‫التقييم‬ ‫‪Column1‬‬

‫الشروط العامة‬ ‫م‬

‫رسم هندسى معتمد من مهندس نقابى للمبنى بقياس رسم ‪1/150‬‬ ‫‪1‬‬
‫مايفيد مالءمة المبنى الداء الغرض المنشأ له فنيا وتقنيا وصحيا‬ ‫‪2‬‬
‫توضيح توزيع وتقسيمات وحدات المبنى الداخلية بالتفصيل كل طابق على حده فى حالة تعدد الطوابق‬ ‫‪3‬‬
‫ان تكون حجرات المنشأة الطبية جيدة التهوية واالضاءة‬ ‫‪4‬‬
‫ان تكون المنشاة مزودة بوسائل تغذيتها بالمياه النقية بصفة مستمرة‬ ‫‪5‬‬
‫ان تكون المنشاة مزودة بوسائل الصرف الصحى المناسبة‬ ‫‪6‬‬
‫ان تزود المنشاة بالوسائل واالدوات الصحية الالزمة للتخلص من القمامة والفضالت‬ ‫‪7‬‬
‫ان تزود المنشاة باالجهزة الالزمة الطفاء الحريق‬ ‫‪8‬‬
‫شهادة من إدارة الدفاع المدنى والحريق بتوفر االشتراطات الالزمة لحماية المركز من الحريق‬ ‫‪9‬‬
‫ان تكون المنشأة مزودة بوسائل االسعافات االولية‬ ‫‪10‬‬
‫شهادة تداول المواد والنفايات الخطرة‬ ‫‪11‬‬
‫ما يفيد التعاقد مع محرقة للنفايات الطبية‬ ‫‪12‬‬
‫التقدم بخطة محدد بها االسلوب الذى سوف يتبع لمنع انتشار العدوى بالمنشاة‬ ‫‪13‬‬
‫التقدم بخطة محدد بها االسلوب الذى سوف يتبع للتخلص االمن من النفايات‬ ‫‪14‬‬
‫بيان واضح باالجهزة الموجودة للتشغبل‬ ‫‪15‬‬
‫التقدم ببيان من أطباء وتمريض وفنيين وخالفه‬ ‫‪16‬‬
‫صور تراخيص مزاولة المهنة لالطباء وهيئة التمربض والفنيين‬ ‫‪17‬‬
‫تعهد بااللتزام بتنفيذ االشتراطات الفنية والصحية المحددة بالقانون رقم ‪ 51‬لسنة ‪ 1981‬الخاص بالمنشات الصحية والئحته التنفيذية والقرارات‬
‫‪18‬‬
‫الوزارية المكملة وتعديالته بالقانون ‪ 153‬لسنة ‪2004‬‬
‫‪19‬‬
‫‪20‬‬
‫‪21‬‬
‫‪22‬‬
‫‪23‬‬
‫‪24‬‬
‫‪25‬‬
‫‪26‬‬
‫‪27‬‬
‫‪28‬‬
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 ‫‪31‬‬
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‫‪33‬‬

‫المجموع‬
‫اإلجمــــالى‬
‫النسبة‬
‫المدة الزمنية‬ ‫المسئول‬ ‫````````````````````````````````````````````````````````````````````````‪1‬‬
‫االجراء التصحيحى‬
 M
The patient’s safety policy defines Egyptian & WHO Patient Safety Docum.
recommendations & solutions, including at least the following:
NSR.1.1 Accurate standardized patient identification in all service areas.
NSR.1.2 Standardized process for dealing with verbal or telephone orders
NSR1 NSR.1.3 Handling critical values/tests
NSR.1.4 Hand hygiene throughout the organization
NSR.1.5 prevention of patients risk of falling

Implem.

Met
At least two (2) ways are used to identify a patient when giving medicines, blood, Docum.
or blood products, taking blood samples & other specimens for clinical testing,
&/or providing any other treatments or procedures .
NSR2
Implem.

Met
A process for taking verbal or telephone orders & for the reporting of critical test Docum.
results, that requires a verification by write down and "read-back" of the
complete order or test result by the person receiving the information is
NSR3 implemented
Implem.

