Ref.

Requirement Criteria
Fulfillment
Policy Section Measurable Elements:
1. Organization Management
a. Human Resources
Governance Structure
HR001 The healthcare provider’s governance Healthcare 48 Evidence: Approved and well constructed Human Resources Policy manual is
structure is described in written documents. Provider available and accessible to all staff that covers planning and internal control of
Policy manpower operation and governance responsibilities and accountabilities.
Manual
HR002 There is a current approved organization Healthcare 49.4 Evidence: There is a current approved organization chart showing the job titles, the
chart. Provider units functions and communication channels.
Policy
Manual

Organization Ethics
The healthcare provider maintains the Healthcare Evidence: There is a well constructed and approved policy on ethics and code of
highest ethical standards and ensures that Provider conduct acknowledged by the staff.
every member of their staff behaves at all Policy
times with courtesy, respect, dignity and Manual
HR003 37.4
discretion in their
dealings with Patients.

Orientation Programme
All staff should receive training on relevant Healthcare Evidence: 1. basic orientation to the Facility at which he will be located.2.
rules and regulations and traditional culture Provider orientation on value diversity and acceptable norms and cultural issues in the UAE.
and compliance. Policy 3. training in the policies, plans and procedures of the Provider which are relevant
Manual to his role. 4. training in the quality management, patient safety and infection
HR005 81.2.2 control systems that apply to the Facility. 5. training in the HAAD regulations,
policies and standards that are relevant to his role.

Personnel Files

Each Healthcare Provider must maintain
current organized and standardized
HR007
personnel files in a secured environment for
all members of its staff.
Evidence: The retention period of these files is at least two years following
employee's leaving. Permanent disposal of personnel files can be made five years
following employee's leaving or department. Each file should include: 1. copy of
license and current assigned privileges. 2.Copy of staff resume/work history. 3.
Copy of certifications and qualifications. 4. Specific Job description signed by the
Healthcare
employee and management. 5. Results of recruitment and performance evaluation.
Provider
80.1/80.2 6. Record of any disciplinary action against the staff. 7. Record of in- service
Policy
education or any other education or training received. 8. Signed confidentiality
Manual
letter/agreement by the staff and management.
HR Performance Measures
The performance evaluation of clinical staff Healthcare Evidence: There is a well defined competency framework and checklists and
include an assessment of their ongoing Provider performance evaluation policy conducted on an annual basis.
HR008 clinical competence. Policy 84.2.2
Manual

Comments: No Comment.
b. Quality Management
Each Healthcare Provider must meet all relevant Patient Safety Goals as set out in the HAAD
Standard for Patient Safety Goals.
1- Each service has a well documented policies and guidelines to ensure the quality and
patient safety. Evidence and Document Review: There are policies and guidelines assigned
for each service and staff are implementing them.
2- Clinical audit programs are initiated to identified risk processes and actions are taken to
resolve audit concerns. Evidence and Document Review: There is a clear policy on clinical
audit and associated forms and audit reports and action plans are completed for identified
risk processes.
3- Re-audits are performed to evaluate the impact of corrective actions. Evidence and
Document Review: Re-audit reports are available and findings are analysed and actioned.
4- Technology is used to generate electronic reliable reports. Evidence and Document
Review: The data used for quality and performance evaluation reports and are generated
from the Health Information System.
5- The leadership have identified quality performance indicators for monitoring and they
are valid, evidence-based, and the purpose of each indicator is well defined and
understood. Data can be traced to the source and is signed off by the owner. Evidence and
Ensure there are assurances in place at all levels Policy/Quality 4.1 Document Review: There is an approved clear KPI Defnitions to ensure consistency and
and Patient
to drive health quality and patient safety Objective 1 reliability and includes KPI title, Description, Rationale, Target, Calculation, Data Sources,
Safety/V1.0
Data Collection Frequency, Inclusion/Exclusion Criteria, International Benchmark, KPI
Reporting Frequency, Evidence-based Reference.

QM001

Ensure a robust governance structure is in place Policy/Quality
with clear roles and responsibilities, protocols and Patient
and escalation procedures for high-quality care Safety/V1.0
and patient safety throughout the organization
QM002
1- Roles and responsibilities are clearly defined throughout the organization. Evidence and
Document Review: Each staff member have a clear understanding of their role in achieving
quality whether in their service unit, teams, or committees and this can be chacked by staff
interview and if in doubt, check written documentation.
2- There is an organization-wide committee structure with defined terms of reference and
are active. Evidence and Document Review: Approved committee structure organizational
chart showing the reporting relationship of the committees. Terms of reference include
purpose, objective, membership, Attendance, Quorum, Declaration of Conflict of Interest,
Dutieis and Responsibilities, Reporting Relationship, Authority, Distribution of
minutes.Current minutes of meetings should be availalbe and signed by members and
chairman.
3- There is a clear structures cascading responsibilities such as chain of command policy,
delegation of authority. Evidence and Document Review: Delegation of staff, Staff Decision-
making, Limits on Delegated Authority, Delegation Matrix/Schedule.
4- Quality and patient safety are a standing agenda item in executive management
committees and relevant sub-committees. Evidence and Document Review: Committee
Agendas
4.1 5-There are defined and clear processes for escalating and resolving issues and for quality
Objective 1 performance management and patient safety issues such as reporting errors and
whistleblower. Evidence and Document Review: There is a clear, widely understood
incident reporting policy. There is a whistleblower policy to encourage staff to speak up
and includes concers to be raised, identity confidentiality, process of reporting concerns,
communication process, investigation, review and feedback, and lessons learnt.
 Evidence and Document Review:
1- There is a policy on risk management policy and approach to risk management.
2- There is an up-to-date risk register submitted by all services/units addressing current
and future risks to quality and patient safety.
3- Front-line staff are raising concerns when quality and patient safety is compromised.
These concerns are studied and actioned.
4- All staff are aware of the clinical risk registers through training programs on risk
management and escalation processes.
5- Risk-based internal audit is conducted proactively to assess critical systems.
Policy/Quality 4.1 6- There is a robust system for capturing errors and near misses fostering a just culture
QM003 Have in place programs for Risk Management and Patient 7- There is a clear, defined policy and for adverse and sentinel events including internal
Objective 1
Safety/V1.0 and external reporting/investigation requirement and associated forms.

QM004 1- Improve accuracy of Patient identification. Policy/Quality 4.1 Evidence and Document Review: Policy should address availablity of two patient identifiers
and Patient Objective 1 when administering medication, blood/blood components, collecting samples, treatments,
Safety/V1.0 and procedures. The policy includes the process for minors and disabled patients, and
process of lost patient ID band.

2- Improve effectiveness of communication Policy/Quality 4.1 Evidence and Document Review: a- Policy on reporting critical results should include list
among care givers. and Patient Objective 1 defintion or critical results and acceptable length of reporting from the time of results
Safety/V1.0 release. the reporting mechanism should be clearly stated. b- Handover is the transfer of
professional responsiblitiy and accountability. The policy should be clear and should
address the process in every transition of patient care and involvement of patients in the
process. ISBAR and other tools should be used for this process. Evidence of
implementation should be available and documented. c- Verbal orders policy to define
QM005 when the process is acceptable such as emergency situations. The policy should describe
the process and the time frame to authenticare verbal orders.

3- Improve the safety of using medications and Policy/Quality 4.1 Evidence and Document Review: The organization has a process to prevents errors in
medical devices. and Patient Objective 1 administration of concentrated electrolytes and there are not present in patient care nits
Safety/V1.0 areas only when clinically necessary. The organization has a list of all high-alert
medications, including look-alike/sound-alike medications and has strategies to improve
QM006 medication safety including storage, prescribing, preparation, administration, or
monitoring processes. unlabeled medication are discarded immediately.
 4-Ensuring correct site, correct procedure, Policy/Quality 4.1 Evidence and Document Review: There is a preprocedure process for correct patient and
correct patient for all procedures . and Patient Objective 1 correct site involving the patient when possible.The full surgical team conducts and
Safety/V1.0 documents a time- out procedure in the area in which the surgery/invasive procedure will
QM007 be performed, just before starting a surgical/invasive procedure.

Policy/Quality 4.1 Evidence and Document Review: The organization consistently prmotes hand hygiene
and Patient Objective 1 practices to patients and healthcare providers. There is a program to monitor hand
Safety/V1.0 hygiene compliance including audits, collecting and reporting data, and maintenance of
5-Reducing the risk of healthcare associated
QM008 the knowledge of healthcare providers in hand hygience techniques.
infections.

QM009 6- Reducing risk of patient harm resulting from Policy/Quality 4.1 Evidence and Document Review: There is a policy and system for patient assessment and
falls. and Patient Objective 1 locations assessment for fall risks. Actions are taken to reduce risks such as set up of
Safety/V1.0 inpatient bathrooms, Placing signs for patients at fall risk. Patient falls are reported and
actions are taken.

QM010 7- Accurately and completely reconcile Policy/Quality 4.1 Evidence and Document Review: There is a system to obtain information on the
medications across the continuum of care. and Patient Objective 1 medication the patient is currently taking before admission or in the outpatient settings.
Safety/V1.0 This is documented to be useful for those who manage medications.

8- Encourage patients active involvement in
their own care as a patient safety strategy.
QM011
Policy/Quality 4.1 Evidence and Document Review: The organization develops a patient-focused strategies to
and Patient Objective 1 reduce diagnostic errors, and improve the safety and quality. Doctors and nurses offer
Safety/V1.0 encouragement and enforcement to patients to be actively involved in their care and take
a more proactive role in their own care and safety by empowerng patients to speak up and
be active in taking part in making decisions in the care provided to them. Evidence would
be brochures, and campaigns, educational vidoes available to patients.

Have in place programs for Quality Improvement Policy/Quality 4.1 Evidence and Document Review: There are defined performance indicators to monitor the
and Patient Safety and Patient Objective 1 implementation of patient safety goals and clinical effectiveness. These are analyzed and
Safety/V1.0 improvement actions are taken. Performance metrics are compared with well defined
QM012 targets based on historic own performance or external benchmarks.

2.0 Quality and Patient Safety Culture

 Utilize processes in order to strengthen quality
and patient safety, improve patient and staff
awareness and education to inform service
improvement plans
QM013
Policy/Quality 4.2 Evidence and Document Review:
and Patient Objective 5 1-The leadership is involved actively in the quality improvement program and takes pro-
Safety/V1.0 active approach such as applying lessons learnt from other organizations.
2-The leadership assigns resources for quality initiatives such as money, time, and
dedicated staff.
3-The leadership encourage staff to participate in quality programs and fosters no blame
and just culture to empower staff to report on errors.
4-There is regular internal communication to all staff on quality initiatives.

