Ambulatory Health Care Standards Saudi PDF

# Ambulatory Health Care Standards Saudi ## Central Board for Accreditation of Healthcare Institution Effective 2020 1st edition ## 1. Leadership of the Organization (LD) ### Sub Standards | No. of Sub Standards ------- | -------- LD 1.1 The governing body defines its structure and operational r...

# Ambulatory Health Care Standards Saudi ## Central Board for Accreditation of Healthcare Institution Effective 2020 1st edition ## 1. Leadership of the Organization (LD) ### Sub Standards | No. of Sub Standards ------- | -------- LD 1.1 The governing body defines its structure and operational responsibilities in a written document | 6 LD 1.2 The governing body approves and evaluates the center's quality and patient safety program and risk management program | 3 LD 1.3 The center has a current organizational chart. | 3 LD 1.4 The center is managed effectively by a qualified director. | 6 LD 1.5 The leaders together with governance develop the center's scope of services based on community needs. | 4 LD 1.6 The leaders work collaboratively to develop the center's strategic plan. | 5 LD 1.7 The leaders transform the approved strategic plan into an operational plan. | 5 LD 1.8 The leaders work collaboratively to develop the operational budget. | 2 LD 1.9 The leaders work collaboratively to fulfill the mission and provide quality care. | 4 LD 1.10 The leaders develop a staffing plan for the center. | 3 LD 1.11 The leaders develop a policy and procedure for staff recruitment. | 2 LD 1.12 All categories of staff have clearly written job descriptions. | 4 LD 1.13 The leaders develop an effective process for credentialing and recredentialing all healthcare providers. | 6 LD 1.14 All medical staff members have current delineated clinical privileges. | 4 LD 1.15 All new employees attend a mandatory orientation program. | 3 LD 1.16 The leaders develop and implement a policy that ensures nurses and other allied healthcare staff are competent in specific procedures. | 4 LD 1.17 The leaders ensure staff are trained and test competent in the safe operation of equipment including medical devices. | 3 LD 1.18 The leaders support continuing education and training for all categories of staff. | 3 LD 1.19 Staff are trained and kept up to date with cardiopulmonary resuscitation. | 3 LD 1.20 The leaders develop an effective process to evaluate staff performance at least annually. | 3 LD 1.21 The leaders implement a comprehensive program to protect the health and safety of staff. | 5 LD 1.22 The leaders support and protect the patient and family rights. | 4 LD 1.23 The leaders ensure that patients/families have the right to be involved in their own care and treatment. | 5 LD 1.24 The leaders develop and implement a policy and procedure to describe the patients' right to voice their complaints and concerns. | 4 LD 1.25 The leaders ensure that patients/families have the right to accurate billing for provided services. | 3 LD 1.26 The leaders develop ethical standards to guide patients' care and employees' code of conduct. | 4 LD 1.27 The center provides assistance to patients with special needs. | 5 LD 1.28 The center has an implemented policy for controlling the development and maintenance of key documents. | 7 LD 1.29 The leaders develop a comprehensive quality improvement and patient safety program. | 7 LD 1.30 The leaders prioritize and select a set of indicators that focus on the structure, process, and outcome of the services provided within the center. | 7 LD 1.31 The leaders develop and implement a comprehensive risk management program. | 6 LD 1.32 The leaders develop and implement an incident reporting policy. | 5 LD 1.33 The leaders oversee any contracts for clinical or operational services. | 5 LD 1.34 The leaders ensure the integrity and security of telemedicine, teleradiology and interpretation of other diagnostic remote contracted services. | 3 LD 1.35 The leaders implement policies and procedures to guide the efficient procurement of equipment either purchased or donated, medications and essential medical consumables in accordance with national laws and regulations. | 4 LD 1.36 The leaders ensure an aesthetic appeal for the center. | 4 ### 1.1. The governing body defines its structure and operational responsibilities in a written document | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.1.1 The governing body approves and periodically reviews, the center's mission, vision and values and make it public | | | | | 1.1.2 The governing body approves the center's scope of services, the center's plans, programs and all policies and procedures | (O,DR) | | | | 1.1.3 The governing body approves the center's operating and capital budgets, as well as other resources required to manage the center efficiently | (DR) | | | | 1.1.4 When the center is part of network, the governing body plans for services and functional relationships among the network components | (DR) | | | | 1.1.5 The governing body defines any approval authority delegation | (LI) | | | | 1.1.6 The governing body appoints a qualified director responsible for managing the center | (LI) | | | ### 1.2. The governing body approves and evaluates the center's quality and patient safety program and risk management program. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.2.1 The governing body annually approves the quality and patient safety program, including risk management. | | | (DR) | | 1.2.2 The governing body receives and evaluates the quality and patient safety reports, including the corrective actions and outcomes from the center, including risk management, at least quarterly. | | | (DR, LI) | | 1.2.3 Recommended corrective actions by the governance are documented and received by the center director for implementation. | | | (DR) | ### 1.3. The center has a current organizational chart. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.3.1 An approved and updated organizational chart identifies the relationship between the center's governance, leadership, and other directors with names and titles | | | (DR) | | 1.3.2 The organizational chart is communicated to all staff. | | | (SI) | | 1.3.3 The staff are aware of the organizational chart and its intent and can demonstrate their relationship to it. | | | (SI) | ### 1.4. The center is managed effectively by a qualified director | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.4.1 The center director has a written job description and his/her qualifications match the requirements in the job description | | | (LI) | | 1.4.2 The center director, with other leaders, develops the mission, vision and values statements. | | | | | 1.4.3 The center director ensures the center's compliance with all relevant laws and regulations. | | | (LI) | | 1.4.4 The center director recommends to the governing body required new policies for approval and ensures compliance with approved policies. | | | (LI) | | 1.4.5 The center director ensures the availability of adequate and proper resources for the planned services in accordance with the approved operating budget. | | |(LI) | | 1.4.6 The center director ensures a safe and functional facility environment for patients, visitors, and staff. | | | (LI) | ### 1.5. The leaders together with governance develop the center’s scope of services based on community needs. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.5.1 The scope of services includes the range of coverage in relation to preventive medicine, health promotion, curative and rehabilitative medicine. | | | (DR, LI) | | 1.5.2 The scope of services includes the specialty services that the center provides, the number of clinics for each specialty, the level of professional coverage. | | | (LI) | | 1.5.3 The scope of services includes the age group that can be served and the working hours. | | | (SI) | ### 1.6. The leaders work collaboratively to develop the center’s strategic plan. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.6.1 The strategic plan is guided by the mission, vision and inputs from patients/service users, their families, staff and where possible the wider community. | | |(DR) | | 1.6.2 The strategic plan is based on a comprehensive evaluation of the internal and external environmental factors. | | | (LI) | | 1.6.3 The strategic plan addresses all clinical and non-clinical services and programs. | | | (SI)| | 1.6.4 The strategic plan spans a period of three to five years and is reviewed on a regular basis.| | | (LI) | | 1.6.5 The strategic plan includes the broad goals and objectives required to fulfill the center's mission. | | | (LI) | ### 1.7. The leaders transform the approved strategic plan into an operational plan. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.7.1 Goals and objectives are translated into operational plans with defined projects, clearly delineated responsibilities, required resources and time frames. | | | (DR) | | 1.7.2 Governance approves the resources required for executing the operational plans. | | | | | 1.7.3 Operational plans are implemented and closely monitored for progress by structure and process indicators. | | | | | 1.7.4 The plans are communicated to department directors and other staff. | | | (DR, LI) | | 1.7.5 Department directors develop annual departmental plans in alignment with the center’s strategic plan. | | | (SI) | ### 1.8. The leaders work collaboratively to develop the operational budget. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.8.1 The leaders plan and budget for the upgrade or replacement of buildings, equipment, and other resources. | | | (DR, LI) | | 1.8.2 The budget process allocates resources to all patient care units based on the scope of care and complexity of patient care must ensure a safe and effective facility. | | | (O, SI) | ### 1.9. The leaders work collaboratively to fulfill the mission and provide quality care. