Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Health ‫وزارة الصحة‬

East Jeddah Hospital ‫مستشفى شرق جدة‬
Nursing Administration ‫ادارة التمريض‬
Nursing Quality Department ‫قسم الجودة التمريضية‬

ESR- Q1 Round Plan

Team Members –Selected Standard –Areas Distribution
No 15/02/2022 16\02\2022 20\02\2022 21/02/2022 23\02\2022 28\02\2022 01\03\2022 02/03/2022 Action Needed
10am - 10am - 10am - 10am - 10am - 10am - 10am - 10am -
12pm 12pm 12pm 12pm 12pm 12pm 12pm 12pm
1 MMW 1. Review the standard you will assess
2 FMW 2. Do the survey for the following part :
3 MSW - Document Review.
4 FSW - Staff Interview
- Patient File Checkup.
5 PW
- HN-CN Interview
6 OB-W - Personal file checking
7 L&D - Observing
8 NICU 3. Submit the round report to HNQ
9 PICU
10 AICU
11 OR
12 DSU
13 ENDOSC
OPY
14 HBD
15 ED
16 OPD
No Name \ Date Standard will be asses
1 CI in the areas MS.7.1-MS.7.2 MS.7.3 –MS.7.4- PC.25.1 -PC.33.1-PC.5.3-PC.15.2-PC.15.1-PFR.4.1.
2 Ms. Rowena .P PC.25.2-PC.25.3-PC.25.4-PC.25.5 –PC.25.8- PC.25.9-PC.25.10
3 Ms.Eman. J -PC.26.1-QM.17- QM.18.1,2-QM.18.3
4 -QM.18.4 -QM.18.5-QM. 18.6-AN.2.1-AN.2.2-AN.2.3-
5 Mrs. Nouf AN.2.4-AN.5-AN.15.2-AN.15.3MM.41.7-MM.41.8-MM.41.10-
6 Ms.Norah. K MM.41.12-IPGS.2-IPSG.2.1-IPSG.2.2-IPGS.6-IPSG6.1-
7 Ms.Mona. S NR.5.3.12-NR.5.3.14-NR.5.3.2- -ER.9.2.8-ER.9.2.9 FMS.11.3.1
8 Ms. Areej Report the result in the link
https://docs.google.com/forms/d/1-zt70IyH4bLqvAe6KmnFQ1Atiu3NKz5NPvfPBuhIEwU/edit?
usp=sharing_eil&ts=60301cf7
Standard Arrangement

Prepared by: Approved by:

Ms. Saadiah Alhedrity Ms. Nujud Alnhdi
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 Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
East Jeddah Hospital ‫مستشفى شرق جدة‬
Nursing Administration ‫ادارة التمريض‬
Nursing Quality Department ‫قسم الجودة التمريضية‬

Patient centered care is the core of health care Leader Name: NORAH KHNBASHI

No Question And Marks - Meet –Not Meet- PARTIALLY MET

1. MM.41.12 What is the Near miss? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

2. MM.41.12 What is the sentinel event? (Staff Interview) *

Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

3. MM.41.12 What should you do if you discover sentinel event? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

4. IPSG.2 What is the process of verbal and/or telephone communication among caregivers? (Staff Interview- document review ) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

2
 Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
East Jeddah Hospital ‫مستشفى شرق جدة‬
Nursing Administration ‫ادارة التمريض‬
Nursing Quality Department ‫قسم الجودة التمريضية‬

5. IPSG.2.1 What is the process of reporting critical results of diagnostic tests? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

6. IPSG.2.2 How is the handover carried out in the hospital? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

7. IPSG.6 How does the hospital reduce the risk of patient harm resulting from falls for the inpatient population? (Staff Interview- document review) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

3
 Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
East Jeddah Hospital ‫مستشفى شرق جدة‬
Nursing Administration ‫ادارة التمريض‬
Nursing Quality Department ‫قسم الجودة التمريضية‬

8. IPSG6.1 How does the hospital reduce the risk of patient harm resulting from falls for the outpatient population? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

9. IPSG6.1 What are the effective measures used to reduce the patient harm resulting from falls among the risk patient(s)? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks
Comment

4
 Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
East Jeddah Hospital ‫مستشفى شرق جدة‬
Nursing Administration ‫ادارة التمريض‬
Nursing Quality Department ‫قسم الجودة التمريضية‬

ESR-CBAHI 3Q Round Plan.

