Category Archives for "Quality"

What You Need To Know About Accreditation Standards

Accreditation Standards

Accreditation Standards

A requirement is a statement of quality, or a specific fixed assumption that specifies the crucial features, procedures, structures and tasks needed for healthcare facilities to guarantee the arrangement of risk-free and top quality treatment and services.

Requirements are established by peer professionals in the field and it’s against the requirements that consistency of the healthcare institution is examined. Simply specified, the standard explains a healthcare establishment’s appropriate efficiency degree. Within this context, there ought to be no complication between certification body requirements and licensure requirements.

When licensure of a private institution, the requirement is often a very little degree developed to secure public health and safety and security. Certification requirements, on the other hand, are created as attainable and ideal which, when , would result in a top quality degree in a system.

Types of Accreditation Standards

Generally talking, certification requirements, in addition to all other appropriate accrediting organizations are of 3 primary kinds relying on which location they are dealing with.

Structure requirements deal with the system’s inputs, such as the healthcare facility beds available, the workforce, the layout of the healthcare facility structure, the accessibility of personal protective equipment for health workers, such as masks and gloves, and the accessibility of equipment and products, such as microscopes and lab reagents.

Process requirements deal with the management and scientific treatments or tasks performed within the medical facility in the treatment of patients or in the management of the healthcare facility or its personnel. Instances include patient evaluation, patient education, drug administration, and alike.

Outcome requirements look at the evaluation of the advantages of an intervention and whether the anticipated objective of the task was accomplished. They offer details regarding whether anticipated end results are being recognized. Instances of outcome indicators include mortality rates, foreign object retained after surgical treatment, air embolism, blood incompatibility, stress abscess, falls, vascular catheter-associated infection, catheter-associated urinary system infection, and symptoms of inadequate glycemic control.

Accreditation standards set assumptions for healthcare facility efficiency that are reasonable, obtainable, measurable and consequently, survivable. Requirements were constructed to act as the basis of an unbiased analysis procedure that can assist healthcare establishments measure, enhance and evaluate efficiency. Accreditation is making every effort to be a country wide acknowledged icon of quality, valued throughout the industry and by other appropriate authorities as a guarantee that certified health care establishments fulfill extensive requirements of top quality and functional honesty that emphasize individual defense and patient interaction. To this end, the procedure of requirements advancement at certification complies with a durable and lengthy approach to make certain that the requirements are appropriate, evidence-based, pertinent and clear. The initial draft of certification requirements are established by specialized task forces, focus groups, and requirements advancement boards that use input from a range of resources, including:

  • The requirements established by the professional scientific societies, regionally and worldwide.
  • Scientific research evaluation and research studies.
  • Relevant legislations, policies, and policies.
  • National (or global) arising problems associated with medical care high quality and patient safety and security.
  • Input from healthcare patients, experts, and service providers.

Process for Creating Accreditation Standards

The procedure of requirements advancement can last as much as 18 months or even more prior to a preliminary draft is made. The draft standards are after that distributed country wide for evaluation and provided for comment on the requirements Field Evaluation web page of the accreditation body web site. Based upon the comments obtained from the field evaluation, the draft requirements might be changed and once again examined by the technological boards and appropriate professionals. The draft requirements are lastly authorized by the Standards Development Committee and provided to the Board for remarks and statements prior to entry to the Health Council for authorization. After that, requirements are provided in paper and digital styles and dispersed to all medical facilities and e-version is offered on accreditation body web site. To abide by the standards of the International Society for Quality in Healthcare (ISQua), 6 months duration is permitted releasing the requirements prior to they work. When the requirements are in effect, continuous comments is sought for the function of constant enhancement. The study procedure is after that customized as required to deal with the brand-new requirements, and property surveyors are enlightened regarding exactly how to examine conformity with the requirements.