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.9.1 The leaders communicate the mission, vision and values to all staff and customers. | | | (SI) | | 1.9.2 The leaders ensure the use of evidence-based and best practice information to develop and improve the center’s services. | | | (O, SI) | | 1.9.3 The leaders work collaboratively to develop and carry out plans, policies, and procedures. | | | (SI)| | 1.9.4 The leaders meet regularly to review the key performance indicators of services, survey, audits and feedback and use the collected data to improve the center’s operations. | | | (SI,LI) | ### 1.10. The leaders develop a staffing plan for the center. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.10.1 The staffing plan ensures that services meet the needs of safe patient care. | | | (DR) | | 1.10.2 The staffing plan defines the number, type, and credentials of required staff, and their roles.| | | (SI,DR) | | 1.10.3 The center recruits and assigns appropriately qualified staff in accordance with the staffing plan. | | | (PF) | ### 1.11. The leaders develop a policy and procedure for staff recruitment. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.11.1 The policy and procedure highlight the receiving authority(s) of staff resumes, the short listing process, and the accepted method for interview. | | | (DR) | | 1.11.2 Applicants are informed of their acceptance or refusal within a set time frame. | | | (DR) | ### 1.12. All categories of staff have clearly written job descriptions. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.12.1 The job description outlines the knowledge, skills, and attitude necessary to perform the job responsibilities. | | | (DR)| | 1.12.2 The job description clearly defines roles and responsibilities for the position. | | | (DR) | | 1.12.3 Job responsibilities and clinical work assignments are based on evaluation of staff credentials. | | | (PF) | | 1.12.4 The job description is discussed with and signed by the employee upon his/her hiring and is located in his/her personnel file. | | | (PF) | ### 1.13. The leaders develop an effective process for credentialing and recredentialing all healthcare providers. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.13.1 The credentialing process applies to all clinical staff members: medical staff, nursing staff, and other clinical staff licensed to provide patient care. | | |(DR) | | 1.13.2 The credentialing process includes gathering, verifying, and evaluating credentials including license, education, training, experience and competence. | | | (PF)| | 1.13.3 To the extent possible, the credentials are verified from the original source directly or through a third party with documented evidence. | | | (PF) | | 1.13.4 The center ensures the registration of healthcare professionals with the Saudi Commission for Health Specialties and licensing by the Ministry of Health in accordance with laws and regulations. | | | (PF) | | 1.13.5 The credentialing process guides the appointment of healthcare staff to their appropriate job assignment and is repeated every two (2) years to ensure that staff are still capable of performing their job functions. | | | (SI, PF) | | 1.13.6 Information about staff credentials, privileges, competencies, orientation, training, education, and evaluation are kept securely in an updated personnel file. | | | (PF) | ### 1.14. All medical staff members have current delineated clinical privileges. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.14.1 The center has a policy and procedure for granting privileges to medical staff. | | |(DR) | | 1.14.2 Clinical privileges are determined based on the center’s documented competency and available services. | | | (SI) | | 1.14.3 The medical staff's clinical privileges are recommended by the medical director and approved by the governing body, either directly or by appropriate delegation. | | | (PF) | | 1.14.4 The clinical privileges are reviewed and updated every two (2) years, and earlier if needed. | | | (SI) | ### 1.15. All new employees attend a mandatory orientation program. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.15.1 The new employees' general orientation program includes information about the center's mission, vision, values, and organizational structure; patient and family rights; safety and security; the basics of infection control; and an introduction to the center's quality and patient safety and risk management programs. | | | (DR) | | 1.15.2 Each new employee attends a department-specific orientation program, including specific infection prevention and safety issues, that helps in executing the specific job responsibilities as outlined in the job description. | | | (SI) | | 1.15.3 The new employee orientation is documented in the employee's personnel file. | | | (PF) | ### 1.16. The leaders develop and implement a policy that ensures nurses and other allied healthcare staff are competent in specific procedures. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.16.1 The policy contains a list of procedures requiring competency assessment in each and every staff category. | | | (DR) | | 1.16.2 All newly hired staff are initially tested for the required competencies. | | | (SI, PF) | | 1.16.3 All staff are tested annually for the required competencies. | | | (SI) | | 1.16.4 All test results are available in staff personal files. | | | (PF) | ### 1.17. The leaders ensure staff are trained and test competent in the safe operation of equipment including medical devices. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.17.1 A policy is in place to ensure staff are trained on the safe operation of the current and newly introduced equipment and medical devices. | | | (DR) | | 1.17.2 The policy addresses the required training and competency testing of staff operating specialized equipment.| | | (SI, PF) | | 1.17.3 Only trained and competent staff handle specialized equipment and medical devices. | | | (O, SI) | ### 1.18. The leaders support continuing education and training for all categories of staff. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.18.1 The center has a scheduled educational and training program based on the center's needs and person-centred care including quality, patient safety, risk management and infection control practices. | | | (SI, DR) | | 1.18.2 The leaders grant financial support and/or time off for staff to attend educational and training activities relevant to the center's scope of services and in line with labor law. | | | (SI) | | 1.18.3 Employees' records show documented evidence of training and education. | | | | ### 1.19. Staff are trained and kept up to date with cardiopulmonary resuscitation. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.19.1 All staff members who provide direct patient care receive training on basic life support (BCLS). | | | (SI, PF) | | 1.19.2 The center identifies other staff members to be trained in advanced life support as appropriate to the age groups they serve (ACLS, PALS, NRP). | | | (SI, PF) | | 1.19.3 All staff maintain the validity of their life support certification. | | | (PF) | ### 1.20. The leaders develop an effective process to evaluate staff performance at least annually. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.20.1 The performance evaluation is based on objective criteria and is consistent with the expected competencies such as knowledge, skills and attitude required to perform the employee's job responsibilities as outlined in his/ her job description. | | | (SI, DR) | | 1.20.2 The evaluation is done at the end of the initial probationary period and annually thereafter | | | (PF) | | 1.20.3 Staff are involved in the evaluation of their performance by commenting on the required corrective action. | | | (SI)| | 1.20.4 Evaluations include personal goals to achieve for the next year that the employee will carry out. | | | (SI) | | 1.20.5 Both the employee and his/her supervisor sign the performance evaluation, which is kept in the employee's personnel file. | | | (PF)| ### 1.21. The leaders implement a comprehensive program to protect the health and safety of staff. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.21.1 The program covers all employees and is consistent with laws and regulations. | | | (DR) | | 1.21.2 The program is based on the protection of staff from occupational health and safety hazards and violence in the workplace. | | | (SI) | | 1.21.3 The program is coordinated with the center's quality, safety, risk management, and infection control programs, including health screening, immunization, and post exposure management. | | | (O, SI) | | 1.21.4 Staff have confidential and secure medical records that reflect their health status. | | | (MR) | ### 1.22. The leaders support and protect the patient and family rights. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.22.1 The leaders develop and maintain a patient rights and responsibilities statement and develop processes that support their implementation. | | | (0) | | 1.22.2 The leaders ensure that patient rights and responsibilities are available to patients and families and ensure patients are informed about their rights and responsibilities in a manner they can understand. | | | | | 1.22.3 The leaders ensure that patients' dignity, privacy and confidentiality are respected. | | | (SI) | | 1.22.4 The leaders ensure that staff are provided training and education on patient and family rights and responsibilities. | | | (0, PF) | ### 1.23. The leaders ensure that patients/families have the right to be involved in their own care and treatment. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.23.1 Patients/families have the right to be informed of their illness, the proposed treatment and its prognosis. | | | (DR) | | 1.23.2 Patients/families have the right to be involved in the decision making of their care plans. | | | (MR) | | 1.23.3 Patients/families have the right to professional assessment and management of pain. | | | (MR) | | 1.23.4 Patients/families have the right to refuse or discontinue treatment or ask for a second opinion. | | | (MR) | | 1.23.5 Patients/families have the right to request a detailed medical report and sick leave notification. | | | (MR) | ### 1.24. The leaders develop and implement a policy and procedure to describe the patients’ right to voice their complaints and concerns. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.24.1 Patients' complaints are resolved in a time frame described in the policy. | | | (DR, SI) | | 1.24.2 The center assigns a staff member responsible for managing complaints | | | (SI) | | 1.24.3 Patient satisfaction surveys are conducted at least quarterly | | | (DR, SI) | | 1.24.4 Data collected from surveys and complaints are analyzed and trended, and the information collected is used for improvement and integrated into the quality and safety program. | | | (SI) | ### 1.25. The leaders ensure that patients/families have the right to accurate billing for provided services. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.25.1 The leaders ensure the availability of the price list for services provided to patients and their sponsors. | | | (DR)| | 1.25.2 The patients and families have the right to receive an initial estimated cost of required services. | | | (0) | | 1.25.3 The patients and families have the right to obtain an invoice for services rendered. | | | (0) | ### 1.26. The leaders develop ethical standards to guide patients' care and employees' code of conduct. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.26.1 Marketing for staff and services, if performed, is carried out ethically as per laws and regulations. | | | (SI) | | 1.26.2 The leaders develop a set of values and a professional code of conduct for all employees. | | | (SI, DR) | | 1.26.3 The leaders ensure that patients and their families are fully informed and protected when they are involved in clinical research projects. | | | (DR) | | 1.26.4 The leaders develop a process to receive and resolve ethical dilemmas, patient and non-patient related in a reasonable timeframe as determined by the center. | | | (DR) | ### 1.27. The center provides assistance to patients with special needs. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.27.1 Dedicated street parking and drop-off points are available. | | | (0) | | 1.27.2 Handrails for staircases are constructed. | | | (0) | | 1.27.3 Ramps for elevated areas are available. | | | (0) | | 1.27.4 The center’s entrance allows wheelchair access and elevators have wheelchair access doors. | | | (0) | | 1.27.5 Wheelchair-accessible toilets are available. | | | (0) | ### 1.28. The center has an implemented policy for controlling the development and maintenance of key documents. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.28.1 The center has a unique identification for each key document, with title, number, date of issue, and date of revision. | | | (DR) | | 1.28.2 Key documents are developed, approved, revised, and terminated by an authorized individual. | | | (DR)| | 1.28.3 Key documents are dated and current. | | | (DR) | | 1.28.4 Key documents are revised according to a defined revision due date. | | | (DR) | | 1.28.5 Key documents are communicated to relevant staff and are always accessible. | | | (SI) | | 1.28.6 A process is in place to ensure that key documents are always implemented. | | | (0)| | 1.28.7 A process is in place to ensure that only the last updated versions of key documents are available for use in the center. | | | (0) | ### 1.29. The center develops a comprehensive quality improvement and patient safety program. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.29.1 The leaders develop the program collaboratively. | | | (LI) | | 1.29.2 The program utilizes key performance indicators, and patient and staff surveys to measure performance and improve clinical and managerial areas. | | | (SI, LI) | | 1.29.3 The information generated is readily accessible on a timely basis to those responsible for and/or involved in the delivery of the services, and is utilized for making improvements and supporting the leaders' decision making. | | | (PF) | | 1.29.4 The program utilizes an evidence-based quality improvement method such as "FOCUS - PDCA." | | | (SI) | | 1.29.5 The center implements at least one improvement project per year. | | | (O, SI) | ### 1.30. The leaders prioritize and select a set of indicators that focus on the structure, process, and outcome of the services provided within the center. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.30.1 The selection process is based on the center's important processes and priorities. | | | (L) | | 1.30.2 Each indicator has an operational definition, data collection method, frequency for collection, analysis by qualified staff, mathematical expression such as a ratio, with a defined numerator and denominator or a percentage and a desirable target. | | | (SI, DR) | | 1.30.3 Structure indicators may include, but not be limited to the following: availability of essential supplies and equipment, availability of medical records, availability of emergency medications, surgical volume, and staff ratios. | | | (O, DR) | | 1.30.4 Process indicators may include, but not be limited to the following: waiting time, documentation in medical records, site marking, and time out processes. | | | (O, DR) | | 1.30.5 Outcome indicators may include, but not be limited to the following: Patient and staff satisfaction, patient's complaints, health-care-associated infections, medication errors, sentinel events and various adverse events. | | | (O, DR) | | 1.30.6 The performance monitoring results are discussed with staff, utilized in their evaluation, and reported quarterly to the governance together with action plans taken for improvement. | | | (SI) | | 1.30.7 The indicators are compared internally by historical trends and externally by benchmarking to other similar centers when available. | | | | ### 1.31. The leaders develop and implement a comprehensive risk management program. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.31.1 The program addresses clinical, managerial and financial risk. | | | (DR) | | 1.31.2 The reporting of incidents and variances, patients' morbidities, and clinical and financial claims constitute the program's essential reactive arm. | | | (DR)| | 1.31.3 The center develops and implements at least one proactive risk management approach per year. | | | (SI) | | 1.31.4 The center develops and periodically updates a risk register for all potential clinical, managerial, and financial processes in the center. | | | (0) | | 1.31.5 The center utilizes an evidence-based process for grading risks based on severity, frequency, and/or likelihood of occurrence. | | | (0) | | 1.31.6 Information from the risk management program, including incidents, analysis, and improvement projects, is communicated to staff and the governing body at least quarterly. | | | (SI, DR) | ### 1.32. The leaders develop and implement an incident reporting policy. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.32.1 The policy outlines the types of incidents to be reported internally and to relevant regulatory authorities and the time frame and mechanism for reporting. | | | (SI, DR) | | 1.32.2 The center utilizes a risk scoring matrix to categorize the severity of incidences. | | | (0) | | 1.32.3 Incidences, including near misses, involving patients are documented in the medical record and patient and family are informed by the physician of any investigation results. | | | (SI, DR) | | 1.32.4 The center compiles a report on incidences according to type and severity, and an action plan to prevent its recurrence is distributed to staff and governance at least quarterly | | | (MR) | | 1.32.5 Sentinel events and severe near miss incidents are reported and investigated and findings utilized to prevent recurrence. | | | (DR) | ### 1.33. The leaders oversee any contracts for clinical or operational services. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.33.1 Contracted entities are selected based on evidence-based criteria that the relevant department develops | | | (DR) | | 1.33.2 The center director ensures relevant leaders' recommendations and approvals on contracts | | | (DR) | | 1.33.3 The leaders ensure that the contracted entity and services provided meet applicable laws and regulations | | | (LI) | | 1.33.4 The leaders ensure that the services provided are integrated into the overall quality and patient safety program | | | (LI) | | 1.33.5 The leaders regularly monitor and document the compliance of contract services with the appropriate standards and take documented corrective actions for improvement when standards are not met | | | (DR, LI) | ### 1.34. The leaders ensure the integrity and security of telemedicine, teleradiology and interpretation of other diagnostic remote contracted services. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.34.1 Telemedicine, teleradiology and interpretation of other diagnostic remote contracted services are registered with Ministry of Health. | | | (DR) | | 1.34.2 The leaders ensure the credentialing and privileging of the physicians involved before starting the service. | | | (PF) | | 1.34.3 The leaders ensure the security and confidentiality of patient information that may be exposed as a result of the telecommunication process. | | | (0) | ### 1.35. The leaders implement policies and procedures to guide the efficient procurement of equipment either purchased or donated, medications and essential medical consumables in accordance with national laws and regulations. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.35.1 Leaders ensure that all medical devices and supplies contractors and suppliers have a Medical Device Establishment License (MDEL). | | | (DR) | | 1.35.2 Leaders ensure that all newly purchased medical devices have a Medical Device Marketing Authorization (MDMA) certificate. | | | (DR) | | 1.35.3 Leaders approve newly introduced consumables based on a formal testing and feedback process from end users. | | | (DR) | ### 1.36. The leaders ensure an aesthetic appeal for the center. | Sub Standards | Value | Percent | Evaluation | | -------- | -------- | -------- | -------- | | 1.36.1 The center is clean and tidy at all times. | | | (0) | | 1.36.2 The center is free of broken furniture, scratched and distorted walls. | | | (0) | | 1.36.3 The ambient temperature is maintained between 20 - 24.4 Celsius. | | | (0)| | 1.36.4 Nonirritant air freshener is used to control unwanted odor in the center. | | | (0) |