3.0 Quality Governance Systems Structures and

Ensure health professionals utilized evidence- Policy/Quality 4.1 Evidence and Document Review:
based practice and maintain their knowledge and Patient Objective 1 There is evidence that the organization is using evidence-based standards and protocols in
QM014 and skills to maximize patient safety and patient Safety/V1.0 their practice such as policies, guidelines, pathways, performance measures, etc.
outcomes

5.0 Patient Centered Care

Evidence and Document Review:
1- There is a patient-centered culture that all caregivers are considered care givers from
the housekeeper to the CEO.
2- Policies and procedures that support the involvement of patients in their own care.
Strengthen patient-centered care, transparency Policy/Quality 4.1 3- Documentation of discussion and care givers on care plan and patient preferences
QM015 and Patient including self-management of their condition available in patient's chart.
and patient choice Objective 1
Safety/V1.0

Comments: No Comment.

c. Complaint Management
Each complainant has been offered at least a Complaints HAAD/CMH Evidence and Document Review:
meeting to communicate findings of the Management F/SD/1.2 The complaint policy should contain the process of offering at least a meeting to
investigation and that all communications are in Healthcare communicate findings of the investigation.
CM001 documented. Facilities

Complaint process is in place and widely Complaints Evidence and Document Review:
published, using as a minimum Arabic and Management There are posters to illustrate the complaint management process in both languages and
English languages, and be mounted at visible in Healthcare including the timeframes of acknowledgement and resolution and the option of contacting
sites within the facility. Facilities HAAD if the complainant was still not satisfied with the resolution provided by the facility.
HAAD/CMH The poster should include the contact number and email address. Also there should be
F/SD/1.2 complaint boxes clearly labelled and complaint forms visible to patients in main entrances
of the facility.

CM002
 A process in place to refer complainants to Complaints HAAD/CMH Evidence and Document Review:
HAAD Complaints Management process when a Management F/SD/1.2 This should be evident in posters and also included in the complaint management policy.
complainant is not satisfied with the provided in Healthcare
CM003 resolution. Facilities

The Healthcare provider has a governance and Complaints
oversight body/structure responsible for Management
reviewing, investigating and recommending in Healthcare
actions and reporting on complaints Facilities
management, with roles and responsibilities of
the governing body clearly identified.
Evidence and Document Review:
Complaint analysis reports should be discussed regularly at a governing body such as
quality council committee or management committees and action plans should be
prepared, implemented and re-evaluated. The complaint management policy should
HAAD/CMH reflect this process. This should be also evident in committee minutes and available
F/SD/1.2 complaint analyses and action plans

CM004
Comments: No Comment.

2. Medical Requirements
(The facility should comply with local and federal law, rules, regulations
and the audit may not be limited only to this audit tools)

a. Clinical Practice
Process in place to list the privileges that the Two different layers of privileges can be seen
Practitioner is allowed to do
One is the full professional list that is available in the practitioner’s personal file in
HR section,we can ask for a copy of the practitioner and check in patients’ files if
HAAD Circular No.
(CEO any practice done which is not listed.
Standard for
CP001 Clinical 40/10) The other level of the privileges is that we are asking to be posted under the name
Privileging PHP/POS/FA and specialty of the practitioner for the public to raise the public awareness and
Framework CL/Pr/V0.9 this should be in general not in details just to be known to the public that the
internist for example is doing consultations in internal medicine for adults (13 years
old and above)
The facility delivers services that fall within the Healthcare Scope of services for example are:
approved boundaries of the scope of Provider Healthcare General medicine, orthopedic, ENT, dermatology, pediatric…..etc.
professional and facility licensing Policy Manual Professions Any other practice not related to the scope of practice of the facility needs to be
and the questioned.
CP002 Scope of
Practice
10.2
 The health care providers are working according Federal Law
to their professional license No. (10) of
2008 In Chapter One
respect of Medical
Medical liability
Liability Roles and
CP003 Healthcare Responsibili
Provider To observe or detect any clinical practice not listed in the practitioner’s privileges.
ties
Policy Article (2),
Manual (3), (4)
7

Staff members posses relevant professional HAAD Standard 2.

certificate(s) and competence(ies) required to Standard for Inpatient
perform Basic Life Support and/or ACLS, ATLS, Minimum and
and PALS as applicable Preparedness Outpatient
for Common Healthcare
Medical Facility
Emergencies Service
In Inpatient Requireme
Care Setting, nts
Outpatient 8.2.1
Care Setting,
Ambulance
Services and
Interfacility
CP004 Patient ask to see the certificate
Transfer
 Clinical practice guidelines relevant to the
practitioner specialty should be complete and
implemented in accordance with the recognized
scientific and technical principles to provide the
necessary care for patients.
CP005
HEALTHCARE The availability of updated international clinical practice guidelines to be checked
PROFESSIONA with the practitioners while checking some patients’ files assessments.
LS Examples:
POLICY
MANUAL 1. Evaluation of patients with acute flank pain; Following initial US assessment,
Federal Law NCCT has become the standard for diagnosing acute flank pain, and has replaced
No. (10) of intravenous urography (IVU).
2008 In 2. Asymptomatic pregnant with positive ANA with a PH of recurrent miscarriage,
respect of low dose Aspirin is recommended..
Medical 3. Wide excision of primary tumors with safety margins of 0.5 cm for in situ
Liability melanomas, 1 cm for tumors with a thickness of up to 2 mm, and 2 cm for thicker
tumors
4. Children (ages two to five) developed serious adverse effects or died after taking
codeine for pain relief after tonsillectomy and/or adenoidectomy
5. Oral antibiotics may have significant adverse effects and do not provide
2.5.1, 3.5.2 demonstrable benefit after tonsillectomy. Avoidance of oral antibiotics can reduce
Article (3) the spread of antibiotic resistance and the risk of opportunistic infections.
6. Endocarditis prophylaxis the indication for antibiotic prophylaxis has been
significantly reduced in the recent guidelines. Antibiotic prophylaxis should be
considered for high- risk procedures in high-risk patients.
In addition, we can ask the practitioner to give an example on what changes done
on his/her usual practice after using the updated clinical guidelines.

Patients are identified accurately with atleast Internation

two identifiers before receiving treatment, al Patient
performing procedure(s), administering Safety
medications, blood or blood products and taking Goals
samples High Risk
Care
Ambulatory Processes
CP006 Care Practically look for the evidences that patient has been identified according to their
(HRC) PCQ.1 policies and procedures.
Standards HRC.34
 The Patients ,family and decision maker are Ambulatory Communica
educated on the risk, benefits, treatment, Care tion (CCC)
potential complication and alternatives related Standards High Risk
to the plan medical and surgical procedures. Care
Processes
(HRC)
CP007 CCC.27 ask the patients, Interviewing the patient
HRC.21
HRC.25

Ambulatory HRC.1, Personal space: Patients may feel that their personal space has been breached
Care CCC.16 when staff move patients’ belongings around without discussion or when staff enter
Standards Article (5) closed curtains or doors without asking.
Federal Law
No. In a facility setting, health care workers should close doors or fully draw bedside
(10) of 2008 In curtains when privacy is needed.
respect of Privacy of the body: People undergoing healthcare are at risk of bodily exposure as
Medical they often need to undress for procedures or examinations and need help with
Liability personal care. Examples of privacy breaches are: bedside curtains which are not
fully closed when patients are exposed, removal of clothing without discussion or
consent, or providing clothing that does not cover patients’ bodies adequately, e.g.
the gowns that do not close fully at the back
When a patient’s body is exposed for a procedure or examination, only the
minimum clothing should be removed, ensuring that the rest of their body is
covered, by bed linen or clothing. Some patients will not wish to expose their
bodies to staff of the opposite sex; religious beliefs may influence individual views
about modesty. Health care workers should behave sensitively and respect
Patient’s privacy and confidentiality are people’s wishes.
CP008 maintained Privacy of information: confidentiality: Respecting confidentiality relates to all staff.
Any sharing of information must be legitimate; "For the purposes of direct care,
relevant personal confidential data should be shared among the registered and
regulated health and social care professionals who have a legitimate relationship
with the individual”
It happened during an audit when a doctor received a call from a husband of a
patient asking for the results of tests done to his wife and the he informed him
everything about the case, I asked to check the medical record for this patient and I
asked if she came with her husband then I found that she came with her sister only
and the husband was not accompanying her …
 Each patient’s initial assessment(s) include an Ambulatory High Risk
evaluation of physical, nutritional, psychological, Care Care
social, and economic factors and each complete Standards Processes
CP009 assessment include physical examination and (HRC) HRC. 3 Checking the documentations and the criteria being used to do these
health history. assessments.

HAAD HAAD/EMS 1. Transferring patients should be based on a patient’s need for specialized care
Standard for /SD/0.9 that is
Minimum Also refer to not available in the referring facility,ineligibility for treatment in the referring facility
Preparedness all related
for Common appendices or the preference of the patient.
Medical 2. All transfers must be coordinated directly between the physicians in the referring
Emergencies facility and the accepting facility. The concerned physician in the receiving facility
In Inpatient must accept the transfer prior to any other procedures. This is not applicable for
Care Setting, transfers from a primary health center or a private clinic to an emergency room
Outpatient department where direct verbal physician to physician referral can be done, and
Care Setting, should be done prior to the anticipated patient arrival.
Ambulance 3. Personnel involved in the referral will properly identify themselves during referral
Services and communications.
Interfacility
Patient 4. Patient safety during transfer must be ensured by the transferring facility. This
Transfer includes, but is not limited to, providing qualified personnel, medical equipment and
appropriate transportation means. It is the responsibility of the referring physician
to ensure continuity of care and patient safety during the transfer process. This is
not applicable during disasters where coordination and decision-making could be
Transfer/ referral of patients are in compliance done indirectly or through administrative personnel.
CP010 6. The patient due to be transferred or referred must receive necessary
with HAAD standards.
management without delay.
7. For non-emergencies, the appointment date for the patient needing referral can
be secured directly by the referring facility from the receiving hospital. The patient
will be notified by the referring facility of the appointment date.
8. The receiving facility shall send a complete feedback form/report to the referring
facility. Initial and final feedback will be provided if the patient medical condition
requires repeated follow-up. Type of feedback shall be indicated in the form. The
referring facility may follow-up the referred patient later.
Physician in the referring hospital or clinic should:
a. Inform the patient or next of kin regarding the transfer and obtain consent prior
to any arrangements being made.

CP011 Consent/s has/have been obtained as per HAAD HAAD Consent/V1 The most important is to make sure that the informed consent has been obtained
standards Guidelines for January, before the procedure.
patient 2016
consent
 The Diagnosis and Management of Asthma in HAAD HAAD/PDM Only pediatric specialists or consultants physicians treat or supervise the treatment
children and young adults are in comliance Standards for A/SD/0.9 of children with Asthma
with HAAD standards Initial Version 0.9 Spirometry - For children 6 years and older; must not be used alone to establish a
Diagnosis and
Management diagnosis of asthma in children.
of Asthma in For children under 6 years of age, spirometry is not suitable for diagnosis
children and
CP012 young adults

CP013 The Diagnosis and Management of Asthma in HAAD HAAD/IDM Spirometry (with or without bronchodilator assessment) is the preferred initial test
Adults are in comliance with HAAD standards Standards for A/SD/0.9 to diagnose and to detect the presence and the severity of airflow obstruction;
initial Version 0.9 Clinical diagnosis (without spirometric testing) can be sufficient for diagnosis of
Diagnosis and
Management asthma in patients who cannot perform spirometry.
of Asthma in If occupational asthma is suspected the patient must be referred to
Adults asthma/pulmonary specialist
 Professional should participate in continuing medical education; a minimum of 10
hours per year must be in the specialty of the physician
Metastatic work up is indicated for high risk patient or as directed by signs and
symptoms and is not to be routinely performed for early invasive breast cancer,
(cT1-2 , N0-1);
Chest imaging; X-ray or Computed Tomography (CT) scan; bone scan; abdomen ±
pelvis ultrasound (or CT scan, or MRI); 18F-FDG (Fluorodeoxyglucose) PET/CT
scan , is considered as a "complementary" imaging modalities in the following high
risk patients:
Locally advanced breast cancer (stage IIIA, stage IIIB); including inflammatory
breast cancer;
strong clinical suspicion of stage IV disease; and triple negative breast cancer.
18F-NaF (Sodium Fluoride) PET/CT Bone scan is preferred for high risk patients
HAAD
Standard for HAAD/MGB instead of a conventional bone scan.
The Management of Breast Cancer is as per the Surgery to the Breast:
CP014 HAAD standards Management C/SD/0.9 Breast conserving surgery (BCS), excision of tumor with clear margins followed by
of Breast Version 0.9 radiotherapy; or
Cancer modified radical mastectomy. Mastectomy
Intraoperative specimen radiography must be carried out for all cases of Ductal
Carcinoma In Situ (DCIS) treated by breast conservation surgery.
Breast conserving surgery with removal of the nipple-areola complex is offered as
an alternative to mastectomy for patients with Paget's disease of the nipple that
has been assessed as localised