Met
Current published & generally accepted hand hygiene guidelines, laws & Docum.
regulations are implemented to prevent healthcare-associated infections.
NSR4
Implem.
 Each patient's risk of falling, including the potential risk associated with the Docum.
patient's medication regimen, is assessed & periodically reassessed. Action is
taken to decrease or eliminate any identified risks of falling
NSR5
Implem.

Met
Astandardized system for patient referral process including feedback Docum.
mechanism is implemented
NSR6
Implem.

Met
Policy & Procedures for medication management safety including at least the Docum.
following:
NSR. 7.1 Abbreviations not to be used throughout the organization
NSR.7.2 Documentation & communication of patient's current medications &
discharge medication
NSR 7 NSR.7.3 Labeling of medications, medication containers & other solutions
NSR.7.4 Prevent errors from high risk medications
NSR.7.5 Prevent errors from look-alike, sound-alike medications

Implem.

Met
Abbreviations not to be used throughout the organization are: • U/ IU • Q.D., QD, Docum.
q.d., qd. • Q.O.D., QOD, q.o.d., qod. • MS, MSO4 • MgSO4 • Trailing zero (5.0) • No
leading zero ( .5) • Dose x frequency x duration
NSR8
Implem.

Met
A process is implemented to obtain and document a complete list of the patient's Docum.
current medications upon assessment and with the involvement of the patient.
NSR9
 A process is implemented to obtain and document a complete list of the patient's
current medications upon assessment and with the involvement of the patient.
NSR9
Implem.

Met
All medications, medication containers (e.g., syringes, medicine cups, basins), Docum.
&/or other solutions are labeled.

NSR10
Implem.

Met
High risk medication are identified , stored and dispensed to assure that risk is Docum.
minimized

NSR11

Implem.

Met
Look-alike & sound-alike medications are identified, stored & dispensed in a way Docum.
which assures that risk is minimized.
NSR12
Implem.

Met
Policy & Procedures for surgical procedures safety including at least the Docum.
following:

NSR.13.1 Preoperative marking of site of surgery

NSR.13.2 Process for preoperative verification of all documents & equipment
needed for surgery procedures .
NSR13 NSR.13.3 Accurate documented patient identification preoperatively, and just
before surgery (time out).
 Policy & Procedures for surgical procedures safety including at least the
following:

NSR.13.1 Preoperative marking of site of surgery

NSR.13.2 Process for preoperative verification of all documents & equipment Implem.
needed for surgery procedures .
NSR13 NSR.13.3 Accurate documented patient identification preoperatively, and just
before surgery (time out).

Met
The precise site where the surgery will be performed is clearly marked by the Docum.
physician with the involvement of the patient.
NSR14
Implem.

Met
A process or checklist is developed & used to verify that all documents & Docum.
equipment needed for surgery or invasive procedures are on hand, correct &
functioning properly before the start of the surgical procedure.
NSR15
Implem.

Met
There is a documented process of accurate patient identification preoperatively Docum.
& just before starting a surgical or invasive procedure (time out), to ensure the
correct patient, procedure, & body part
NSR16
Implem.

Met
 There is a well-structured & implemented fire & smoke safety plan that Docum.
addresses prevention, early detection, response, & safe exit when required by
fire or other emergencies & including at least the following:
NSR.17.1 Frequency of inspecting fire detection & suppression systems,
including documentation of the inspections
NSR.17.2 Maintenance & testing of fire protection & abatement systems in all
areas
NSR17 NSR.17.3 Documentation requirements for staff training on fire response &
evacuation
NSR.17.4 Assessment of fire risks when construction is present in or adjacent to
the facility Implem.

Met
Fire drills are conducted at least quarterly in different clinical areas & during Docum.
different shifts, including
at least one unannounced fire drill annually.
NSR18
Implem.

Met
There is a well-structured & implemented plan for hazardous materials (Hazmat) Docum.
& waste management for the use, handling, storage, & disposal of hazardous
materials & waste addressing at least the following:
NSR19.1 Safety & security requirements for handling & storage
NSR19.2 Requirements for personal protective equipment
NSR19.3 Procedures & interventions to implement following spills & accidental
NSR19 contact or exposures
NSR19.4 Disposal in accordance with applicable laws & regulation
NSR19.5 Labeling of hazardous materials & waste
NSR19.6 Monitoring data on incidents to allow corrective action Implem.

