MS ByLaws 2018

MEDICAL STAFF
BY LAWS,
RULES
AND REGULATIONS
ABUARISH GENERAL HOSPITAL
ABUARISH, GIZAN, KSA
Table of Contents:
1 Acknowledgments
3 PREAMBLE
4 Section 1. INTRODUCTION:
5 Section 2. PURPOSE:
6 Section 3. DEFINITION:
8 Section 4. POLICY:
9 Section 5. MEDICAL STAFF BY LAWS, RULES AND REGULATIONS
50 Section 6. MATERIALS AND EQUIPMENT:
50 Section 7. REFERENCES:
PREAMBLE
WHEREAS
this Hospital is a corporation organized under the ministry of health laws.; and
WHEREAS,
its purpose is to serve as a general hospital providing patient care, education, and
research; and
WHEREAS,
it is recognized that the medical staff is responsible for the quality of medical care in
the hospital and must accept and discharge this responsibility, subject to the ultimate
authority of the hospital governing body, and that the cooperative efforts of the
medical staff, the chief executive officer and the governing body are necessary to
fulfill the hospital's obligations to its patients.
THEREFORE,
the physicians and dentists practicing in this hospital hereby organize themselves
into a medical staff in conformity with these bylaws.
Section 1. INTRODUCTION:
Abu Arish General Hospital is a healthcare facility that provides secondary medical services for the
community of Jazan. The Hospital aims for full utilization of available resources in the highest
standards of care services. The Hospital also supports the academic programs in different health care
aspects within its scope of services.
The Hospital recognizes that it is under the guidance and support of the Ministry of Health and
Ministry of Finance. The ultimate responsibility for the provision of care, staff development and
outcome of services is with the MOH Director appointed by the Ministry of Health. The Medical
Director holds responsibilities relevant to the conduct of the medical staff and the department and
services under his supervision.
Section 2. PURPOSE:
The purposes of the Medical Staff By Laws, Rules and Regulations are:
2.1. To facilitate provision of quality care to Hospital patients admitted to or treated in any of the
facilities, departments, or divisions of the Hospital regardless of race, gender, creed, disability or
national origin.
2.2. To create a system of self-governance, and to initiate and maintain rules and regulations
governing the conduct of the Medical Staff, subject to the ultimate authority and the standards set forth
by national and the relevant international accreditation agency or agencies that have been selected by
the Hospital.
2.3. To constitute a professional body to provide its Medical Staff members with mutual education,
consultation, and professional support, and to maintain a level of quality and efficiency.
2.4. To serve as the professional body through which individual practitioners may obtain
membership and clinical privileges at the Hospital.
2.5. To provide a method whereby the Medical Staff may participate in the decision-making process
pertaining to medical matters that may be resolved by the Medical Staff in collaboration with the
Hospital Executive Committee and the Directorate of Health Affairs.
2.6. To provide a means or method by which members of the Medical Staff can formulate
recommendations for the Hospitals’ policy-making and planning processes.
2.7. To prepare a mechanism whereby all physicians are systematically integrated into the Medical
Staff.
2.8. To assume the responsibility for the quality of professional services provided by individuals
with clinical privileges.
2.8. To provide a framework whereby medical staff members can understand their duties and
obligations so as to act with a reasonable degree of freedom and confidence
Section 3. DEFINITION:
For the purposes of these By Laws, the following terms shall have the meaning stated, unless the
context clearly requires otherwise. The meanings shall be equally applicable to the masculine/feminine
and singular/plural forms.
3.1. Allied Health Professional: an individual, other than a Practitioner (see definition below),
possessing qualifications in one of the categories of ancillary health care, which may be determined
from time to time to be beneficial to and required for patient care within the Hospital
3.2. Appeal: an application from a Practitioner who is the subject of a warning or limitation of
clinical privileges, and is requesting a reconsideration of the decision
3.3. Attending Physician/Most Responsible Physician (MRP): the qualified medical practitioner
or surgeon, possessing inpatient privileges, who is responsible for care of inpatients under his service
3.4. Board: means the Executive Board of Abu Arish General Hospital
3.5. Categories: description of the types of Medical Staff members according to status (e.g.,
Permanent, Trainee, Temporary)
3.6. Clinical Privileges: means authorization by the Board of the Hospital following
recommendation by appropriately authorized committees of the Medical Staff to provide specific
patient care and treatment services at the Hospital, based on the individual's license, education,
training, experience, competence and judgment
3.7. Contractual Relationships: means formal contractual relationships between the Hospital and
other institutions, organizations, groups, or physician members of the Medical Staff, to which contracts
have been approved by the appropriate Department Head and by the Hospital officials
3.8. Corrective Action: the process activated in the event of finding a substandard professional
practice
3.9. Emergency: a situation in which there is an immediate danger of loss of life or serious disability
and in which any delay in treatment might increase that danger
3.10. Ethics: moral principles and values adopted by the particular profession of each Practitioner
and/or Allied Health Professional, which shall be consistent with the policies of the Hospital and laws
within the Kingdom of Saudi Arabia
3.11. Head of Department: means the individual charged with the medical direction of a Division
3.12. Hospital: means Abu Arish General Hospital
3.13. Job Description: the legal document which describes in detail each authorized employee's
position in terms of organizational relationships, duties, responsibilities, and qualifications
3.14. Licensure: A license to practice in the indicated field of medicine issued from the Saudi
Commission for Health Specialties
3.15. Medical Staff: means the physicians, dentist, and other practitioners herein specified who
have been granted membership on the Medical Staff with clinical privileges to attend patients at the
Hospital.
3.16. Medical Students/Interns: means an individual enrolled in an undergraduate training