CP015 Patients' life may not be ended for whatsoever Federal Law Article (9) Check if the staff are aware about this law or not.
reason even upon their request or their No. (10) of
guardians or custodians'. 2008 In
respect of
Medical
Liability
 HAAD Outpatient and Primary healthcare providers must:
Standard for 1. Limit their clinical services for childhood diabetes only to diagnosing diabetes in
diagnosis and 2. Ensure that primary care physicians providing clinical diagnosis of childhood
management
of Childhood diabetes have completed appropriate training, including CME training in support of
Diabetes HCFs this Standard;
Policy 3. When performing fasting glucose and/or oral glucose tolerance testing (OGTT)
PPR/HCP/P00 at the facility, the primary care physician supervises the testing and that
24/07 appropriate staffing and care management resources and system support are
available to manage emergency situations that may arise. Primary care physicians
are encouraged to consult pediatric endocrinologist or pediatrician with specialist
interest in diabetes;
4. Immediately refer children (same day) suspected and/or confirmed to be diabetic
to pediatric endocrinologist or pediatrician with specialist interest in diabetes
5. Immediately refer children with suspected DKA and give initial treatment
Inpatient healthcare providers must:
1. Provide the full spectrum of clinical services for childhood diabetes following the
care pathway provided at Appendix 1 and including diagnosis, care and
HAAD/DMC management services in accordance with Appendices 2 and 3;
CP016 The diagnosis and management of Childhood D/SD1.0
Diabetes are in comliance with HAAD standards 2. Ensure that children with diabetes referred to their facility receive same day
Version 1.0
inpatient care, including further clinical testing if necessary, and treatment
coordinated through a multidisciplinary team comprised of pediatric endocrinologist
or pediatrician with specialist interest in diabetes, diabetic educator (preferably
children’s), dietitian, child psychologist and social worker (preferably children’s);
3. Communicate findings to the child’s parents or guardian and ensure that plans
for ongoing care including treatment, management and follow up (Appendix 3) is
shared with the child’s parents or responsible guardian; and
4. Ensure that treatment and care management are supervised by the pediatric
endocrinologist or pediatrician with specialist interest in diabetes. If considering
delegating care management and follow up to a primary care physician (such as in
cases to support patient convenience and/or limited access to inpatient
care facilities due to remoteness of services), the pediatric endocrinologist or
pediatrician with specialist
 1) HAAD Date: Check the availability of the policy and procedure Staff are aware about it
Standards for 03.10.2010 Stool sample and laboratory confirmation to identify the cusative organisim have
Notifying Vital HAAD/VSNS been done.
Statistics, /
Non-fatal SD/VIPCD/0
Injury and 3/1.1
Poisoning Cercular No.
Cases and (CEO 57/10)
Communicabl
e Diseases in
the Emirate of
The Facility management has developed and Abu
CP017 implemented food posining notification Policy Dhabi
and Procedures 2) Subject:
Food
Poisoning

These are some points that can be checked:

To check that these procedures (Microdermabrasion, Botulin Toxin (Type A),
Dermal Fillers, Chemical Peels, IPL Treatment, Laser Treatment)) are being done
only by Plastic Surgeon (Consultant and Specialist), Dermatologist (Consultant and
Specialist), General Surgeon (Consultant and Specialist)
HAAD And those staff are having BLS training certificates
Standard for PPR/HCP/ In Pulse Laser Treatment; a patch test must be undertaken and the patient must be
Non surgical cosmetic procedures practice is Non-Surgical given at least 1 week prior to treatment
CP018 P0012/07
within HAAD standards Medical Registered Nurse or Medical Practitioner, can only work under supervision of the
Cosmetical Version 1.0 specialist in (IPL Treatment, Laser Treatment) but not start a case and only after
Procedures having completed certified training acceptable for HAAD There are many other
points can be checked as per the standards
 Staff members are familiar with all facility’s Ambulatory Communica
policies and procedures and follow them. Care tion (CCC)
Standards CCC.2
High Risk
Care
Processes
CP019 (HRC)
CCC.27 interview staff
HRC.21
HRC.25

Comments: No Comment.

b. Medication
Med001 Medications, material and equipment available Ambulatory
comply with facility's license & scope of services Care This depends upon the scope of services in the facility and it varies between the
offered and professional's scope of practice Standards centers.
2008
Med002 Facility has developed and implemented Healthcare The policy and procedures is specific managing the available medications and
Medications and Materials Management Policy Provider materials in the center.
and Procedures Policy Manual

Multi Dose Usage of Medications/Materials Healthcare For every item using as multi-dose, a specific protocol should be available and
protocols are available and implemented Provider implemented.
Med003 Policy Manual

Med004 Medications are stored properly, securely and Ambulatory Storage of medications should clearly mentioned the location, environments
not accessible to patients. Care monitoring, safety, continuity; according to the recommendations of manufacturer
Standards of every specific medication in the facility with evidences of the recommendations
2008
from the manufacture are attached to the policy.

Med005 Expiry of supplies, material & medications are Ambulatory Records of monitoring are available, dated and signed by the staff
tracked regularly by a designated responsible Care
staff Standards
2008

Competency program for staff on
Medications/Materials usage and practices.
Med006
HAAD Related to medication and material are being used and practiced in the facility that
Standards (JCI) can be done by the practitioners in the facility for their staff annually and can be
(HS) updated any time when new items are to be in practice or new staff joined the
LDS15 facility.
This to keep the quality of services provided to patients maintained in case of staff
has to work with deferent specialties.
 HAAD Check the compliance with standers; these are examples of the items that should be available: Portable
Standard for oxygen delivery system capable of delivering a flow of 10 liters per minute for 30 minutes, two cylinders,
Minimum each with a pressure reduction valve and flow meter (Entonox, portable cylinder).
Preparedness Portable mechanical vacuum suction pump with appropriate suction catheters (8FR, 10FR & 14FR),
tubing, portable suction check plug in and check unplugged and feeding tube Automated blood glucose
for Common measurement device
Medical Automated External Defibrillator (AED) with self-adhesive pads (Adult & Pediatric) and connecting
Emergencies cables.
In Inpatient 1) Adrenaline (epinephrine) 1:10,000 prefilled syringe IV (5 if not used with vasopressin)
Care Setting, 2) Vasopressin arginine/Argipressin 20 units (2 amps)
Outpatient 3) Prefilled Syringe Lidocaine 100mg or Lidocaine vial 2% 20mg/ml
Care Setting, 4) Prefilled Syringe Calcium Chloride 100mg/ml or Calcium Chloride 100mg/ml Ampoules
Ambulance 5) Glucagon Hypokit
6) Glucose 50%
Services and 7) Glucose Gel 75g tubes
Interfacility 8) Hydrocortisone 100mg /2ml
Patient 9) Adenosine 6mg/2ml
Transfer 10) Amiodarone 150mg/3ml
11) Glyceryl Trinitrate (50mg/50ml)
12) Magnesium Sulphate 50% (1g/2ml) vial – High Alert
Med007 Emergency kit is as per HAAD Standard 13) Acetylsalicylic acid 75mg (give 4 tablets = 300mg or 3 tablets of 100mg)
14) Glyceryl Trinitrate Spray 15) Glyceryl Trinitrate Tabs (100)
16) Dextrose Saline 500ml/1000ml 17) Dextrose Water 5% 500ml/1000ml
18) Dextrose Water 10% 500ml/1000ml
19) Ringer Lactate 500ml/1000ml 20) Ringer Solution 500ml/1000ml
21) Normal Saline 500ml/1000ml 22) Buretrol IV Admin (Soluset)
23) Water for injection
24) Adrenaline 1mg (1:1.000) IM
25) Chlorpheneramine 10mg

Med008 No Medications/Materials are being sold at HCF Federal law

unless authorized to do so # 18

Comments: No Comment.
d. Sick Leaves
SL001 Sick leaves are issued after physical HAAD Policy Ask the Doctors to show you the number of sick leaves that they issued during last
examination of the patients. month. Randomly select the patient names with medical file numbers to whom the
sick leaves were issued. Review the files and see that on the day of issuing the
sick leave, all physical examintion findings with SOAP note is completely
documented in patient's medical or dental files.
 Ask the Doctors to show you the number of sick leaves that they issued during last
month. Randomly select the patient names with medical file numbers to whom the
sick leaves were issued. Review the files and see that on the day of issuing the
Sick Leaves are documented in the patients’ sick leave, HAAD sick leave form copy is available in the patient's file and also see
SL002 HAAD Policy
files. in the patient care documentation that the days of sick leaves are documented.

SL003 The Doctors are issuing sick leaves only to HAAD Policy By reviewing the documentation of sick leaves, the HAAD Auditor check and
patients who fall within their scope of ensure that the reson for issuing sick leaves must be fall under the scope of
practice and clinical privileges. services/privillages of Doctor who issued sick leave certificate.

SL004 Each doctor is responsible for his own sick HAAD Policy Ask and observe the Doctor that his/her access for issuing sick leaves must not be
leave system log in details and should not shared with any staff of the facility. The stamp of the Doctor must be kept in safe,
share it with anyone else. secure and locked cabinet or drawer.

Comments: No Comment.

e. Medical Record
HAAD The medical records are stored in place that maintain safety and security. Access
Management to the medical record storage is monitored.
of Medical Medical records are requested through special forms singed by requester.
MR001 Compliance with storage. Records Medical grade cabinets for hard copy medical records, and safe secured back up
system for electronic medical records.

HAAD The medical record should be individual with unique file number. The medical
Management record should contains relevant forms like:
of Medical registration form, consent forms, clinical assessment forms, nursing notes forms,
Records progress notes, follow-up forms, consultation forms, medications charts, copies of
MR002 Compliance with filing prescriptions, investigations request forms and reports, order forms, referral forms,
feed back reports from HCFs that accepted the referral. discharge summary form.

MR003 Compliance with patient’s care HAAD The documentations should be complete and reflects the actual care provided to
documentation Management the patient; dated, timed and signed.
of Medical
Records
 No information is to be written, stamped or pasted on the outside of the patient’s
medical record folder, other than the medical record number, patient name, death
sticker, year band label or ID sticker, which may contain the birth date and sex of
the patient
All patient information recorded on any medium such as paper, computer disc,
microfilm, that needs to be destroyed or purged, shall be processed in a manner
which ensures patient and healthcare organization confidentiality.
Medical record information shall not be released outside the healthcare facility
unless authorized by patient consent
Computer User ID, passwords or other types of system access authorizations are
GENERAL
assigned on an individual basis and must not be shared with anyone.
CONFIDENT
MR004 Compliance with confidentiality Each user is responsible to ensure that he/she properly logs-off from the computer
IALITY
workstation when his/her transaction is complete or when leaving the workstation
POLICY
for a period of time.
Users must be aware that there is no guarantee of complete privacy or security
when using electronic mail; therefore the utmost vigilance is required to avoid the
circulation of patient specific information through email.

