Kingdom of Saudi Arabia
Ministry of Health
Health Affairs of Hail Region
Regional Nursing Administration
ESSENTIAL SAFETY REQUIREMENTS – NURSING STANDARDS ACCOMPLISHMENT REPORT
HOSPITAL: MATERNITY AND CHILDREN’S HOSPITAL – HAIL
STANDARD ACTIVITY
AN.15  Moderate and Deep Sedation
Seminars and Training.
HR.5  Non- Saudi Staff - are required to
complete the verification process of
their License from the origin
country, School Credentials and
Employment Certificates from
SCFHS Date Flow Group.
 Saudi Staff – List of Saudi Staff
and Verification of College Degree
form was given to the Human
Resource Department for their
verification process.
PC 25  The newly revised Policy and
REQUIRED DOCUMENTS
(PER STANDARD)
 Certificate of attendance and
completion of trainings.
 Data Flow Results for School
Credentials, Employment
Certificates and License from the
country of origin.
 Using the two patient identifiers
‫المملكة العربية السعودية‬
‫وزارة الصحة‬
‫الشئون الصحية بمنطقة حائل‬
‫إدارة التمريض‬
March 2019
PERCENTAGE OF PROCEDURES TO ACHIEVE
COMPLETION STANDARD
25%  To coordinate with the Medical
Director to organized more
trainings and seminars for
clinical staff who are involved
in caring for patient receiving
moderate or deep sedation.
88%  Coordinates with the Head
Nurses to follow up new staff
compliance with the compliance
of SCFHS requirements
 Still waiting for the result from
the Human Resource
Department of the result of the
verification of Saudi Staff.
100%  Organized Quality Talk
 Procedure for Blood and Blood
Products administration and Blood
Transfusion Reaction has already
been in effect. Staff Orientation is
still on going to promote awareness
of the policy.
QM 17 Implementation of the Policy and
Procedure on Correct Patient
Identification
QM 18 There is an existing Policy and
for correct patient identification
prior the procedure.
 Cross matching sample with the
collecting and witnessing nurse
indicated in the blood request
form.
 Verification Process by double
checking of two staff nurses
prior to the start of the
procedure.
 Transfusion Reaction Form to be
completed and submitted if any
incident occurs.
 Using the two patient identifiers
(e.g. patient full name and
Medical Record Number)
before any procedure.
 Use of ID Band and patient are
involved in the identification
process.
 Surgical Safety Checklist - Sign
In, Time Out and Sign Out
procedure at Operating Room.
 Pre- Operative Checklist Form
Activity in the entire
department to be conducted by
the Quality Designees to
promote awareness among
staff nurses.
 Monthly Nursing Quality
Annual Mandatory Quality Re-
Program
 Continuous Competency
Program of CNE Department.
100%  Monthly Nursing Quality
Mandatory Re- Orientation
Program.
 Patient participates actively in
the process of patient
identification.
 Encourage staff nurses to
report incidences that requires
OVR.
 Regular Ground Rounds to
monitor the compliance.
100%  Continuous Competency
 Procedure in preventing wrong
patient, wrong site, and wrong
surgery/procedure.
NR.1 (1.1-1.6)  Nursing Director has passed and
met the qualifications set by the
CBAHI. She is a graduate of
Bachelor of Science Major in
Nursing. Has a License and
registered with the Saudi
Commission for Health
Specialties.
 There is an organizational chart
which indicates the departments
and job positions that are under
the supervision of the Nursing
Director.
 There is an existing Continuing
Nursing Education Department
and Quality Improvement
Department in MCH also under
the management of the Nursing
Director.
 In the absence of the Nursing
 Surgical Safety Checklist Form
– Sign In, Time Out and Sign
out procedure at operating room
 Appointment Certificate from
the Hospital Director and
Approval from the Ministry of
Health.
 Saudi Council Registration
Card and Basic Life Support
Certificate.
 Valid Education Credentials.
Program by the CNE
Department.
 Monthly Nursing Quality
Mandatory Re- Orientation
Program Lectures to promote
staff awareness of the policy.
 Regular Grand Rounds to
monitor compliance.
100%  Continuously attends Seminars
and Lectures related to the
improvement of Managerial
and Leadership Skills.
 The responsibility is
 Director, there is a Deputy
Nursing Director who will
assume the administrative and
clinical issues of the department.
NR.2 (2.1-2.4)  The Nursing Director is an active
member of the 17 hospital
committees.
NR.3 (3.1-3.8)  The Nursing Department has
policies and procedures duly
signed and approved by the
Nursing Director and Hospital
Director.
NR.4 (4.1.8-3.8)  The newly revised Departmental
Policies and Procedures Manual
are already distributed including
nursing reference manuals.
NR.4.2  Adherence to the Hospital
Policies and Procedures Manual.
 Our Nursing Director actively
participate in all the decision
making of the committee and
has met the required number of
attendance in all committee
meetings.
 Nursing Department Policies
and Procedures Manual.
 Hospital Administration
Policies and Procedures
Manual.
 Department Policies and
Procedures Manual.
 Nursing Department Policies
and Procedures Manual.
 Medical Records Review and
Quality Audit tool.
delegated / endorsed to the
Deputy Nursing Director in the
absence of the Nursing
Director.
100%  Regularly attends the
scheduled monthly hospital
committee meetings.
100%  Conducting CNE Ward
Lectures and Seminars to
promote knowledge and
awareness of staff nurses.
 Nursing Quality Improvement
Mandatory Re-Orientation
Program and Quality Talk to
enhance staff knowledge of the
Hospital Policies and
Procedures.
100%  The Policy and Procedure
Manuals are all available in all
the department and staff nurses
are aware of these manuals.
100%  Monthly Nursing Quality
Mandatory RE-Orientation
Program.
 Monthly Grand Rounds in all