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Healthcare accreditation: Definition and importance

Healthcare accreditation

is an evaluation procedure that includes a strenuous, clear, as well as detailed examination by an exterior independent accreditation body. The healthcare institution goes through an assessment of its systems, procedures, and also efficiency by peer customers or property surveyors to make certain that all is carried out in a fashion that satisfies suitable established as well as publicised global criteria. Prior to the outside examination, i.e., the study check out, the healthcare institution is anticipated to perform an extensive self-assessment to pick the degree of its readiness as well as exactly how much or exactly how close it is from accomplishing complete conformity with the requirements. Accreditation for that reason, stands for a public recognition by the healthcare accreditation body of the accomplishment of accreditation requirements by a healthcare institution. Criteria laid out a typical structure to sustain healthcare institutions to give reliable, prompt as well as top quality solutions. They are made to supply enhanced degrees of treatment and also therapy to the citizens. There is great proof from clinical research study that reveals that taking part in a durable healthcare accreditation program enhances the framework, procedure as well as result of treatment offered by healthcare institutions. Accreditation is not just a certification to get and also hold on the wall surface. If used effectively, accreditation can supply the adhering to advantages:

Healthcare accreditation

Healthcare accreditation

It gives a structure for the business framework as well as administration: mostly all accreditation requirements concentrate on the administration and also management frameworks and also features within a healthcare institution as well as the proper administration of its organisation as well as everyday tasks.

Healthcare accreditation and near misses:

It aids enhance individual security as well as reduce the danger of near misses, negative end results, as well as clinical mistakes: making sure person security with threat monitoring and also danger decrease goes to the heart of all accreditation criteria as well as is the supreme objective of the self-assessment as well as the study tasks.

Accreditation improves neighborhood self-confidence in the high quality as well as safety and security of treatment given: when a healthcare institution accomplishes accreditation, the message is clear; its leaders are devoted to supplying a country wide approved criterion of treatment in health services shipment.
Evaluated healthcare institutions have actually located that seeing their very own procedure with the eyes of skilled property surveyors offered them with a beneficial, much more unbiased evaluation of their interior management and also professional procedures as well as reliable propositions for additional enhancing their procedures and also solutions to the area.

Accreditation, on the future, verifies to raise the performance as well as improve the lean methods, which converts right into reducing waste as well as even more optimum outcomes with much less intake of sources.

Accomplishing accreditation assists enhance the competition of a healthcare institution: climbing public self-confidence in a recognized institution will at some point motivate even more people to look for treatment and also therapies because institution which will favorably affect its competition in the healthcare industry as well as boost its market share.

Repayment by insurance companies and also various other 3rd parties: there is an expanding propensity, country wide and also globally, to connect attaining accreditation with qualification for insurance policy compensation.

Healthcare accreditation

offers a durable tool for the continual top quality initiatives in the healthcare institutions: making every effort non-stop to abide by accreditation criteria aids the management of the institution to make sure the sustainability of the high quality renovation tasks and also efforts.

Accreditation attends to a learning as well as academic possibility: via team education and learning on the most effective techniques and also by including focus on the significance of person education and learning as well as person civil liberties.

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What You Need To Know About Medication Errors!?

Why should we care about medication errors!?

Medication errors are a huge deal in any healthcare settings, in some situations it can lead to a lawsuit that settles with a sum of millions, or sometimes it can be a cause of patient death.

Medication errors are an avoidable event that can be anticipated, and most of the times actively prevented, when everyone is working by the international standards and the "hospital / healthcare organization" is forcing their policies to minimize ME.

For a healthcare worker, ME are to be learned from and our aim is to prevent future occurrences. Learning means identifying the cause and asking the involved individuals about what circumstances that lead to the error to happen. This leads to the preventing stage and measure to be taken to prevent ME in the future.

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Starting QM Department

When a hospital chooses to initiate its own quality department and not only hiring experts from outside; then it's raising the standard of healthcare service to the community and aims to offer/deliver competitive healthcare. It does so by applying the current medical practice, supported by advanced technology, state of the art facilities and skilled professionals. In addition, addition, the organization strives to deliver top tier healthcare grade in a safe and patient-centered environment.

The QM Plan and Programs are a collaborative effort made by every single member of the staffing power of the organization.

The design and program employ a systematic approach to quality / patient safety and address's coordination among all components of the organization's quality measurement and control activities.

The plan sets a strong emphasis about measurable safety and performance evaluation of the whole organization that exemplifies and provides services to patients and customers consistent with worldwide standards of excellence.

The aim of this department to support the implementation of the hospital Mission, Vision and Core Values and to enable the creation of an efficient, value driven organization dedicated to meet the needs and expectations of all its patients and customer.