program affiliated with Abu Arish General Hospital
3.17. Nursing Staff: means certified nurse practitioners and certified nurse-midwives who are
authorized to provide patient care services in the Hospital because they are employees of the Hospital
or otherwise have defined responsibilities under contractual relationships
3.18. Notice: the oral or written transmission of information by posting within the Hospitals,
inclusion in publications distributed to the intended recipients, general announcements, telephone,
personal delivery, mail delivery, or any other means reasonably calculated to inform
3.19. Policy & Procedures: an authorized document that describe in details staff responsibilities,
how to carry out and conduct different processes and procedures and how to act in different situations
3.20. Practitioner: any physician or dentist licensed by the Saudi Commission for Health
Specialties (SCHS) to practice his profession within the Kingdom of Saudi Arabia
3.21. Peer Review: means the process that includes monitoring, evaluation, or action taken to
improve the delivery, quality and efficiency of health care services of Abu Arish General Hospital,
including but not limited to recommendations, consideration of recommendations, actions with regard
thereto, the implementation of these action
3.22. Physician: means an individual who has received a doctor of medicine degree and who is
currently fully licensed in the Kingdom to practice Medicine
3.23. Resident: means an individual pursuing specialty qualified and licensed under the supervision
of specialist and consultant who holds such licenses as are required by the Kingdom to provide patient
care services
3.24. Qualifications: all of the factors which are prerequisites to eligibility for, or which are relevant
to, the evaluation of an individual for a particular appointment or undertaking
3.25. Technician: this means staff assigned to perform specific technical and instrument task
(directly or indirectly) related to patient care supervision or unsupervised
3.26. Warning: a verbal or written communication issued by way of Corrective Action to a

Practitioner or Allied Health Professional indicating that his or her performance has been found to be
below acceptable standards and requiring improvement to be demonstrated
Section 4. POLICY:
4.1. The Hospital's Medical Staff By Laws shall govern the organization, functions, and
responsibilities of the medical staff.
4.2. The Medical Staff By Laws shall be approved by the governing body.
4.3. Medical Staff By Laws shall be consistent with acceptable medical staff practices and laws
and regulations.
4.4. The Medical Staff By Laws shall describe the organizational structure of the medical staff and
the reporting relationships, including all medical departments and committees.
4.5. The Medical Staff By Laws shall address:

4.5.1. The Medical Staff ranking and the qualifications required for each rank.
4.5.2. Categories of the medical staff membership (e.g., full time, part time, and locum).
4.5.3. Roles and responsibilities of the medical staff members.
4.5.4. Appointment, promotion, and reappointment of medical staff members.
4.5.5. The process for verification of the medical staff credentials.
4.5.6. Granting and maintaining clinical privileges, including temporary privileges (e.g., for
locums and emergency situations).
4.5.7. Disciplinary procedures for medical staff members, including corrective actions and
appeals.
4.6. The Medical Staff By Laws shall describe the acceptable standards of patient care and
professional conduct, including:
4.6.1. Admission, referral, transfer, and discharge processes.
4.6.2. Documentation in medical records.
4.6.3. The conduct of care expected for all levels of medical staff (e.g., daily rounds).
4.6.4. The professional conduct (e.g., handling ethical issues) of the medical staff.
4.7. The Medical Director and heads of medical departments shall ensure that the Medical Staff
By Laws are made accessible and communicated to all members of the medical staff.
4.8. The Medical Director and heads of medical departments shall enforce the Medical Staff By
Laws along with relevant rules and regulations.
Section 5. MEDICAL STAFF BY LAWS, RULES AND REGULATIONS:
5.1. ARTICLE I. Mission, Vision, Values and NAME
5.1.1. AAGH Mission Statement
The mission of the Abu Arish General Hospital is to provide the best medical service to
the patients in an atmosphere of mastery and safety.
5.1.2. AAGH Vision
The vision of the Abu Arish General Hospital is to be the best secondary care hospital in
Jazan Region.
5.1.3. AAGH Values
Teamwork.
Respect.
Honesty.
Sincerity.
5.2. Article II. PURPOSES:
The purposes of the Medical Staff By Laws, Rules and Regulations are:
5.2.1. To facilitate the provision of quality care to Hospital patients regardless of race, gender,
creed, disability or national origin;
5.2.2. To promote professional standards among members of the Medical Staff;
5.2.3. To provide a means whereby problems may be resolved by the Medical Staff in
collaboration with the Executive Committee and the Jazan General Directorate of Health Affairs;
5.2.4. To create a system of self-governance, and to initiate and maintain rules and regulations
governing the conduct of the Medical Staff, subject to the ultimate authority of the Executive
Committee.
5.3. Article III. MEDICAL STAFF ORGANIZATIONAL STRUCTURE
Membership in the Medical Staff of Abu Arish General Hospital follows the organizational
structure mentioned below, and illustrated in the Organizational Structure of the Medical Service.
(please refer to Attachment 6.1. for the illustration)
5.3.1. Hospital Director
5.3.2. Medical Director
5.3.3. Medical Executive Committee
5.3.4. Head of Departments
5.3.4.1. Accident and Emergency Department
5.3.4.2. Anesthesia Department
5.3.4.3. Dermatology Department
5.3.4.4. General Surgery Department
5.3.4.5. Laboratory & Blood Bank Department
5.3.4.6. Internal Medicine Department
5.3.4.7. Obstetrics and Gynecology Department
5.3.4.8. Ophthalmology Department
5.3.4.9. Oral/Maxillofacial Surgery Department Head
5.3.4.10. Orthopedics Department
5.3.4.11. Otorhinolaryngology Department
5.3.4.12. Pediatrics Department
5.3.4.13. Radiology Department
5.3.4.14. Urology Department
5.3.5. Consultants
5.3.6. Specialists
5.3.7. Residents
5.3.8. Post Graduate Interns
5.3.9. Medical Staff Related Committees
There are standing committees of the Medical Director as provided herein. The Medical
Director shall appoint and may remove the Chair of each committee. The Medical Director shall
appoint committees as may be required to carry out properly the duties of the Medical staff and the
Executive Committee. Such committees shall confine their work to the purposes for which they are
appointed and shall report to the Medical Director. They shall have no power of action unless such is
specifically granted by the motion that created the committee.
5.3.9.1. Medical Executive Committee/Medical Board