Met
There is a well-structured & implemented safety & security plan/s Docum.
NSR20
 There is a well-structured & implemented safety & security plan/s
NSR20
Implem.
Met
The hospital has well-structured & implemented radiation safety program Docum.
NSR21
Implem.
Met
There is a well-structured & implemented Laboratory & pathology safety Docum.
NSR22 program.
Implem.
Met
There is a well-structured & implemented plan for selecting, inspecting, Docum.
maintaining, testing, & safe usage of medical equipment that addresses at least
the following: :
NSR23.1 Inventory of all medical equipment
NSR23.2 Schedule for inspection and preventive maintenance according to
manufacturer's recommendations and frequency of repair and breakdown.
NSR23.3 Testing of all new equipment before use and repeat testing, as part of
the preventive maintenance
NSR23 NSR23.4 Testing of alarm systems including clinical alarm
NSR23.5 Qualified individuals who can provide these services.
NSR23.6 Data monitoring for frequency of repair or equipment failure.
NSR23.7 Ensure only trained and competent people handle specialized Implem.
equipment.

Met
 There is a well-structured & implemented plan for regular inspection, Docum.
maintenance, testing & repair of
essential utilities addressing at least the following:
NSR24.1 Electricity; including stand-by generators
NSR24.2 Water
NSR24.3 Heating, ventilation, & air conditioning including; air flow in negative &
positive pressure rooms, appropriate temperature, humidity, & odors eliminates
NSR24.4 Medical gases
NSR24.5 Communications systems
NSR24.6 Waste disposal
NSR24.7 Regular inspections
NSR24.8 Regular testing
NSR24 NSR24.9 Regularly scheduled maintenance Implem.
NSR24.10 Correction of identified risks & deficiencies

SCORE
TOTAL
%
 In prog. NM ‫اسباب عدم التطابق‬ ‫االجراء التصحيحي‬

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

In progress Not Met

‫المسئول عن التنفيذ‬ ‫‪ ...‬المدة الزمنيه من ‪ ..‬الى‬ ‫مالحظات‬
‫االجراء التصحيحى‬ ‫اسباب عدم التطابق‬ ‫التقييم‬ ‫المعيار‬
1. Unit overview:
a. A brief general description of the unit .
b. Scope of services.
c. Organizational charts
d. NO Smoking policy
e. Internal and external communication processes
f. Contract oversight/ monitoring
2. Management of information system:
a. Data management plan
b. List of approved & prohibited abbreviations
c. Data retention process.
d. Data backup process.
3. Medical record:
a. Initiation
b. Contents and organization
c. Medical record release
d. Tracking
e. Retention/storing
f. Standardized coding system
h. Medical record destruction
i. Standardized forms
j. Monitoring of medical record completion
4. Provision of Care
a. Consistent process of registration
b. Patient identification policy
c. Uniform care process
d. patient assessment
e. Communication with patient having special communication
needs.
f. Effective system to provide cardiopulmonary resuscitation
across all areas
g. Pain management.
h. Plan of care development
i. Referral (and transport) to other organization.
5. Quality management & Patient safety:
a. Quality improvement , Patient safety & risk management plans

b. OVR management system

c. Sentinel events management system.
d. Process to prevent wrong patient , wrong site ,wrong surgery
/procedure,including not limited to:
i. Site marking
ii. Time out
e. Patient fall:
i. Identification of patient at risk
ii. Assessment
iii. Intervention
f. Verbal and telephone communication.
6. Infection prevention and control:
a. Infection prevention and control structure
b. Infection prevention and control plan
c. Handling sharps
d. Standard and transmission based precautions.
e. Housekeeping P&P:
i. A list of all environmental services to be cleaned
ii. Schedule of cleaning
iii. Procedures to be used
iv. Agents to be used
f. Handling blood /body fluids spills
g. Safe disposal of medical waste.
h. Laundry:
i. Linen management
ii. Handling , transfer and storage of clean linen
i. Personnel protective equipment use.
j. Proper hand hygiene practices
k. Reporting of communicable diseases to relevant authorities
l. Employees' immunization & post exposure management.
m. Safe injection practices
7. Effective patient & family education process
8. Patient & family rights:
a. Patient & family rights and responsibility statement.
b. Patient privacy throughout the care process.
c. Protection of Patient belongings
d. Patient protection against abuse, unauthorized access.
e. Informed consent policy
f. Dealing with patient who refuse treatment
g. Patient complaints policy
9. Radiology service:
a. Radiation safety policy
b. Reporting critical results
c. Proper staffing
10. Medication management:
a. Medication management plan including:
i. Procurement
ii. Storage
iii. Prescribing
iv. Preparing
v. Dispensing
vi. Administration
vii. Monitoring
b. Handling high alert medications
c. Handling look-alike & sound-alike (LASA) medications
d. Storage & safe management of hazardous medications and
pharmaceutical chemicals
e. Accessibility, availability, monitoring & security of emergency
medications.
f.Verbal orders of medications
f. Labeling of medications
g. Infection prevention and control in pharmacy
h. Handling recalled, discontinued and damaged medications.
i. Pharmaceutical outpatient education and counseling
j. Handling adverse drug reactions
i. Handling medication errors
11. Dental services:
a. Scope of serices
b. Comprehensive assessment
c. Dental policies
d. Informed consent
e. Infection control in dental services.
12. Laboratory services:
a. Clear scope of services
b.Physical structure
c. Staffing plan and qualifications
d. Comprehensive training and competency assessment program.