MR005 Compliance with patient’s rights and Patient Patient has the right to access their Medical Record and Medical Information
responsibilities Rights and
Responsibiliti
es

Comments: No Comment.

f. Dental Service
DS001 There is one dental assistant per chair. CBAHI DN.2.3 The dental assistant presence at the time of audit is mandatory.Ask and see HAAD
License for the said staff.
DS002 There are Material Safety Data Sheets for Abu-Dhabi FSE.7 Ask and check the file for Material Safety Data Sheets. The dental material that
all chemical/Dental agents Hospital used by Dentists in treatment.
Standards

DS003 Gloves, protective gowns and masks are CBAHI DN.6 Physically check and ensure that the enough quantity of gloves, disposable gowns
used for each patient and masks are available.

DS004 Protective eyewear (face shield) are worn by CBAHI DN.6 Observe and check thet the staff involved in dental treatment are wearing the face
staff shields.
DS005 Protective eyewear are worn by patient. CBAHI DN.6 Observe and ask from the Dentists that the patients are wearing googles during the
Transparent or colored goggles dental procedures.
 Each patient’s dental care is planned and CBAHI Randomly select the patient's files and read the documentation for patient care and
documented in the medical record. Dental Board ensure that all the required documentation mentioned in this standard is complete,
DS006 . of Australia DN.4 partially complete or not complete.
1. History of allergic reactions.
2. Chronic illnesses (e.g., congenital heart
disease, rheumatic heart and diabetes).
DS007 Informed consent
3. Infectious is obtained for all high-risk
diseases. CBAHI DN.5 Check in the patient's dental files that the patient in written fill the consent forms for
procedures.
4. Hematological diseases (e.g., dental procedures or not. All the fields mentioned in consent forms must be
hemophilia). 5 .Chief complaints. completely filled
patients are educated
6. The need andprophylaxis.
for antibiotic informed about
7 Federal Law Review the patient's files and see the documentation. This should be document in
cost of services
.Radiological procedures needed. No. 4 of patient's dental files.
8. Treatment plan including procedure(s) to 2015
be performed. regarding the
9. Dose of local anesthesia, the tooth private
treated and the material used. health
10. medicine/drug prescribed, administered facilities,
or supplied or any other therapeutic agent
DS008 X-ray lead apron
used (name, available
quantity, dose,and used for
instructions) IAEA #115 Physically check and ensure the availability of X-Ray Lead Apron.
patients
Comments: No Comment.

g. Dental Lab
DL001 Laboratory practice observed and performed HAAD Ventilation shoukld be with exhausted system to remove dust out of the place
satisfactorily Hospital
Standards
DL002 Sufficient/proper aspiration and ventilation in AIA & NFPA
place in the dental lab

DL003 Disinfection of impressions is carried out for APIC & CDC

the dental lab

DL004 Surface and work station of the dental lab APIC & CDC
are disinfected between procedures

DL005 Organisational flow chart is in place to ISO 10007

ensure awareness of and compliance with
roles and responsibilities

DL006 Labeling of casts and models with ISO 13485

anonymised patient identifier and date is CDL
carried out Standards
DL007 Receiving and delivering procedures are in HAAD Policy
place to ensure operational quality and PPR/FLI/PI
safety CDL
Standards

DL008 Technicians are working according to their HAAD Policy

professional license and scope of practice – Proficiency
licensing

DL009 Policies, guidelines in place in accordance HAAD

with international evidence based standards Standards
(JCI)HS
#PCQ12.2c

Personal Protective Equipment is used HAAD

a. Eye goggles/face shield Standards
b. Gloves (JCI)HS
DL010 c. Gown #HRC62
d. mask

Comments: No Comment.

i. Clinical Research
Research Governance: Institutions conducting research involving human subjects provide
adequate and effective oversight
CR000 The Facility has an approved clinical *HAAD check approval given from haad
research program. Healthcare
Regulator
Manual
(Chapter V:
Human
Subject
Research);
52.1

Comments: No Comment.

3. Infection control
a. Infection Control General Requirements
 Health care facility has an infection control Frst edition HRC.53 Measurable Elements:
program based on applicable Law, of the Health 3.1.2 1. The infection control program is based on current scientific knowledge.
regulations and standards including: Authorty - 2.4. .6.7 2. The infection control program is based on accepted practice guidelines.
a.Vision Abu Dhabi M 3. The infection control program is based on applicable law and regulation.
b.Mission statement c.Authority statement Health Care
d.Risk assesment e.Plan Standards
for facilitys.
Infection
Prevention
and Control
Management
HAAD/
HSED/ST/00
17/HS_
EHSMS
IC001 Policy for
Infection
Control in the
Health Care
Facilities
PPR/HCP/P0
010/07
Frst edition
of the

Health
Authorty -

Abu Dhabi
Health

HRC.51
 Care
Standards
for facilitys.
HRC.51
JCI PCI.1
Infection 3.1.3 ,4.5.6
Prevention
and Control
Management
HAAD/
HSED/ST/00
17/HS_
EHSMS

Policy for 6.4

Infection
Control in the

Health Care
Measurable Elements:
PPR/HCP/P0 1. One or more individuals oversee the infection control program.
Qualified staff is oversee all infection 010/07 2. The individual(s) is qualified for the facility’s size, level of risks, and program
IC002 prevention and control activities. scope and complexity.
Infection
Prevention
and Control

Management
HAAD/ 3.1.11
HS 3.5.6.4
ED/
Frst edition
ST/
of the
Vaccination records for hepatitis B required 001
to be 7/H
available and documented for all health care S_
Health
Authorty - Measurable Elements:
providers and any staff at risk Abu Dhabi Plan and program required to be available
Health
The effectiveness of the vaccination must be Care HRC.57
Standards
for
 documented by anti -HBs titer facilitys. Evidence required to be provided
Policy for
Infection
Control in the

Health Care 1.3

Facilities
PPR/HCP/P0
010/07
IC003
Infection 3.1.11 Measurable Elements:
Prevention HRC.57 consent form is required to be seen
and Control
Management
HAAD/
HSED/ST/00
17/HS_
EHSMS
Frst edition
Needle stick injury and exposure to blood of the Health
IC004 borne pathogen consent form is required for Authorty -
the source. Abu Dhabi
Health Care
Standards
for facilitys.
 Education and training in infection control Policy for 6.8 Measurable Elements:
practices provided to all health care Infection FSE.16 1. The facility provides education about infection prevention and control.
providers and workers and others as Control in the 2. All physicians and staff members are oriented to the policies, procedures, and
required Health Care practices of the infection prevention and control program.
Facilities 3. Periodic staff education includes new policies and procedures.
PPR/HCP/P0
010/07
Frst edition
of the Health
Authorty -
Abu Dhabi
IC005
Health Care
Standards
for facilitys.

Gloves, masks, eye protection and other Policy for Measurable Elements:
protective equipment are available and Infection M 1. The facility identifies those situations for which gloves and/or masks or eye
used correctly when required Control in the protection are required.
The organization identifies those situations Health Care M 2. Gloves and/or masks or eye protection are correctly used in those situations.
for which gloves and/or masks or eye Facilities M 3. The facility identifies those areas where hand washing and hand disinfection
protection are required and correctly used in PPR/HCP/P0 or surface disinfecting
those situations 010/07 JCI 6.6 procedures are required.
IC006
PCI.9 M 4. Hand washing and hand disinfection procedures are used correctly in those
areas.
M 5. The facility has adopted hand hygiene guidelines from an authoritative source.
 Supplies necessary for adherence to hand Frst edition HRC.62
hygiene are available and accessible to of the Health 3.5.2
Health Care Providers in patient care areas. Authorty -
I. Alcohol-based hand gel Abu Dhabi
ii. Handwashing sinks Health Care
iii. Soap Standards
iv. Paper Towels for facilitys.
Infection
Prevention
and Control
Management Measurable Elements:
IC0107
HAAD/ policy required and and observation during the round
HSED/ST/00
17/HS_
EHSMS

Infection Measurable Elements:

Prevention M 1. The facility regularly tests e sources of water and following applicable
and Control regulatory policies or laws.
Management M 2. The facility documents the results of such tests.
HAAD/ M 3. Water used in chronic renal dialysis is tested regularly.
HSED/ST/00 test from alll sources of water with specification according to the equipments :
17/HS_ autoclave , dental chairs
EHSMS

Water quality management program in

IC008 3.5.16
place.
 All furniture, fixtures and fittings used in Infection Measurable Elements:
health care facilities can be easily Prevention policy required and observation during the round
decontaminated in accordance with and Control
manufacturer’s instructions. Management
HAAD/
IC0109 HSED/ST/00 3.1.10
17/HS_
EHSMS

Decontamination of Equipment including

specific
devices (IV drip stand, blood glucose meter,
portable Nebulizer casing,
Sphygmanometer..etc.)
Measurable Elements:
- Policy and procedure available. Policy for 1. Equipment cleaning and disinection methods are appropriate for the
Infection
- Staff can correctly describe the procedure Control in the type of equipment.
according to the manufacturer’s instructions. Health Care 2. Equipment cleaning, disinfection
1.13
- Equipment clean indicator tape/tag dated Facilities 1.7 methods conducted according manufactures instructions
and
signed PPR/HCP/P0
010/07
-Decontaminated equipment stored
separately from
used items.
IC010
Comments: No Comment.
B. Patients Vaccination program:
 Vaccination program: 1- HAAD
- Staff are aware of how to access the Policy Standard for
and procedure of ‘The Vaccine Cold and Safe Vaccine
the Guidance for the storage and transport Handling and
of vaccines Cold Chain
- The vaccine refrigerator is medical grade maintenance
- The refrigerator is locked or in a room that in the
is locked when not occupied by a member of Emirate of
staff Abu Dhabi -
- Vaccines are stored immediately on HAAD/VHCC
delivery in a dedicated refrigerator and /SD/0.9
details are recorded on a vaccine log 2- HAAD
- The refrigerator has a separate external Standard for
Measurable Elements:
IC001 non - integral thermometer that shows Childhood 7 & 3
policy and documents required and observation during the round
maximum, minimum and current and Young
temperatures adult
Immunization
HAAD/CHIM/
SD/0.9

1- HAAD
Standard for
Safe Vaccine
Handling and
Cold Chain
maintenance
in the
Emirate of
Abu Dhabi -
Maximum, minimum and current HAAD/VHCC
temperatures are recorded daily and are /SD/0.9 Measurable Elements:
IC002 9.5
within the acceptable range of 2-8°C, and 2- HAAD policy and documents required and observation during the round
the thermometer is reset daily Standard for
Childhood
and Young
adult
Immunization
HAAD/CHIM/
SD/0.9
 1- HAAD
Standard for
Safe Vaccine
Handling and
Cold Chain
maintenance
in the
Emirate of
Abu Dhabi -
HAAD/VHCC
All vaccines are within date and stock is /SD/0.9 Measurable Elements:
IC003 8&9
rotated and used according to date 2- HAAD policy and documents required and observation during the round
Standard for
Childhood
and Young
adult
Immunization
HAAD/CHIM/
SD/0.9