Patient centered care is the core of health care Leader Name: MONA ALSOMALI

No Question And Marks - Meet –Not Meet- PARTIALLY MET

1. NR.5.3.12 What is the process of preventing the pressure ulcer among the risk patient(s)? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks NM PM PM NM NM PM NM
Comment

2. NR.5.3.14 How do you deal with patient on restrain? (Staff Interview) *

Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks PM NM PM PM PM M NM
Comment

3. MS.15.3.2 ICU10.2.5 How do you deal with alarming medical device(s)? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks PM NM PM PM PM M NM
Comment

1. ER.9.2.8 How do you deal with Patient(s) who leave against medical advice (DAMA)? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD

5
 Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
East Jeddah Hospital ‫مستشفى شرق جدة‬
Nursing Administration ‫ادارة التمريض‬
Nursing Quality Department ‫قسم الجودة التمريضية‬

Marks M M PM M PM M PM
Comment

2. ER.9.2.9 How do you deal with Patients who leave without being seen. (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks M M M M PM PM PM
Comment

3. FMS.11.3.1 What type of code used by the hospital to call for the children and neonates abduction. (Staff Interview) *MM.41.12 What is the sentinel
event? (Staff Interview) *
Dept. MMW FMW MSW FSW PW OBW L&D NICU PICU ICU OR DSU Endoscope HBDU ED OPD
Marks M M M M PM PM NM
Comment

6
 Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
East Jeddah Hospital ‫مستشفى شرق جدة‬
Nursing Administration ‫ادارة التمريض‬
Nursing Quality Department ‫قسم الجودة التمريضية‬

No Question
1. MS.7.1 When does EJH staff allowed to practice invasive procedure? (Staff Interview)
2. MS.7.1 When does EJH staff allowed to practice invasive procedure? (Staff Interview)
3. MS.7.1 where can EJH staff find privileges listes? (Staff Interview)
4. MS.7.2 How frequent do privileges get reviewed and updated in EJH? (Staff Interview)
5. MS.7.3 Under which circumstances does EJH grants temporary or emergency privileges ? (Staff Interview)
6. MS.7.4 For how long does EJH grants temporary or emergency privileges ? (Staff Interview)
7. MS.7.4 What about the renewal of the temporary or emergency privileges? (Staff Interview)
8. PC.25.1 What is the process of handling, use, and administration of blood and blood products at EJH? (Staff Interview) show me where is the policy
9. PC.25.2 Who is allowed to order blood? (Staff Interview)
10. PC.25.3 Who should obtain the informed consent for transfusion of blood and blood products? How frequent it should be?? (Staff Interview)
11. PC.25.3 What are the elements that should be included in the informed consent for transfusion of blood and blood products? (Staff Interview- Document review)
12. PC.25.4 How Many staff should verify the patient’s identity prior to blood drawing for cross match and prior to the administration of blood? (Staff Interview)
13. PC.25.5 What is the process of transfusion of blood/product in dire emergency? (Staff Interview)
14. PC.25.8 What should staff do during the blood transfusion? and How frequent? (Staff Interview- Document review)
15. PC.25.9 What should you do if there is Transfusion reactions ? show me where is the policy (Staff Interview)
16. PC.25.10 What should you do if there are Side effects or complications during blood transfusion? (Staff Interview- Document review)
17. PC.26.1 How do you reduce the risk of venous thromboembolism of the In-patient(s)? show me the policy (Staff Interview- Document review)
18. PC.26.1 Who should be screened for the the development of venous thromboembolism? (Staff Interview- Document review)
19. PC.26.2 Based on what the patient(s) receive prophylaxis for VTE? (Staff Interview)
20. QM.17.1, IPSG1 What are the most important patient identifier(s) in EJH? (Staff Interview)
21. QM.17.1, IPSG1 When do you identify the patient(s)? (Staff Interview)
22. QM.17.2 What is the standardized approach to patient identification at EJH? (Staff Interview)
23. QM.17.3 How do you involve the patient actively in the process of identification? (Staff Interview)
24. QM.18.1, IPSG4 How should the wrong patient, wrong site, and wrong surgery/procedure been prevented during all invasive interventions in the operating room or
other locations ? (Staff Interview)
25. QM.18.2 Tell us the process phases of preventing wrong patient, wrong site, and wrong surgery/procedure during all invasive interventions? (Staff Interview)
26. QM.18.3 What patient information data should be included in the pre-procedure verification ? where it should be documented? (Staff Interview- document review )
27. QM.18.4 When should the site marking of the surgical/procedural be done? (Staff Interview- Document review)
28. QM.18.4 Who should perform the site marking of the surgical/procedural ? (Staff Interview- Document review)
29. QM.18.5, IPSG 4.1 when should the sign in, time out and sing out be done? (Staff Interview)
30. QM. 18.6 where should the patient information data been documented? (Staff Interview- document review )
31. AN.2.1 Who should provide anesthesia services in EJH? (Staff Interview)
32. AN.2.2 Where should a qualified anesthesiologist stay throughout the operation? (Staff Interview)
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 Kingdom Of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
East Jeddah Hospital ‫مستشفى شرق جدة‬
Nursing Administration ‫ادارة التمريض‬
Nursing Quality Department ‫قسم الجودة التمريضية‬