~to be continued

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Universal Masking in Hospitals in the Covid-19 Era


As the SARS-CoV-2 pandemic continues to explode, MOH systems are scrambling to intensify their measures for protecting patients and health care workers from the virus. This effort should include universal use of masks by all healthcare workers. In health care settings, First and foremost, a mask is a core component of the personal protective equipment (PPE), HCWs need when caring for symptomatic patients with respiratory viral infections, in conjunction with gown, gloves, and eye protection.

Rationale for Universal Masking Guidance: 

All HCWs working in inpatient units, ambulatory unit, and procedural areas (all clinical units) will be expected to wear surgical face masks, at all times, while in their respective clinical care settings. This universal mask approach will serve to:

  1. Protect patients and HCWs from exposure to infection from asymptomatic COVID-19 infected HCW (a mask achieves source control and decreases the risk of spreading infection)
  2. Protect healthcare workers caring undiagnosed asymptomatic COVID-19 infected patients or patients have mild COVID-19 infection that have not yet been recognized.

Universal Masking Guidance:

  • A single mask can be worn across different cases and between cares of different patients.
  • When providing care to a patient with known or suspected COVID-19 the mask should be removed and wear new one after hand hygiene.
  • Masks must be changed if they become wet or contaminated during a case.
  • Surgical mask is not allowed to be worn outside the clinical care areas.
  • Surgical mask is not allowed to be hanged around the neck or kept in the pocket.
  • Personnel working in nonclinical areas where persons are reliably separated by more than 1.5 meter should not wear masks and when walking through common clinical areas where care is delivered, the mask policy applies. Stop at an entry point prior to entering the clinical area to use surgical masks .These employees should practice principles of social distancing, respiratory etiquette and frequent hand hygiene.

Process to Use and Discard Surgical Mask 

  1. A surgical face mask will be used at the start of each shift, for those individuals working in clinical care units.
  2. Masks will be available at each entrance to the unit, and will be used throughout the shift.
  3. In the event that the mask becomes visibly soiled, wet or damaged, a new mask must be used.
  4. At the end of shift, HCWs will be asked to doff their face masks as they exit the unit. 
  5. Medical waste containers will be placed at each exit for the used masks to be discarded.

Implantation of This Guideline This guideline developed to be applied on the hospital/s that have COVID-19 or any other infectious respiratory disease outbreaks, implementation of this guideline should be under the authority of Regional Command and Control Centre (CCC) with guidance of General Directorate of Infection Prevention and Control (GDIPC).


  1. Universal Masking in Hospitals in the Covid-19 Era, the New England Journal of Medicine, April 3, 2020.
  2. Rothe C, Schunk M, Sothmann P, et al.Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med 2020; 382: 970-1.
  3. Bai Y, Yao L, Wei T, et al. Presumed asymptomatic carrier transmission of COVID 19. JAMA 2020 February 21 (Epub ahead of print).
  4. Li R, Pei S, Chen B, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science 2020 March 16 (Epub ahead of print).
  5. Hoehl S, Rabenau H, Berger A, et al. Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China. N Engl J Med 2020; 382: 1278-80.
  6. Ng O-T, Marimuthu K, Chia P-Y, et al. SARS-CoV-2 infection among travelers returning from Wuhan, China. N Engl J Med. DOI: 10.1056/NEJMc2003100.

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COVID-19 Safety Guide for Hospital Healthcare Workers

The Saudi Patient Safety Center has launched the "COVID-19 Safety Guide for Hospital Healthcare Workers". The guide recommends Targeted Safe Practices to be applied in light of the Kingdom precautionary measures taken toward COVID-19. The information provided in this guide aims to assist healthcare professionals (healthcare employers/leaders, managers, healthcare practitioners, and healthcare practitioners in specialty areas) to maintain their safety as a   top priority, in addition to; recommendations about surge capacity concept in ICU.

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Continuous IV Checklist

Administering Intravenous Push Medication Through an Existing Infusion (Continuous IV)


Start hand hygiene and wear a suitable glove.


Check doctor order and review patient file for allergies.


Check medication compatibilities with current active medications.


Verify rate of administration.


Start preparing the required dose.


Verify correct patient.


Assess IV for signs and symptoms of infiltration or phlebitis (and if present, stop until new IV site is obtained).


Turn off IV by turning off pump and/or clamping the tubing directly above the access port.


Swab access port with alcohol or other antiseptic agent according to institutional policy.