5.3.9.1.1. Duties and Responsibilities:
5.3.9.1.1.1. The Medical Executive Committee shall review policies,
procedures and evaluations in diagnostics and therapeutic categories;
5.3.9.1.1.2. develop effective medical services;
5.3.9.1.1.3. study, prepare and recommend medical research projects;
5.3.9.1.1.4. periodically assess scientific and practical activities of the
clinical departments and provide assistance;
5.3.9.1.1.5. study problems and propose solutions and
recommendations related to medical services;
5.3.9.1.1.6. prepare medical emergency plan and monitor
implementation and development;
5.3.9.1.1.7. assess possibilities of material quality and quantity of
medical services; and assess the availability of qualified human resources for all clinical departments.
5.3.9.1.2. Membership:
The Medical Executive Committee shall be chaired by the Medical
Director, co-chaired by the Deputy Medical Director, with members including: the Chiefs of the
Clinical Departments and Services including Accident and Emergency, Oral and Maxillofacial
Surgery, Internal Medicine, Anesthesia, Obstetrics and Gynecology, Pediatrics, Urology,
Otorhinolaryngology, Ophthalmology, Dermatology, Orthopedics, Day Surgery, Radiology,
Laboratory and Blood Bank, and OPD Triage Supervisor.
5.3.9.1.3. The Medical Executive Committee shall meet monthly and as needed
at the call of the Chair.
5.3.9.2. Blood Utilization Review Committee

5.3.9.2.1.1. The Blood Utilization Committee shall study the use of
blood with the requirements set out by the Ministry of Health standards for hospitals to ensure effective
use of blood and blood products;
5.3.9.2.1.2. consider and assess all blood transfusions and all responses
and efficiency of transfusions;
5.3.9.2.1.3. study methods for blood products and checking usages that
require full blood components are fully in accordance with the standards established and agreed on by
the Commission on Medical Device;
5.3.9.2.1.4. review and develop policies and procedures and the use of
evidence adopted by the Ministry of Health;
5.3.9.2.1.5. save and submit reports on the recommendations and
actions taken and statistical information;
5.3.9.2.1.6. establish the guidelines for the proper transfusion of blood
and its components;
5.3.9.2.1.7. observe the blood transfusion practice in the Hospital for
the different medical cases and to look for the indications for ordering and transfusing blood to
patients;
5.3.9.2.1.8. minimize the use of blood and its components and try to
find substitutions; encourage the autologous blood donation system for the patients with the
cooperation of the Directorate of Blood Banks and Blood Transfusion Services;
5.3.9.2.1.9. try to establish a vital and active system for having enough
blood stock to cover emergencies; and supervise and revise blood transfusion forms frequently.
The Blood Utilization Committee shall be chaired by the Medical
Director, co-chaired by the Chief of Laboratory with members including: Chief of Accident and
Emergency Department, Chief of Surgery, Chief of Internal Medicine, Nursing Director, Quality
Management Director, OIC of Blood Bank, Chief of Obstetrics and Gynecology Department, and
Pharmacy Director.
5.3.9.2.3. The Utilization Committee shall meet every three (3) months or
according to the committee calendar of activities and/or as needed at the call of the Chair.
5.3.9.3. Cardiopulmonary Resuscitation and Rapid Response Committee