e. laboratory safety program

f. infection control training program
g. Requests for laboratory tests
h. Contract oversight
i. Specimen collection, handling and management
j. Correct specimen labeling
k. Quality control of test methods
l. Results reporting including
i. Contents of its reports.
ii. critical results reporting
13. Facility Management and Safety
a. The facility management and safety program including the
following written and approved plans:
i. Safety of the Building.
ii. Security.
iii. Hazardous materials and waste disposal.
iv. External emergency.
v. Internal emergency.
vi. Fire Safety.
vii. Medical equipment.
viii. Utility
score
total
%
‫المدة الزمنية‬ ‫المسئول‬
‫االجراء التصحيحى‬ ‫اسباب عدم التطابق‬ ‫التقييم‬ ‫المعيار‬

1. Leadership manual including:

2. Administrative:
2 i. unit –Mission, Vision and Values Statement
2 ii. Unit Organizational Chart
2 iii. Leadership Structure
2 iv. Leadership Responsibilities
1 vii. Culture of Safety and Quality
2 viii. Leadership Support of Quality Initiative
Monitoring and Improvement Activities.
1 xii. Confidentiality of Information –General Rules
1 xiii. Community Needs Assessment
1 xv. Release of Patient Information to News Media
2 xvii. Dress code.
1 xviii. Disruptive and Inappropriate Behavior
b. Ethics:
1 iv. Sexual Harassment
1 v. Conflict of Interest
1 3. Governance Policy
1 4. Strategic and operational plans.
1 5. Departmental leadershippolicy
1 6. Contract monitoring policy.
1 7. Quality, Patient safety and risk management
plan/s)
1 8. Key performance indicators
1 a. Policy
1 b. indicators
2 9. unitl wide committees Structures and functions
12. Training program of unit leaders including not
limited to
2 a. Quality concepts, skills and tools.
11
1 c. Conflict resolution
1 d. Team management
1 e. Communication skills
1 f. Data management (as related)
g. Change management
score
total
%
‫المدة الزمنية‬ ‫المسئول‬
‫المدة الزمنية‬ ‫المسئول‬ ‫االجراء التصحيحى‬ ‫اسباب عدم التطابق‬ ‫التقييم‬ ‫المعيار‬
1. Staffing plans (Departmental &
2 unit wide )
1 2. Credentialing process.
1 3. Competency assessments
1 4. Privileging process.
5. Employee Manual including
not limited to the following
processes:
1 a. assignment and reassignment
1 b. staff appraisal
1 c. Staff complaints
1 d. Staff satisfaction
1 e. Code of conduct
1 f. Disciplinary actions
1 6. Medical Staff Bylaws.
1 7. Nursing Staff Bylaws.
1 8. Staff health program.
9. Job descriptions
1 a. policy
1 b. forms
10. New employee orientation
program:
0 a. general orientation program
0 b. specific orientation programs
11. Personnel file:
2 a. Initiation
2 b. Management
1 c. Contents
1 1
1 e. Retention time
1 f. Disposal
 12. Identification of staff training
1 & educational needs.
13. Ongoing scheduled
1 educational program.
14. Basic and advanced life
support certification (as related
1
score
total
%
general requirments
NSR
operation manual
leaderships requirment
workforce requirments
total