1- HAAD
Standard for
Safe Vaccine
Handling and
Cold Chain
maintenance
in the
Emirate of
Abu Dhabi -
HAAD/VHCC
/SD/0.9
2- HAAD
Alternative and appropriate storage is Standard for
Measurable Elements:
IC004 available in the event of a breakdown, repair Childhood 12
and Young policy and documents required and observation during the round
or during defrosting of the refrigerator
adult
Immunization
HAAD/CHIM/
SD/0.9
 1- HAAD
Standard for
Safe Vaccine
Handling and
Cold Chain
maintenance
in the
Emirate of
Abu Dhabi -
HAAD/VHCC
/SD/0.9
2- HAAD
Standard for
Is there a designated person responsible for Childhood 3.1. Measurable Elements:
IC005
monitoring of the vaccine cold chain? and Young 7.1. documents required and evidence
adult
Immunization
HAAD/CHIM/
SD/0.9

Comments: No Comment.

c.Waste Management & Sanitation

Frst edition
of the

Health
*Authorty -
Abu Dhabi
Health
Care
Standards
for HRC.59
facilitys. FSE.7
* HAAD
-Medical
Waste
Management
 in Health P0002/07-
Care 2.4
Facilities -
PPR/HCP/P0 PCI.7.2
002/07-
2.4
* JCI EHSMS -
* Medical 3.1 - 3.12
Waste
Management
/HAAD/
HSED/ST/00
The Health care facility has a waste 16/HS_
management program, policies and Measurable Elements:
WMS001 procedures EHSMS -3 policy and documents required and evidence is required
Good practice and management of sharps Frst edition HRC.60 Measurable Elements:
are followed of the Health PCI.7.3 M 1. Sharps and needles are collected in dedicated, puncture-proof containers
Authorty - which are not re-used.
Abu Dhabi M 2. The facility disposes of sharps and needles safely or contracts with sources
Health Care that ensure the sharps
Standards containers are disposed of in dedicated hazardous waste sites or by an appropriate
WMS002 for facilitys. process.
JCI

WMS003 Sharps boxes should be situated in a safe First edition HRC.60 Measurable Elements:
and secure place and not accessible to of the Health PCI.7.3 policy and documents required and observation during the round
other patients or visitors In rooms or areas Authorty -
where boxes do not need to be moved, they Abu Dhabi
should be wall-mounted Health Care
Standards
for facilitys.
JCI
 Sharps boxes must be labeled with date and * Medical Measurable Elements:
signature, when assembled, locked and Waste policy and documents required and observation during the round
disposed of. They must be labeled with their Management
source prior to disposal and expiry date /HAAD/
WMS004 HSED/ST/00 PCI.7.3
16/HS_
EHSMS
JCI

Solid waste: Collection, Packaging, Frst edition FSE.7 Measurable Elements:

segregation- colored bags, Labeling, of the Health 2.1 , 2.3, M 1. The facility identifies hazardous and medical waste
Storage, Transport, Pretreatment ,Treatment *Authorty - 2.6, 2.9, 2. The plan includes safe handling, storage of hazardous waste The plan includes
and disposal according to the standard Abu Dhabi 2.14 proper disposal of medical waste.
Health Care PCI.7.3 3. The plan includes reporting and investigation of spills, exposures, and other
Standards incidents. M 4. The plan includes the proper handling of waste within the
for facilitys. organization and disposal of hazardous waste in a safe and legal manner
HAAD The plan includes labeling hazardous wastes and sharps
-Medical
Waste
Management
in
WMS005
Health Care
Facilities -
PPR/HCP/P0
002/07-
JCI

HAAD
-Medical
Waste
Management

in
Health Care

Facilities -
WMS006 PPR/HCP/P0
002/07-
Medical
Waste
Management
/HAAD/
 HSED/ST/00
16/HS_
Waste containers with cover and foot control 2.3 Measurable Elements:
and should be cleaned with no dirt or rust EHSMS 2.8 & 2.9 policy and documents required and observation during the round
HAAD
-Medical
Waste
Management
in
Health Care
Facilities -
PPR/HCP/P0
A well secured and ventilated room shall be 002/07-
allocated to store medical waste 6.2,6.3,
- room temperature should not exceed 15 6.3.3.1 Measurable Elements:
WMS006 degree centigrade JCI PCI.7.3 policy and documents required and observation during the round
WMS007 A log bock for tracking and maintain a HAAD Measurable Elements:
record of all disposed medical waste is -Medical policy and documents required and observation during the round
required to be available Waste
Management
in
Health Care 2.7
Facilities -
PPR/HCP/P0
002/07-

Personal protective equipment appropriate HAAD 6.2,6.3, Measurable Elements:

to the risks associated with handling, -Medical 6.3.3.1 policy and documents required and observation during the round
storage & disposal of wastes are provided Waste PCI.7.3
to & used properly Management
in
Health Care
WMS008 Facilities -
PPR/HCP/P0
002/07-
JCI
WMS009 Vaccination records for hepatitis B required First edition HRC.62 Measurable Elements:
to be available and documented for waste of the Health PCI.7.3 policy and documents required
handler staff The effectiveness of the Authorty -
vaccination must be documented by anti Abu Dhabi
-HBs titer. Health Care
Standards
for facilitys.
JCI

Comments: No Comment.

d. Housekeeping
HK001 Policy for 1.9
Infection FSE.7
Control in the
Health Care
Facilities
PPR/HCP/P00
10/07
First edition of
the Health
Authorty -
Abu Dhabi
List of approved detergents and disinfectants Health Care Measurable Elements:
solutions used in the facility should be available Standards for policy and documents required
facilitys.4

Policy for
Infection
Control in the
Health Care
Facilities
PPR/HCP/P00
10/07
HAAD
-Medical
Waste

1.9
1.13
 Management 2.5
in
Health Care
Facilities -

PPR/HCP/P00
Housekeeping equipment used for cleaning is 02/07- Measurable Elements:
HK002 available and well identified by the staff policy and documents required and observation during the round
Color coding system is in place for cleaning
materials
and equipment (cloths (reusable and
disposable),
Policy for
mops, buckets, aprons and gloves) Color coding Infection
as: Control in the
Health
Green: Ward kitchen areas and patient food Care Facilities
service at
1.9
ward level. PPR/HCP/P00 1.13
Yellow: Isolation areas. 10/07
Red: Toilets, bathrooms, washrooms, showers, First edition of
basins, the Health

bathroom floors. Authorty - FSE.7

Abu Dhabi
Blue: General areas including wards, offices Health Care
departments, and basins in public areas. Standards
for facilitys.4

The color coded chart is displayed in the

domestic’s
room and dirty utility room. Measurable Elements:
HK003 policy and documents required and observation during the round
HK004 First edition of FSE.7 Measurable Elements:
the Health 1.13 policy and documents required
Authorty - The plan includes reporting and investigation of spills,
Abu Dhabi
Health Care
Standards for
facilitys.
Policy for
Infection
Control in the
Cleaning spills of blood and body substances kit Health Care
is available Facilities
PPR/HCP/P00
10/07

First edition of FSE.7 Measurable Elements:

the Health 1.13 policy and documents required and observation during the round
Authorty -
Abu Dhabi
Health Care
Standards for
facilitys.
Policy for
Infection
Control in the
Health Care
Facilities
HK005 Pest Control program in place PPR/HCP/P00
10/07

Frst edition of
the

HRC.53
 Health
Authorty -
Abu Dhabi
Health Care

HRC.53
Standards for
facilitys.

Infection
Prevention
and Control

Management
HAAD/HS
ED/ST/0017/H 3.1.2
S_EHSM
Housekeeping policies & procedures manual in Measurable Elements:
HK006 place/signed off by staff and monitored S 3.5.14 policy and documents required and observation during the round
Orientation & training program for First edition of FSE.16 Measurable Elements:
housekeeping staff is in place and documented the Health 2.6 policy and documents required
Authorty -
Abu Dhabi
Health Care
Standards for
facilitys.
HAAD
-Medical
Waste
Management
in Health Care
HK007 Facilities -
PPR/HCP/P00
02/07-
 Vaccination records for hepatitis B required to HAAD Measurable Elements:
be available and documented for all -Medical policy and documents required
housekeeping staff The effectiveness of the Waste
vaccination must be documented by anti -HBs Management
titer. in Health Care
Facilities -
HK008 PPR/HCP/P00 2.13
02/07-

Comments: No Comment.

e. CSSD
Appropriate storage practice is observed for Comprehensiv ANSI
sterile instruments and supplies: Temperature e guide to /AAMI ST79 :
between 18- 22°c, Humidity between 30% to steam 2010- page
60% sterilization 25
& sterility
assurance in
CSSD001 health care Sterile & clean supplies stored, & Monitor for temperature & humidity available.
facilities,

Sterile storage should be located in a limited Comprehensiv ANSI Sterile items stored using open shelves or closed cabinet & dust cover used for sterile
access area. If access cannot be controlled , the e guide to /AAMI ST79 : items when open shelves storage system used
sterile storage area should be enclosed e.g steam 2010- page
cupboard, cabinet, closed cart. sterilization 29-30
& sterility
assurance in
CSSD002 health care
facilities,
 The instrument processing area is physically Comprehensiv ANSI Sterilization department contains three main areas & physically separated from each other
divided into separate areas for receiving, e guide to /AAMI ST79 : with separate entrance for each area ( Decontamination, packing, sterile store).
cleaning & decontamination, preparation & steam 2010- page
packaging, sterilization and storage. sterilization 27
& sterility
assurance in
CSSD003 health care
facilities,

CSSD004 Comprehensiv ANSI

e guide to /AAMI ST79 :
steam 2010- page
sterilization 23-24
& sterility
assurance in
health care
facilities,Comp
rehensi ve
guide to
steam
sterilization &
Negative pressure in decontamination area is sterility Evidence of negative pressure available, monitor displayed to show negative pressure &
required. Displayed monitor to be installed. assurance in daily monitoring checklist available.
health care
facilities,

Positive pressure in assembly, packing area & Comprehensiv ANSI Evidence of positive pressure available, monitor displayed to show positive pressure &
sterile store is required. Displayed monitor to be e guide to /AAMI ST79 : daily monitoring checklist available. Be sure that positive pressure in sterile store is more
displayed. steam 2010- page than positive pressure in packing & assembly area.
sterilization 23-24
& sterility
assurance in
CSSD005 health care
facilities,
 Disinfection, sterilization and validation of Ambulatory , ANSI
sterilization is conducted as per established Care /AAMI ST79 :
policies Standards 2010- page
CSSD006 2008 43 Is the policy available & staff familiar with the policy & the policy implemented.