NR.5.1  The Nursing Director is not
directly involved with the
recruitment and hiring although
she submits reports to the RNA
the staffing needs of MCH.
NR.5.2 (5.2.1-  There is an existing Competency
5.2.3) program Policy under the
Continuing Nursing Education
Department being supervised by
the Nursing Director.
NR.5.3 (5.3.1-  The newly revised Nursing
5.3.17) Competency Program has already
been in effect and implemented.
NR.6.1  There is a Policy and Procedure
for staffing plan as a basis for the
allocation and maintaining
adequate staffing level in each
department.
NR.6.2  Telford Method is being utilized
to obtain the correct the staffing
needs of each department.
NR.6.3  Some new Staff Nurses are not
allocated according to their
specialized area because some are
only here for training for King
Salman Specialist Hospital.
 Staff Allocation sometimes
 Nursing Competency Program
 Mandatory Competency
 Annual Unit – Specific
Competency.
 Written Competency Exam
Result on Staff file.
 Monthly Staffing Plan Report.
 Monthly Department Working
Schedule.
 Training Certificates,
Employment Certificates, and
Job Description, Delineation of
Privileges and Cross trainings.
Nursing Department.
100%  Nursing Competency Exam
 Annual Unit-Specific
Competency Exam
 Mandatory Competency Exam
100%  Nursing Competency Exam
 Annual Unit-Specific
Competency Exam
 Mandatory Competency Exam
100%  Updates staffing plan
regularly.
 Monitoring of Staff Turnover.
100%  Monitors Nurse Patient Ratio
 Patient Acuity
100%  Trainings and Seminars for
staff nurses not assigned to
their specialized area.
 Cross Training of Staff Nurses.
 depends on which department
need it the most due to shortage of
staff.
NR.7.1 (7.1.1-  Monthly Working Schedule in
7.1.7) every department.
 Yearly Submission of Vacation
Plan.
NR.7.2  The working schedule of every
department indicates the number
of staff on duty per shift.
NR.8.1  The Nursing Director ensures that
there is a Monthly Schedule for
Cross Training of Staff Nurses.
NR.8.2  Maintains a schedule for Staff
Cross Training.
NR.9.1  There is a Policy and procedure
for Staffing Plan and compliance
for SCFHS Registration and BLS
Registration.
 Monthly Working Schedule,
Annual Vacation plan, Hajj,
Ramadan Duty and CNE
lectures and training schedule.
 Monthly Working Schedule
and Department Unit
Assignment.
 Cross Training Policy
 Cross Training Program
Summary in Staff File
 Cross Training Program
Certification
 Cross Trained List from CNE
Department
 Data Flow for School
Credentials, Certificate of
Employment and License
from Country of Origin
 SCFHS Registration Card,
BLS Registration
 NRP, PALS and ACLS
Certification
100 %  Head Nurses are required to
submit their working schedule
monthly and yearly for
vacation plan.
100%  Head Nurses are required to
follow the staffing plan and the
required Nurse Patient Ratio.
100%  CNE Department assigns staff
for cross training in other
departments.
100%  All Head Nurses are given a
copy of the List of Cross
Trained Staff and is posted in
their designated department.
100%  Staffs are required to complete
the clearance with CNE
Department and Nursing
Quality Department to monitor
the expiry of its SCFHS and
BLS Registration.
 On - going NRP and PALS