If medication is not compatible with IV solution, flush IV line with 2 to 5 mL of normal saline before administration of medication. If medication is compatible with IV solution, normal saline flush is not necessary; continue to next step.


Connect medication syringe to access port via needleless adaptor.


Pull back on plunger of syringe to observe blood return (which verifies placement of IV in vein).


Gently instill medication over required time frame (typically 2 to 5 minutes).


Assess patient carefully during administration for any adverse reactions.


Disconnect syringe when medication is completed.


Flush IV line with 3 to 5 mL of normal saline, instilling at same rate of medication administration in order to administer the medication left in tubing at proper infusion rate.


Turn IV back on or unclamp tubing, then readjust rate appropriately.


Dispose of syringe in sharps container.


Remove gloves, perform hand hygiene, and document medication administration.

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The communication structure Identify, Situation, Background, Assessment and Recommendation (ISBAR) was created to standardise the effective transfer of information in the US armed forces. ISBAR was adopted by the public health service in the 2000s




Introduction (Hello Dr. my name is) 

  • Who are you?
  • Where are you?
  • Patient's name, age, gender and department


Situation (What’s this about?) 

  • I'm calling because... (describe)
  • I have observed major changes... (ABCDE)
  • I have measured the following values...
  • (RR*, Sp020, pulse/heart rhythm, BPA, capillary refill time, etc...)
  • I have received test results...


Background (Brief & pertinent info) 

If it's urgent and/or you are concerned — speak up.

Brief and relevant case history

Admission diagnosis and date

Previous illnesses of significance

Relevant problems and treatment/interventions to date



Assessment (Your analysis and consideration of options) 

  • I think the problem/reason for the patient's condition is related to (respiration, circulation, neurology).
  • I don't know what the problem is but the patient's condition has deteriorated.
  • The patient is unstable, we need to do something.
  • I am concerned.


Recommendation (What do you want the physician to do?)

I suggest.../What interventions do you recommend?

  • Immediate intervention
  • Investigation/treatment
  • How often should I...

When should I next make contact? When will you be here?

Confirm messages and interventions with a closed loop.

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Improving Patient’s Safety By Controlling The Doctor Orders For Ranged Dose Or Ranged Frequency.

Improving Patient’s Safety By Controlling The Doctor Orders For Ranged Dose Or Ranged Frequency.

Are you familiar with range orders for medications like MORPHINE 2-9MG IV Q6hr PRN at your facility? Does your hospital policy contains any restrictions on these orders?! And in case of a ranged order; how does the nurse determine the exact dose to be given and at which frequency?!

Where I work, we do allow them, and the nurse is giving all the needed training for pain assessment. We’re also using an electronic system, where prescriber must enter the required indication for each scenario. And not leaving the medication order prune to error and assumptions of the other healthcare staff.

Other hospitals might only allow one range... perhaps dose or maybe frequency! Yet, in both cases, the physicians must clearly enter the required dose range [i.e. for pain score 1-3 give 2MG, for pain scale 4-9 give 4MG …. etc.]

In some cases if the physician does not specify – the lowest dose and shortest frequency are used. A nurse must start at the lowest dose unless the patient has recently received a higher dose of the medication (or equivalent)

During the doctor's entry for the ranged order, they were using a free text field, and that doesn’t really help our clinical support system. That's why in most cases we had to verify the ranged doses manually and double checking them while dispensing and administration.

For orders with insulin doses from our insulin pumps and doses from our PCAs; ranged orders are required.

For non-pain medications, we instruct the nurse to start low and assess for effect, then proceed as necessary to address the condition.   Also have a Pain Management policy that guides the nurse to choose the pain order and dose that matches the pain score obtained from the assessment of the patient pain medication asks the prescriber to choose a Pain severity (mild, moderate or severe), all of which have scores assigned to them in the policy. For example, if the dose range is 1-2MG when mild pain, and the patient expressed the higher end of that range, then the nurse would choose 2MG.  If there are multiple products ordered, the nurse first picks the one attached to the pain score and then determines the dose which gives the nurse a guideline, but allows some flexibility in adjusting to the patient response.

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A common medical abbreviation for urgent or rush. From the Latin word statum, meaning 'immediately.'

Often used in medical contexts.

The patient's heart just stopped working.
We need a defibrillator in here stat!

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