5.3.9.3.1.1. The CPR & RR Committee shall work to improve the CPR
response and management for both children and adults;
5.3.9.3.1.2. develop guidelines and internal policies and procedures for
CPR;
5.3.9.3.1.3. review and evaluate CPR and RR reports;
5.3.9.3.1.4. develop and monitor indicators to monitor and evaluate
the structure, processes and outcomes of CPR and rapid response;
5.3.9.3.1.5. promote BLS and ACLS/ATLS trainings in accordance
with the Saudi Health Association guidelines;
5.3.9.3.1.6. review, standardize and approve all policies and
procedures related to CPR;
5.3.9.3.1.7. approve and ensure standardization of new resuscitation
equipment.
The CPR Committee shall be chaired by the Medical Director, with
members including: ICU Specialists, Chief of Anesthesia, Chief of Internal Medicine, Chief of
Pediatrics, Quality Management Director, and Nursing Director.
5.3.9.3.3. The Cardiopulmonary Resuscitation Committee shall meet monthly
and as needed at the call of the Chair.
5.3.9.4. Credentialing and Privileging Committee

5.3.9.4.1.1. The Credentials and Privileges Committee shall govern the
appointment of Medical Staff according to the Medical Staff By Laws and to ensure that appointees
meet established Hospital standards;
5.3.9.4.1.2. make recommendations concerning staff promotions on a
regular basis in accordance with written policies;
5.3.9.4.1.3. review and approve the submissions of the Heads of the
Department in regard to physician's credentials prior to employment;
5.3.9.4.1.4. review and approve requests for clinical privileges
submitted to the Committee by the physician and the head of the Department;
5.3.9.4.1.5. review the granted privileges of all approved Consultant
and Associate Consultants as necessary and at least every two (2) years, for deletions or requested
additions of privileges, as recommended by the Head of the Department.
The Credentials and Privileges Committee shall be chaired by the
Medical Director, with members including: Consultant of Medicine, Chief of Surgery, Consultant of
General Surgery, Chief of Pediatrics, Consultant of Ophthalmology, and Quality Management
Director.
5.3.9.4.3. The Credentials and Privileges Committee shall meet monthly and as
needed at the all of the Chair.
5.3.9.5. Infection Control Committee

5.3.9.5.1.1. The Infection Control Committee shall approve policies
and procedures concerning infection control;
5.3.9.5.1.2. prepare and follow-up of action plan;
5.3.9.5.1.3. identify and train staff regarding infection control;
5.3.9.5.1.4. discover sources of infection;
5.3.9.5.1.5. monitor antibiotic resistance and tolerance;
5.3.9.5.1.6. case detection;
5.3.9.5.1.7. monitor the application of preventive measures;
5.3.9.5.1.8. develop programs to follow-up and monitor places of
confinement;
5.3.9.5.1.9. review and evaluate policies to monitor health of health
care worker;
5.3.9.5.1.10. review and evaluate standards governing the quality of
services; and prepare reports and recommendations for addressing the problems of the environment
and the infection control requirements of the Hospital.
The Infection Control Committee shall be chaired by the Hospital
Director, co-chaired by the Infection Control Director, with members including: the Chiefs of the
clinical departments, QM Director and Nursing Director.
5.3.9.5.3. The Infection Control Committee shall meet monthly and as needed at
the call of the Chair.
5.3.9.6. Medical Record Review Committee

5.3.9.6.1.1. The Medical Record Committee shall oversee and monitor
the documentation in medical records for quality, completeness and timeliness;
5.3.9.6.1.2. regularly review a sample of the medical records of
discharged inpatients;
5.3.9.6.1.3. apply regulations, directive and standards for hospital
accreditation issued by the Ministry of Health;
5.3.9.6.1.4. ensure the quality of documentation of all patients;
5.3.9.6.1.5. make use of modern means of recording;
5.3.9.6.1.6. review and recommend requirements section;
5.3.9.6.1.7. train personnel on the medical abbreviations approved by
the Ministry.
The Medical Records committee shall be chaired by the Medical
Director, co-chaired by the Medical Record Director, with members including: QM Director, Chiefs
of Surgery, ER, Medicine, Pediatrics, Obstetrics and Gynecology, and radiology, Nursing Director,
OPD Director, Chief of MOI, and Admissions representative.
5.3.9.6.3. The Medical Record Review Committee shall meet every three (3)
months or according to committee calendar of activities and as needed at the call of the Chair.
5.3.9.7. Morbidity and Mortality Committee