NR.9.2  Appointment of qualified Head
Nurses to meet the CBAHI
Standards.
NR.9.3  There is a Credentialing and
Privileging Committee to screen
the qualification of Staff Nurses
NR.9.4  There is a Credentialing and
Privileging Committee to screen
the qualification of Staff Nurses
NR.9.5
 Leadership Training
Certificates
 Education enhancement
program Certificates from the
government
 School Credentials, License
from country of origin and
Training Certificates, Job
Description
 SCFHS License
 Data Flow Verification
Results
 Unit Specific Competency
Evaluation
 Delineation and Privileges
Form
 Annual Evaluation
Certification for NICU Staff
Nurses
 On – going ACLS certification
for OR, ER, Labor and
Delivery and ICU staff Nurses.
85%  Head Nurses who are Diploma
in Nursing are encouraged to
take Bridging Course to attain
a Bachelor’s Degree.
 Required to attend Leadership
Trainings and Seminars
100%  Staffs are required to maintain
the validity of their license
registration and certificates by
going through clearance from
CNE and Quality prior to
vacation application.
 Requirement for the renewal of
contract.
100%  Staffs are required to do the
Annual Competency
Assessment and Annual
Evaluation.
 Delineation of Privileges.
 N/A
NR.9.6
N/A
NR.9.7
N/A

NR.10.1  There is a Policy and Procedure  Nursing Assessment and 90%  CNE Mandatory Competencies
for Patient and Reassessment Reassessment form
 Grand Rounds and Nursing
Quality File Audit

NR.10.2  All standards are included in the 80%  Nursing Quality File Audit
(10.2.1-10.2.9) Hospital Policy and Procedure on  Nursing Assessment and
Patient Assessment and Reassessment form  CNE Mandatory Competency
Reassessment.

 Grand Rounds.

NR. 10.3  All standards are included in the  Nursing Assessment and 100%  Nursing Quality File Audit
Hospital Policy and Procedure on Reassessment form
Patient Assessment and  CNE Mandatory Competency
Reassessment

NR. 10.4  All staff nurses are required to  Nursing Assessment and 100%  Nursing Quality File Audit
adhere to the Patient Assessment Reassessment Form
and Reassessment Policy and  CNE Mandatory Competency
Procedure  Nursing Care Plan

NR. 10.5  On- going utilization of Nursing  Nursing Assessment and 100%  Nursing Quality File Audit
Assessment and Reassessment Reassessment Form
Form  CNE Mandatory Competency

NR. 11.1  On-going utilization of the  Nursing Care Plan 100%  CNE Mandatory Competency
 Nursing Care Plan Form
 Nursing Quality File Audit

NR. 11.2  Implementation of an  Nursing Care Plan 100%  CNE Mandatory Competency
individualized plan of care is
contained within the patient’s  Multidisciplinary form  Nursing Quality File Audit
record. Routine documentation of
 Patient Assessment and  CNE Ward Lectures
patient assessment, orders, patient
Reassessment
care and discharge planning is
considered evidence of care
planning.

NR. 11.3  At least one nursing care plan is
set every shift and non-resolution
of a problem will require the next
shift to carry on the plan until the
desired outcome is achieved or
new interventions are warranted
 Nursing Care Plan 100%  CNE Mandatory Competency
 Multidisciplinary form  Nursing Quality File Audit
 Patient Assessment and  CNE Ward Lectures
Reassessment

NR. 11.4  Planning the patient’s care based
on clinical, psychosocial,
teaching/learning, spiritual and
cultural needs, and other
identified individual needs
NR. 12.1  MCH maintains a record of all the
(12.1.1-12.1.16) equipment’s available in the
hospital and schedules Periodic
Preventive Maintenance to ensure
the safe use of the equipment.
 Nursing Care Plan 100%
 Multidisciplinary form
 Equipment Checklist Form 80%
 Medical Supply Checklist
Form
 PPM Monitoring Form
 Nursing Quality File Audit
 CNE Mandatory Competency
 CNE Mandatory Competency
 Regular Checking of PPM of
equipment

 Preventive Protective
Maintenance Form
 NR. 12.2  There is a Par Level Policy and  Par Level Form 100%  Monthly Grand Rounds
(12.2.1-12.2.4) Procedure being implemented
 Bed Linen and Gown  Nursing Quality Rounds
Monitoring Form
 Par Level Monitoring

Prepared by: Approved By:

Ms. Shiela May Olimpo,RN. Ms.Manar Saud Al Shammari,RN.

Quality Improvement Nurse Nursing Director