Physical, chemical & biological Monitoring is Comprehensiv ANSI Documents of sterilzation validation available including mechanical, chemical, & biological
routinely done to verify the effectiveness of e guide to /AAMI ST79 : validation.
sterilizer & sterilization process. steam 2010- page
sterilization 83-91
& sterility
assurance in
CSSD007 health care
facilities

Sterilization records are maintained which Comprehensiv ANSI

include load contents, date & time, sterilizer e guide to /AAMI ST79 :
identification number, sterilizing condition steam 2010- page
(mechanical indicator results as cycle printout) sterilization 83-85
& sterility
assurance in log book for sterilization records include load contents, date, time, sterilizer number
CSSD008 health care available.
facilities,

All sterilization & processing of all sterile Comprehensiv ANSI

supplies & equipment shall be under competent e guide to /AAMI ST79 :
supervision. This person shall be qualified for steam 2010- page
the position by education, training & experience sterilization 31
& sterility
assurance in Ask for evidence of qualification, training & experience of CSSD manager as a competent
CSSD009 health care person.
facilities,
 Any staff involved in any aspect of reprocessing Comprehensiv ANSI There is evidence f training, orientation for any new medical devices to be processed for
shall obtain education, orientation & training e guide to /AAMI ST79 : CSSD staff.
specific to the function they performed/medical steam 2010- page
device to be reprocessed sterilization 31
& sterility
assurance in
CSSD010 health care
facilities,

A written policies & procedures for Comprehensiv , ANSI

decontamination e guide to /AAMI ST79 :
& sterilization activities performed in CSSD & steam 2010- page
else ware in the facility. These policies shall sterilization 43
cover all CSSD tasks & sterility
assurance in
CSSD011 health care Steriliztion policies & procedures covered all CSSD tasks available & implemented
facilities,

The Quality of the water used for reprocessing Comprehensiv ANSI

shall be known & checked as required e guide to /AAMI ST79 :
steam 2010- page
sterilization 21-22
& sterility
assurance in
CSSD012 health care Evidence of water quality for hardness. Level of minerals, & microbiology results available.
facilities,

Appropriate personal protective equipment shall Comprehensiv ANSI Is there enough amount of required personal protective equipment available, & staff using
be worn for all reprocessing activities e guide to /AAMI ST79 : required PPE during procvessing of surgical instruments & medical devices.
steam 2010- page
sterilization 33-35
& sterility
assurance in
CSSD013 health care
facilities,
 Vaccination records for hepatitis B required to Comprehensiv , ANSI Evidence of hepatitis B vaccination for all CSSD staff including the housekeeping staff, or
be available and documented for all health care e guide to /AAMI ST79 : evidence of anti-body titer results for all CSSD staff.
providers and any staff at risk steam 2010- page
The effectiveness of the vaccination must be sterilization 33
documented by anti -HBs titer & sterility
assurance in
CSSD014 health care
facilities,

The process & products used for disinfection Comprehensiv ANSI protocol for disdinfection & sterilization of special medical devices available, & chemicals
and/or sterilization of medical devices shall be e guide to /AAMI ST79 : used for disinfection of special devices as per manufacturer's instructions.
compatible with the devices steam 2010- page
sterilization 43
& sterility
assurance in
CSSD015 health care
facilities,

CSSD016 Low temperature sterilization shall be used to Guidelines for page 46-47. Is there any heat sensitive medical devices available in the facility need low temperature
sterilize heat sensitive medical devices disinfection & sterilization, Is there low temperature sterilizer available to sterilize it.
sterilization in
health care
facilities,
2008-

Sterilizer shall be requalified annually & after Comprehensiv ANSI Is there major repairs done for the sterilizer, or relocation of the steriluizer, or unexplained
the following: major repairs, construction, e guide to /AAMI ST79 : sterility failure happened. If yes, show evidence of sterilizer qualification including: vaccum
relocation of the sterilizer, unexplained sterility steam 2010- page leak test three times, Bowie-Dick test three times, Biological spor test three times.
failures Qualification of sterilizer: sterilization 105-109
1. Vacum leak test three times. & sterility
2. Bowie-Dick test three times assurance in
CSSD017 3. Biological spore test three times. health care
facilities,
 The shelf life of a sterile package is according to Comprehensiv , ANSI Policy of sterile items shelf life, Evidence on sterile pack that the shelf life indicated on
the facility policy : e guide to /AAMI ST79 : each sterile pack ( Event realted or time related).
- Event related steam 2010- page
- Time related sterilization 77
& sterility
assurance in
CSSD018 health care
facilities

CSSD019 Single use sterile items shall not be reprocessed Policy for , HAAD/2007 Policy that prohibit sterilization of single use items available, & search for any single use
& reused infection items re- processed.
control in
health care
facilities

Bowie Dick test for high vacuum sterilizer shall Comprehensiv ANSI Check for evidence & documentation that Bowie-Dick test done for high vaccum sterilizers
be done daily e guide to /AAMI ST79 : daily
steam 2010- page & iterpret the results.
sterilization 87
& sterility
assurance in
CSSD020 health care
facilities,

Internal chemical indicator shall be used inside Comprehensiv ANSI Check that all sterilie packs have internal chemical indicator, External chmical indicator not
each wrapped package e guide to /AAMI ST79 : enough.
steam 2010- page
sterilization 88
& sterility
assurance in
CSSD021 health care
facilities,
 Acquisition of supplies after normal working Comprehensiv ANSI Ask for the daily working hours, & how they can manage for thev supply of sterile items to
hours or any time the CSSD considered closed or e guide to /AAMI ST79 : operating rooms or wards after working hours.
unstaffed procedure is available steam 2010- page
sterilization 43
& sterility
assurance in
CSSD022 health care
facilities,

If biological indicator is positive, loads shall be Comprehensiv , ANSI Policy & procedure for recall of sterile items available, Documentation of any recall of
recalled e guide to /AAMI ST79 : itmes done
& the positive test shall be investigated steam 2010- page & what was the cause.
A procedure shall be established for the recall of sterilization 118
improperly reprocessed medical & sterility
equipment/devices assurance in
CSSD023 health care
facilities

Comments: No Comment.

4. Facility and Equipment Management

a. Facility Management
FM001 The facility’s physical environment is visibly Ambulatory FSE.3 Physical inspection
clean. Care
Standards
2008

The facility meets the minimum requirements HAAD Part E -

for space and dimensions for the defined scope Guidelines for Section 1.3
of service and complaince with approved Health Facility & 2.0/ FSE.1
drawing by HAAD Design/
Ambulatory
FM002 Care Physical inspection with reference to Approved drawings
Standards
2008

HAAD Part B
Guidelines for /Section
Health Facility 17.2.2,
FM003 The facility is adequately illuminated. Design 17.3.4 & Presence of Adequate lighting (Natural Light desirable whenever possible)
26.3.5
FM004 The facility is adequately maintained. Ambulatory FSE.3 Utilities are identified, PM is scheduled, inspected and documented
Care
Standards
2008

Written documented environment, health and Ambulatory

safety (EHS) program is required to address the Care
risks and hazards at the facility to mitigate their Standards
impact on safety and security. Hazards such as 2008
FM005 fire, trip, electrical FSE.3 & 4 Check Policy, Risk assessment/ risk register, Incidents Reports and Log
, mechanical, infection etc.

FM006 The facility has an incident record and reporting Ambulatory 4 Check Policy, Incidents Reports and Log
system. Care
Standards
2008

Inspection and servicing of utilities such as Ambulatory

electricity water and air-conditioning is done Care
FM007 regularly Standards FSE.13 By Checking Documentations and Stickers
2008

FM008 Monitoring of environmental parameters such Ambulatory VI. FSE By Checking monitoring system log, calibration reports and Stickers
as humidity, temperature and pressure is done Care
where applicable. (E.g. Fridges, CSSD etc.) Standards
2009

Federal Law / Article 5

HAAD Health point 6
facility /Part B -
Guideline Version 3.3
FM009 The facility ensures patient privacy all times. Section 9.3.2 Physical inspection and process flow audit

Comments: No Comment.

b. Equipment Management
Medical equipment management policy is Ambulatory
available in the faculity. Care
EM001 Standards FSE.11 Review of Management plan and its reflection in maintaining medical equipment
2008
 Medical equipment inventory is available, Ambulatory
complete with all necessary information and is Care
EM002 updated on regular basis. Standards FSE.11-2 Inventory list
2008

The facility has outsourced the maintenance of Ambulatory

medical equipment if there is no in-house Care
EM003 biomedical department. Standards FSE.11-7 check Warranty certificate and service contract with reference to Inventory list
2008

Planned preventive maintenance (PPM) Ambulatory

schedule for medical equipment is available and Care
EM004 implemented. Standards FSE.11-5 Check PPM Schedule
2008
All medical equipment (purchased, Ambulatory
demonstration, Care
loaner etc.) are tested for safety (electrical, Standards
mechanical, radiation etc.) and QC & calibration 2008
is done upon installation, PPM and major
EM005 repairs. According to type, use and FSE.11- 3-5 Check History files
recommendations of their

All service records, test results, calibration & Ambulatory

adjustment and QA/QC records are documented Care
and maintained for each piece of equipment. Standards
EM007 2008 FSE.11 Check History files

EM008 Staff are trained on use, safety and up keeping Medical 4 Check History files, training forms and end user knowledge
of the medical equipment installed at the liability law of
facility. UAE ( issued in
2016)

Calibration Certificates for the test tools are in Hospital Care

place. All test tools used for maintenance of Standards
medical devices are calibrated through a 2008
EM009 company certified by a competent national or FSE12-3 Check Inventory list, calibration report & service contract if applicable
international body.

Comments: No Comment.

c. Fire & Safety

FS001 The healthcare facility has a fire safety plan Ambulatory FSE-6.1 Review of Safety Plan
to ensure that all the occupants are safe Care
from fire and smoke. Standards
2008
FS002 The fire safety plan provides for the safe Ambulatory FSE-6.3 Review of Safety Plan
evacuation of the occupants. Care
Standards
2008

FS003 Firefighting resources including fire alarms, Ambulatory FSE.7 Physical inspection, service report and stickers
extinguishers (red & black) and smoke Care
detectors are available , regularly inspected Standards
2008
and inspection records are maintained.

FS004 Fire safety posters (RACE & PASS signs) Ambulatory FSE-6 Physical inspection
are displayed at various prominent Care
locations. Standards
2008

FS005 Staff members are familiar with fire safety Ambulatory FSE-7.3 Documented Training and drill attendance forms. Staff knowledge testing
and evacuation procedures. Care
Standards
2008

Comments: No Comment.

5. Radiology
a. General Radiology Requirements
Rad001 FANR License is available FANR Article (4) By Checking FANAR license/ Documentations
Regulation
24
Dose Levels and Optimisation for the workers
Rad008 There are means of dose optimisation in the FANR Article (8) Review of Radiaition Protection Manuel
facility's policy to protect the staff from over Regulation
exposure to radiation 24

Rad009 The Occupational Dose Level in the facility FANR Article (10) Review of Radiaition Protection Manuel, and check if identified
is set at 20 mSv/year or Lower Regulation
24
Rad012 the Equivalent Dose to the foetus of a FANR Article (10) Review of Radiaition Protection Manuel, and check if identified
pregnant staff should not exceed 1 mSv for Regulation
the reminder of the pregnancy 24

Rad013 The Dose Constraint level in the facility is FANR Article (8) Review of Radiaition Protection Manuel, and check if identified
set at 3 mSv/year or lower Regulation Article (6)
24
Regulatory
Guide 7
Investigation Dose for the workers
Rad014 There is an investigation dose level set by FANR Article (22) Review of Radiaition Protection Manuel, and check if identified
the facility Regulation
24
Rad016 The investigation level should be at 0.3 FANR Article (22) Review of Radiaition Protection Manuel, and check if identified
mSv/Month or lower based on the dose Regulation Article (7)
limits in the facility 24
Regulatory
Guide 7

Rad017 The investigation level for a female pregnant FANR Article (22) Review of Radiaition Protection Manuel, and check if identified
worker is at 0.1 mSv/Month Regulation Article (7)
24
Regulatory
Guide 7

Reporting of Over Exposure to Radiaiton

Rad024 There is a process in place to report to FANR Article (17) by checking Documentations
FANR when any dose limits of the workers Regulation Article (8)
are exceeded within 24 hours 24
Regulatory
Guide 7
Radiation protection Officer
Rad031 The facility assigned a Radiation protection FANR Article (12) by checking Nomination letter signed
Officer Regulation
24