5.3.9.7.1.1. The Mortality and Morbidity Committee shall ensure that
there is a regular review of morbidity and mortality issues within the Hospital clinical structure at the
departmental level;
5.3.9.7.1.2. receive written reports on a regular basis from intra-
Departmental Mortality and Morbidity Committees which indicate a structured mortality incident
review process of arising issues;
5.3.9.7.1.3. initiate independent social focus reviews of all adverse
clinical outcomes resulting in mortality;
5.3.9.7.1.4. advise the Medical Director in matters of corrective measure
indicated;
5.3.9.7.1.5. collect and trend statistical data and analyses the same
resulting in a written report system to the Medical Director and to the Hospital Administrator;
5.3.9.7.1.6. identify issues related to appropriate clinical actions and the
study of diagnostic and surgical procedures
5.3.9.7.1.7. review of deaths from unintended technical errors within the
Hospital and provide better quality of service to reduce mortality.
The Mortality and Morbidity Committee shall be chaired by the
Medical Director, with members including: Chief of Accident and Emergency Department, Quality
Management Department, Head of Medicine, Head of Pediatrics, Head of Anesthesia, Head of
Obstetrics and Gynecology Department, In-Patient Pharmacist and Nursing Director.
5.3.9.7.3. The Mortality and Morbidity Committee shall meet monthly and as
needed at the call of the Chair.
5.3.9.8. Operating Room Committee

5.3.9.8.1.1. The OR Committee shall oversee appropriate utilization
and shall coordinate policies and procedures relating to operating rooms;
5.3.9.8.1.2. continually review practices in OR and RR;
5.3.9.8.1.3. continually review appropriateness of OR and RR use.
The OR Committee shall be chaired by the Medical Director, co-
chaired by the Chief of Surgery, with members including: Chief of Anesthesia, Chief of Obstetrics and
Gynecology, Chief of Ophthalmology, Chief of ENT, OR Manager, QM Director, Nursing Director
and Surgical Ward Supervisor.
5.3.9.8.3. The OR Committee shall meet every three (3) months or according to
Committee Calendar of activities and/or as needed at the call of the Chair.
5.3.9.9. Pharmacy and Therapeutics Committee

5.3.9.9.1.1. The Pharmacy and Therapeutics Committee shall
describe controls in drug preparation and dispensation according to the policies and procedures of the
Ministry of Health;
5.3.9.9.1.2. prepare recommendations and proposals to add or delete
any medications, evaluate in-hospital drug therapy for some medical conditions;
5.3.9.9.1.3. develop and update antibiotic policies;
5.3.9.9.1.4. ensure compliance with the drug policy of the Ministry
of Health;
5.3.9.9.1.5. refer cases due to medication complications and their
interactions to the senior pharmacists;
5.3.9.9.1.6. follow-up on reports and make the necessary
recommendations;
5.3.9.9.1.7. examine serious drug side-effects and prepare necessary
proposals and recommendations;
5.3.9.9.1.8. serve in an advisory capacity to the Medical Staff and
Hospital administration in all drug-related matters;
5.3.9.9.1.9. develop and revise a Hospital-based drug formulary;
5.3.9.9.1.10. establish programs and procedures that ensure cost-
effective drug therapy;
5.3.9.9.1.11. establish or plan educational programs on drug-related
matters;
5.3.9.9.1.12. review adverse drug reactions occurring in the
Hospital;
5.3.9.9.1.13. make recommendations on drugs to be stocked in
specific patient care areas.
The Pharmacy and Therapeutics Committee shall be chaired by the
Medical Director, co-chaired by the Pharmacy Director, with members including: Chief of Surgery,
Chief of Internal Medicine, Quality Management Director, Nursing Director, Chief of Medical Store,
and Pharmacists.
5.3.9.9.3. The Pharmacy and Therapeutics Committee shall meet every three (3)
months or according to the committee calendar of activities and as needed at the call of the Chair.
5.3.9.10. Tissue Review Committee

