

PR. 16.6 Research

B M P N NA PR.17 Informed consent is obtained and documented as required by law

B M P N NA PR. 20 Consent forms are available in all applicable locations.

B M P N NA PR. 21 The organization advertises and markets honestly in accordance with

C M P N NA PR. 24 Patients and families are informed of alternatives to the provided

A M P N NA PR. 25 Policy defines the organization's responsibilities regarding patients’

PR. 25.1 Who is responsible