Rad032 The role of the Radiation Protection Officer FANR Article (12) by checking Documentations/Radition Protection Manuel,
are identified Regulation
24
Calibration and Clinical Dosimetry

Rad033 All X-Ray Machines must be inspected by a FANR Article (38) by checking QC reports
Licensed Medical Physicist Regulation
24

Rad035 The Quality Assurance testing is done FANR Article (38) by checking QC reports
Periodically for All X-ray Machines by a Regulation
licensed Medical Physicist 24

Rad038 Appropriate clinical dosimetry is performed FANR Article (24) Physical inspection
by providing radiation badges to workers Regulation Article (36)
24
Rad039 Clinical Dosimetry is documented FANR Article (24) by checking Dosimetry Reports
Regulation Article (36)
24

Protective Equipment
Rad044 Lead aprons are available in all x-ray rooms FANR Article (22) Physical inspection
including General, Fluoroscopy and CT Regulation
rooms. 24
Rad046 Quality check is done on all Lead Aprons FANR Article (22) by checking Documentations
Periodically. Regulation
24

Comments: No Comment.
6. Laboratory
a. Laboratory Requirements
SCOPE OF SERVICE:
LAB MANAGEMMENT:
Lab002 Scope HAAD Offered services shall be posted with approved dates
Clinical
Laboratory
Standards

Lab003 Workload HAAD Preferred every six month or annual with required staff, current staff and the
Clinical needed staffs shall be identified and justified
Laboratory
Standards
Lab004 Referral Policy HAAD a detailed referral policy for each referral lab describing the process of
Clinical transportation and the turnarround time of results.
Laboratory
Standards

Lab005 Ongoing Monitoring of Lab Processes HAAD policy or procedure describing the process of lab monitoring of samples from
Clinical patient identification to the release of the results
Laboratory
Standards
LAB STAFFING:
Lab007 Valid HAAD license
Lab008 Staff Competency & on-going Training HAAD evidence of on going monitoring of training and annual staff competency report/s
Clinical
Laboratory
Standards
ORIENTATION & TRAINING:
Lab010 Documentation of CME/CPD’s HAAD Copies of CME/CPDs shall be kept in staff's file
Clinical
Laboratory
Standards
LAB INFRASTRUCTURE AND EQUIPMENT MANAGEMENT:
Lab017 5-files are prepared for each instrument: HAAD there shall be five files (1-5) prepared for each instrument
Clinical
Laboratory
Standards
GENERAL LAB POLICIES:
Lab029 Referral policy includes: HAAD adetailed referral policy shall be prepared and it shall include the, among others
Clinical the following four components
Laboratory
Standards
Lab031 2. Transportation HAAD Detailed description of the whole process of transportation and the associated
Clinical document/s that shall be signed, dated and the number of famples are included
Laboratory
Standards
Lab032 3. Turnaround time HAAD the claimed time it takes from sample collection to the release of the result.
Clinical
Laboratory
Standards

Lab033 4. Samples Rejection monitoring HAAD A Sample rejection form with the criteria/reasons for rejection listed and marked,
Clinical followed by a section on what action was taken for this rejected sample/s.
Laboratory
Standards
Reporting results policy
Lab034 Hard copies: HAAD It shall be noted on the reported results that hard copies are provided.
Clinical
Laboratory
Standards

Lab036 2. Retention period HAAD Retention period shall be identified as per haad retion of docuemnts policy.
Clinical
Lab037 3. Security/Confidentiality HAAD
Laboratory The shall be a limited access to the secure location of the stored douments/results
Clinical
Standards
Laboratory
Standards

Lab038 Soft Copies HAAD Are those electronic copies of results vailable with at least one backup drver.
Clinical
Laboratory
Standards
Lab040 2. Retention Period HAAD As permitted by the har/sof ware and not to be less than haad required period
Clinical
Laboratory
Standards

Lab041 3. Security/Confidentiality HAAD Limited access to rooms or files and staff's passward
Clinical
Laboratory
Standards
STANDARD OPERATING PROCEDURES (SOPS):
Lab045 Test Summary monitoring list Is prepared HAAD Once the SOPS are completed for each test, approved, and reviewed by the staff,
Clinical an SOP minitoring list shall be completed for convenient monitoring of completion
Laboratory and dates for re- review
Standards

INTERNAL QUALITY ASSURANCE/CONTROL (QA/QC):

Lab046 Policy for each Instrument /system HAAD Internal quality control policy/procedure shall be written for each instrument
Clinical describing the daily QC process and the number of controls (muse include the low
Laboratory and high QC)
Standards
Lab047 Detailed SOP foe each test HAAD Each test must have a section on internal and external quality control, describing
Clinical the level and frequency.
Laboratory
Standards

External QUALITY ASSURANCE/PROFICIENCY TESTING (EQA/PT):

Lab049 Policy for each Instrument/System HAAD external quality assurance policy shall be prepared for each instrument descibing
Clinical the levels used and the frequency
Laboratory
Standards

Lab050 File for each instrument HAAD There shall be an external QA for each file
Clinical
Laboratory
Standards
Lab051 Reviewed with dated Signatures HAAD All external QA reports shall be approved by the apthologist and signed with dates
Clinical by each staff.
Laboratory
Standards
Lab052 Retained EQA reports and results HAAD ALL EQA reports shall be retined as per established policy and not less that the
Clinical required period by Haad
Laboratory
Standards
LAB PRACTICE: SIFIC SECTION FINDINGS
Blood Bank/Transfusion
Lab056 Policies HAAD Blood Transfusion detailed policy shall be prepared with all related logging and
Clinical reporing sheets.
Laboratory
Standards
Lab058 Internal Quality Control HAAD A daily QC for ALL ABO, RhD, and other tests shall be performed and documented.
Clinical
Laboratory
Standards
Lab059 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Chemistry/ Special Chemistry
Lab061 Policies HAAD Clinical chemistry detailed policy shall be prepared with all related logging and
Clinical reporing sheets.
Laboratory
Standards

Lab063 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards

Lab064 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Hematology
Lab066 Policies HAAD Hematology detailed policy shall be prepared with all related logging and reporing
Clinical sheets.
Laboratory
Standards

Lab068 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab069 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Coagulation
Lab071 Policies HAAD Coagulation detailed policy shall be prepared with all related logging and reporing
Clinical sheets.
Laboratory
Standards

Lab073 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab074 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards

Flow Cytometry
Lab076 Policies HAAD Flow Cytometry detailed policy shall be prepared with all related logging and
Clinical reporing sheets.
Laboratory
Standards

Lab078 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards

Lab079 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Special Hematology
Lab081 Policies HAAD Flow Cytometry detailed policy shall be prepared with all related logging and
Clinical reporing sheets.
Laboratory
Standards

Lab083 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards

Lab084 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards

Immunology
Lab086 Policies HAAD Immunology detailed policy shall be prepared with all related logging and reporing
Clinical sheets.
Laboratory
Standards

Lab088 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab089 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards

Serology

Lab091 Policies HAAD Immunology detailed policy shall be prepared with all related logging and reporing
Clinical sheets.
Laboratory
Standards

Lab093 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab094 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards

Virology

Lab096 Policies HAAD Virology detailed policy shall be prepared with all related logging and reporing
Clinical sheets.
Laboratory
Standards
Lab098 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab099 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Clinical Microbiology
Lab101 Policies HAAD Clinical Microbiology detailed policy shall be prepared with all related logging and
Clinical reporing sheets.
Laboratory
Standards
Lab103 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab104 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Lab105 Secure HAAD The department shall be secure with limited access with access card/code
Clinical
Laboratory
Standards
Lab108 Autoclave An autoclave and autoclave room shall be available that meets Haad standard

Lab109 Negative pressure HAAD Negative pressure measurement device shall be installed
Clinical
Laboratory
Standards
Clinical Microscopy
Lab112 Micrometer calibration HAAD Evidence that the micrometer test is perfored regularly
Clinical
Laboratory
Standards
Molecular Biology
Lab118 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab119 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Histopathology
Lab121 Air Filter HAAD Air Filter shall be available, monitored and changed requlary
Clinical
Laboratory
Standards
Lab124 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab125 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Lab126 Storage HAAD All documents shall be stored in a secure location and cabinets
Clinical
Laboratory
Standards
Lab127 Retention HAAD All documents shall be retained as per policy and not less than the haad required
Clinical retention period
Laboratory
Standards
Cytopathology
Lab129 Air Filter HAAD Shall be available and monitored regularly
Clinical
Laboratory
Standards
Lab132 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Lab133 External Quality Assurance Laboratory
Standards
Lab134 Storage HAAD All documents shall be stored in a secure location and cabinets
Clinical
Laboratory
Standards
Lab135 Retention HAAD All documents shall be retained as per policy and not less than the haad required
Clinical retention period
Laboratory
Standards
TB Lab
Lab137 Air Filter HAAD Shall be available and monitored regularly
Clinical
Laboratory
Standards

Lab139 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab140 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Lab141 Storage HAAD All documents shall be stored in a secure location and cabinets
Clinical
Laboratory
Standards
Lab142 Retention HAAD All documents shall be retained as per policy and not less than the haad required
Clinical retention period
Laboratory
Standards
Metabolic Disorder lab
Lab144 Air Filter HAAD Shall be available and monitored regularly
Clinical
Laboratory
Standards

Lab146 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards

Lab147 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Lab148 Storage HAAD All documents shall be stored in a secure location and cabinets
Clinical
Laboratory
Standards
Lab149 Retention HAAD All documents shall be retained as per policy and not less than the haad required
Clinical retention period
Laboratory
Standards
Cytogenetic Lab
Lab151 Air Filter HAAD Shall be available and monitored regularly
Clinical
Laboratory
Standards
Lab153 Internal Quality Control HAAD A daily QC shall be performed for ALL tests and documented.
Clinical
Laboratory
Standards
Lab154 External Quality Assurance HAAD As scheduled, External QA testing shall be performed, reviewed, approved,
Clinical documentd, and retained.
Laboratory
Standards
Lab155 Storage HAAD All documents shall be stored in a secure location and cabinets
Clinical
Laboratory
Standards
Lab156 Retention HAAD All documents shall be retained as per policy and not less than the haad required
Clinical retention period
Laboratory
Standards
Comments: No Comment
b. Blood collection
Facility, Furniture, Safety and Security
BC001 1. Room size > 3X3m2 (as per HA-AD HAAD DR.2.5 HAAD HEALTH FACILITY GUIDELINES , HEALTH FACILITY AND BREIFING AND
Facility Standards) Clinical DESIGN,FUNCTUNATIONAL PLANNIGN UNIT, PATHOLOGY UNIT
Laboratory
Standards
BC002 2. Furniture shall Include:
BC002.1 a. Blood Collection Reclining chair that HAAD DR.2.5 The nurse should be able to adjust the chair to recline it incase if the patient faint.
allows 12” height above the heart for the Clinical
foot piece Laboratory
Standards
Blood collection Policies & SOPs
There shall be a properly indexed Blood HAAD PP.1 all the policies and procedures should be available and accessible by the
collection file with: Clinical phlebotomists
Laboratory
Standards
BC007 1. Blood collection Policies (Patient ID, HAAD PP.1,PP.4 check preanalytical requirements as listed in PP.4
Samples handling and preservation, and Clinical
transportation) Laboratory
Standards
2. Standard Operating Procedure (SOP) for HAAD according to the scope of practice and procedures list, check written policies and
Venous and capillary blood collection. Clinical procedures that are developed to provide specimen collection protocols for each
Laboratory type of specimen submitted to the laboratory. This is also applicable for areas
BC008 Standards PP.1,PP.4 out side of the blood collection area where health care professionals
other than lab staff collect specimens, i.e nurses in wards ,