33. AN.2.3 Who should administer and supervise anesthesia for major/specialized operations or high risk patients? (Staff Interview)
34. AN.2.4 What kind of life support certificate anesthetist should have? (Staff Interview)
35. AN.15.1 What should the physician have to provide moderate and deep sedation/analgesia? (Staff Interview)
36. AN.15.2 What kind of life support certificate should the clinical staff who participate in caring for patients receiving moderate and deep sedation/analgesia have? (Staff
Interview)
37. AN.15.3 What kind of education/training should the clinical staff who participate in caring for patients receiving moderate and deep sedation/analgesia have? (Staff
Interview)
38. MM.41.7 How do you report incident(s)? and when you should report incidents? (Staff Interview)
39. MM.41.7 Tell us what kind of incident(s) you have to report? (Staff Interview)
40. MM.41.8 what should the hospital do when there is significant or potentially significant error(s)? (Staff Interview)
41. MM.41.10 How dose the hospital utilize the reported data (incidents)? (Staff Interview)
42. MM.41.10 What should the hospital providing the health care professionals in relation to the reported data (incidents)? (Staff Interview)
43. MM.41.12 What is the Near miss? (Staff Interview)
44. MM.41.12 What is the sentinel event? (Staff Interview)
45. MM.41.12 What should you do if you discover sentinel event? (Staff Interview)
46. IPSG.2 What is the process of verbal and/or telephone communication among caregivers? (Staff Interview- document review )
47. IPSG.2.1 What is the process of reporting critical results of diagnostic tests? (Staff Interview)
48. IPSG.2.2 How is the handover carried out in the hospital? (Staff Interview)
49. IPSG.6 How does the hospital reduce the risk of patient harm resulting from falls for the inpatient population? (Staff Interview- document review)
50. IPSG6.1 How does the hospital reduce the risk of patient harm resulting from falls for the outpatient population? (Staff Interview)
51. IPSG6.1 What are the effective measures used to reduce the patient harm resulting from falls among the risk patient(s)? (Staff Interview)
52. NR.5.3.12 What is the process of preventing the pressure ulcer among the risk patient(s)? (Staff Interview)
53. NR.5.3.14 How do you deal with patient on restrain? (Staff Interview)
54. MS.15.3.2 ICU10.2.5 How do you deal with alarming medical device(s)? (Staff Interview)
55. ER.9.2.8 How do you deal with Patient(s) who leave against medical advice (DAMA)? (Staff Interview)
56. ER.9.2.9 How do you deal with Patients who leave without being seen.? (Staff Interview)
57. FMS.11.3.1 What type of code used by the hospital to call for the children and neonates abduction.? (Staff Interview)
58. PC.33.1 When do you call for rapid response team? (Staff Interview)
59. PC.5.3 How do you deal with a patient when there is language barrier? (Staff Interview)
60. PC.15.2-5 Who is privileged to admit and manage patient (s) in EJH? (Staff Interview)
61. PC.15.1 Who is responsible for the overall care rendered to that patient.(Staff Interview)
62. QM. 18.6-1 What is the symbol of site mark ?
63. PFR.4.1 what is the process described in a policy for the protection of patient belongings(Staff Interview)
64. PFR.4.1 what is the process described in a policy for the protection of patient belongings(Staff Interview)