BC009 3. SOP for the collection of any special HAAD PP.1,PP.7 locate SOP in each are that practice specimen colelction(electronic or hard copies)
blood samples (e.g., blood culture, GTT, ..., Clinical
etc). Laboratory
Standards
BC010 4. If applicable, SOP for the proper HAAD PP.1,PP.7 locate SOP in each are that practice specimen colelction(electronic or hard copies
collection of all collected non-blood samples Clinical
(Urine, Culture Swaps, Laboratory
…, etc Standards

Staff and Staff Competency

BC015 1. Copies of evidence of Job description, HAAD LP.5 The list should be available including the name of the staff who are trained and
Orientation, On-going training and Clinical authorized to perform in the phlebotomy room (only names). Competency and
competency (Last two)on using the Laboratory other requirements should be available in the personal file of the staff.
Vacutainer, Syringe, Butterfly and Capillary Standards
blood collection, for the authorized staff to
perform the blood collection in the
phlebotomy room. (includeing thier names in
a list)

Blood Collection Log/Sheets/Books/IT

BC016 1. Soft and/or hard copies of records shall HAAD DR.2.6,PP. it should be secured and accessible only by the staff
be maintained and retained for patients that Clinical 12.2
had their blood collected. And it should be Laboratory
secured 24/7. Standards

BC017 2. The record shall have the date. Sequence HAAD PP.9 if it is hard copy, it should be written in a fixed style without leaving gaps or empty
number, patient’s full name. Patient’s unique Clinical spaces Corrector should not be applied to remove errors from the book, only cross
identifier (file number), gender, ordering Laboratory and signature of the one who make the correction.
doctor, , fasting status, type and number of Standards
collected tubes, comments section, and the
timed signature of the phlebotomist who
collected the blood.

Blood Collection Materials and Expiration Date Monitoring

BC019 1. There shall be a mechanism (Policy, SOP, HAAD PP.12.2 Auditor requested document
Protocol) with a recording system for the Clinical
systematic monitoring of blood collection Laboratory
materials. Standards

BC020 2. There shall be a noted evidence (dated HAAD PP.12.2 Auditor requested form
signature with comment/s) that these Clinical
records are monitored by the designated Laboratory
center/clinic/lab staff. Standards
Specimens labeling (patient& Phlebotomist)
BC021 1. Proper label must have, but not limited to, HAAD PP.9 Time of collection should be written by the phlebotomist, not only electronically.
Patients full name, Unique ID number, Clinical Because there is a time gap between printing the sticker and the actual time of
Location (OPD/ER/room number) Laboratory collecting the blood.
Phlebotomist signature/date and time of Standards
collection

BC022 2. If a sticker is used, the phlebotomist shall HAAD PP.9 To prevent any misuse or alteration the actual information, in other words to
initial across the sticker after posting in the Clinical prevent any one to put another sticker with another patient information on the
blood collection logbook/computer. Laboratory actual sticker. So to apply the sticker then initial cross between the sticker the page
Standards of the logbook.

Blood Collection Errors/incidents Monitoring Records (hematoma/>2

Sticks)
 Monitoring log sheets shall be developed for HAAD LP.5,Audito The form should be available or the way of reporting incidents (which be included
phlebotomists to record the occurrences Clinical r requested in the policy). In addition, the action taken after the incidents should be available as
associated with Material Defects ( Tubes Laboratory form well.
without Vacuum, Defective syringes, Non- Standards
polished needles, …, etc); Patient’s
BC023 discomfort [multiple sticks (>1) Fainting];
and patient injuries (Needle stick and
tripping)

Specimens Rejection: monitoring Records

BC024 1. There shall be a mechanism (Policy, SOP, HAAD PP.9.4 REVIEW REJECTION LOGS FOR SAMPLE REJECTION , TRACE SOURCES,
Protocol) with a recording system for the Clinical FREQUENCY, CORRECTION PLANS
systematic monitoring of the different types Laboratory
of samples rejection. Standards

Blood/Specimens Processing, Preservation and Transportation

Commissioning, Calibration & PPM Reports (Centrifuge & Refrigerator/s):

BC028 Calibration report HAAD E.12.1,IE.1 review historical file for each instrument
Clinical 3.3 B
Laboratory
Standards
BC029 Electrical Safety Test report and Printout HAAD IE.14.1 review historical file for each instrument
Clinical
Laboratory
Standards
Refrigerator Temperature monitoring & Temperature Stability test ( using
Grade-A Internal Thermometer)
BC030 Temperature stability at all shelves is HAAD REVIEW HISTORICAL FILE AND DOCUMENTATION
performed (once per year) Clinical
Laboratory
BC031 24/7 Temperature monitoring records (Temp. HAAD IE.6,IE.8,I. REVIEW HISTORICAL FILE AND DOCUMENTATION
Chart or tracer) Clinical E.12.2
Laboratory
Standards
BC032 Evidence of monitoring all Temperature and HAAD I.E.12.2 REVIEW HISTORICAL FILE AND DOCUMENTATION
Centrifuge records (dated signatures & Clinical
comments) Laboratory
Standards

Centrifuge Daily care/Calibration/ PPM Reports:

BC033 Daily care (cleaning inside (Balance HAAD Auditor Log sheet should be available and checked daily by the responsible staff.
buckets) and outside) Clinical requested
Laboratory form
Standards
Specimens Transport Sheet:
Includes, Full name Unique ID, Total & type HAAD DR.2.5 Should be available and clear step by step as mentioned in the point (concern on
of tubes Clinical PP.9 the left). The staff (phlebotomists) should be aware of the full journey of
(Red, Lavender) & sample (Serum Plasma), Laboratory transporting the specimens.
tubes position should be vertical and contact Standards
with frozen or Cold Back, Seal Number or
Key-lock, tech and driver’s timed names &
BC035 signatures. Temperature should be written
and approved at each station; departure,
with the driver once received by him and the
final destination once received in the lab.

Specimens preparation for Transport: (temperature monitoring, isolation

from Cold Pack, and Security Lo)
Completed Sample Transport sheet and locked HAAD
(secure) container Clinical
Laboratory
Standards,D
BC036 EPART SF.3.1 REVIEW TRANSPORT SHEET
MENT
REQUIREM
ENT

Specimens Transport Sheet is available and completed by Sending and

Receiving Facilities:

BC037 Copy of send out sheet are available and HAAD DR.2.5 The copy should be available at the phlebotomy location soft or hard copy, to
retained as per policy. Clinical protect the specimens and the staff. Everyone is responsible.
Laboratory
Standards
Reporting of Suspicious & Positive Infectious diseases Results
Policy & Procedure for Reporting Positive infectious disease results

BC040 Evidence that the ordering physician is HAAD PP.11 The pathologist should make sure that the physician report to HAAD and he
informed as well as Haad Clinical should have a copy or trucking sheet of the process.
Laboratory
Standards
Comments: No Comment
c. Point of care testing
Policies & SOPS
POCT00 POCT Program: HAAD/POCT The program include all the points below
1 /SD/0.9
POCT00 2. POCT Policy HAAD/POCT 1.1,6.1.5 all the policies and procedures should be available and accessible by the
2 /SD/0.9 phlebotomists

POCT00 3. Retention of record Policy HAAD/POCT Auditor all the policies and procedures should be available and accessible by the
3 /SD/0.9 requested phlebotomists
,3.1.4
POCT00 4. SOP for capillary blood collection HAAD/POCT 9.1.2 all the policies and procedures should be available and accessible by the
4 /SD/0.9 phlebotomists
POCT00 5. SOP for the use of each POCT device HAAD/POCT 9.1.2 all the policies and procedures should be available and accessible by the
5 (e.g., Glucometer) /SD/0.9 phlebotomists
POCT00 6. SOP For the QC program/materials, HAAD/POCT 9.1.2 all the policies and procedures should be available and accessible by the
6 analysis and records /SD/0.9 phlebotomists

POCT00 7. SOP for the EQA program / Materials and HAAD/POCT 9.1.2 all the policies and procedures should be available and accessible by the
7 records /SD/0.9 phlebotomists Applicable only for hospitals and clinic or medical centers who have
a lab.

Competency of Staff
POCT00 1. List of trained health professional staffs HAAD/POCT 8 The list should be available including the name of the staff who are trained and
8 that are authorized to perform POCT in each /SD/0.9 authorized to perform in the POCT station (only names). Competency and other
POCT station. requirements should be available in the personal file of the staff.

POCT01 3. Copies of last 2 training/competency HAAD/POCT 8 Should be available in the personal file of the staff
0 documents for each POCT device /SD/0.9
type/system. And on how to perform, log
and interpret QC recorded results.

Equipment/Materials Used: Disposable auto-lancets / single person uses

vs. multi-persons used
devices)
POCT01 1. POCT Instrument/s Validation and regular HAAD/POCT 7.1.3 REVIEW RECORDS OF VALIDATION AND MAINTENANCE UNLESS
2 maintenance /SD/0.9 MANUFACTURERS SPECIFY OTHERWISE.
POCT01 2. It is strongly recommended that POCT HAAD/POCT 7.1.5 The device should be for multi-patient as recommended by manfacture
3 devices for multi - persons use be used /SD/0.9
instead of single person use devices.

POCT01 3. Single use and disposable lancets shall HAAD/POCT Auditor Pen should not be used with the multi-stick lancets, Pen is a source of infection
4 be used and NOT the Multi-Stick lancets’ /SD/0.9 requested Disposable lancets should be used as shown in the picture as example
pen item
POCT01 4. Minimum of two QC levels (Low & High) HAAD/POCT 10.1.2 The open date should be available on the bottle of QC
5 shall be performed daily, once per shift (8 /SD/0.9
hours) and before the first patient.

Daily IQC and Correlation Statistics Log Sheets: (3-month QC & analysis
records)
1. Daily QC recording, monthly statistical
analysis of the recorded results, and
POCT01 correlation between devices shall be HAAD/POCT The record should be available and checked (daily or monthly) by the responsible
7.1.8
6 performed, monitored and retained /SD/0.9 staff

POCT01 The last 3 monthly recording sheets and HAAD/POCT 10.1.2 Should be shared with the staff
7 their Statistical analyses shall be kept in the /SD/0.9
POCT File
EQA program and records: (last two reports & Shared with Staffs)

POCT01 1. Each POCT device shall be enrolled in HAAD/POCT 10.1.5 Applicable only for hospitals and clinic or medical centers who have a lab.
7 EQA program /SD/0.9

POCT01 2. The last 3 EQA reports shall be filed and HAAD/POCT 10.1.2 Applicable only for hospitals and clinic or medical centers who have a lab.
8 shared will all staff /SD/0.9

POCT01 3. For facilities affiliated with hospital or HAAD/POCT 10.1.5 Applicable only for hospitals and clinic or medical centers who have a lab.
9 referral lab, it is required that EQA program /SD/0.9
is implemented and monitored by the lab
director.

POCT Program Management Committee and team:

POCT02 Point of care testing (POCT) committee HAAD/POCT DR.2, Applicable only for hospitals and clinic or medical centers who have a lab.
0 shall be formed under the leader ship of the /SD/0.9 STANDAR
medical director and the lab director, if the D 2,6
facility has a laboratory

Comments: No Comment

Audit Total Score: #DIV/0!

Remarks