5.3.9.10.1. Duties and Responsibilities
5.3.9.10.1.1. that conducts analysis and review of tissues removed
during surgeries and procedures. In particular, the committees should try to ensure that the procedure
is well indicated & properly carried out, that the tissue was properly transported to the lab, including
adequate information about the case & properly dealt with, diagnosed and reported from the lab.
5.3.9.10.1.2. ensure that there is a hospital policy that governs how
to obtain and handle specimens and tissues;
5.3.9.10.1.3. monitor the collection and transportation of
specimens to the laboratory, the accuracy and completeness of histopathology forms (e.g., site of
biopsy, number of biopsies, clinical history, previous biopsies), the accuracy of fine needle
aspirations, & the accuracy of frozen section specimens.
5.3.9.10.1.4. define and approve the list of specimens exempted
from submission to surgical pathology or microscopic examination;
5.3.9.10.1.5. review the appropriateness of all surgical procedures
performed in the hospital, correlating pre- and post-operative surgical diagnoses with pathological
findings;
5.3.9.10.1.6. recommend actions for improvement and evaluates
their effectiveness.
5.3.9.11. Utilization Review Committee

5.3.9.11.1.1. The Utilization Review Committee shall assess the
medical necessity of the services furnished by the Hospital and the Medical Staff members to patients
including appropriateness of admissions, appropriateness and quality of care, length of stay, drug
usage, and efficiency in using various hospital resources;
5.3.9.11.1.2. review use of hospital resources;
5.3.9.11.1.3. study the use of resources in accordance with the
requirements set out in Ministry of Health standards;
5.3.9.11.1.4. contribute to the achievement of the organizational
objectives; and identify strength and weaknesses by a thorough and comprehensive analysis of
hospital resources.
The Utilization Review Committee shall be chaired by the Medical
Director, co-chaired by the Head of Medical Records, with members including: Quality Management
Director, Nursing Director, Accident and Emergency Department Head, Internal Medicine Department
Head, General Surgery Department Head, Anesthesia Department Head, Social Work Department
Head, Obstetrics-Gynecology Department Head, Pediatrics Department head, NICU-Nursery
Department Head, Pharmacy Director, Bed Management Department Head, Medical Supply and
Equipments Department Head, and Medical Record Department Head.
5.3.9.11.3. The Utilization Review Committee shall meet monthly or regular
basis every three (33) months or according to committee calendar of activities and as needed at the call
of the Chair.
5.4. Article IV. MEDICAL STAFF RANKING AND QUALIFICATIONS
5.4.1. The Medical Director
5.4.1.1. Qualifications: The Medical Director shall possess the following qualifications:
5.4.1.1.1. Active Medical Staff member in good standing, graduate of a
recognized University and Board-certified in his field of specialty;
5.4.1.1.2. Demonstrated executive and administrative ability through training and
experience; Five years of clinical practice and experience in the development and management of
utilization review and quality assurance programs or an equivalent combination of relevant education
and/or experience
5.4.1.1.3. Recognized high level of clinical competence;
5.4.1.1.4. Ability to work cooperatively with the other members of the Executive
Committee, the Hospital Director, and the Jazan General Directorate of Health Affairs.
5.4.1.2. Selection: The Medical Director is recommended and appointed by the Hospital
Director. The Jazan General Directorate of Health Affairs is then informed of such recommendation
and appointment.
5.4.1.3. Term of Office: The Medical shall serve until he/she resigns or is terminated.
5.4.1.4. Resignation: The Medical Director may submit a letter of resignation to the
Hospital Director.
5.4.1.5. Removal From Office: The Medical Director may be removed from office by
the action of the Hospital Director. Acceptable grounds for removal include, but are not limited to:
failure to perform the duties of the position in a timely manner, failure to support the Hospital's
mission, failure to satisfy the qualifications of the position. Removal from office alone has no effect
on the physician's Medical Staff appointment status or delineated clinical privileges.
5.4.1.5. Filling of Vacant Position: In the event of vacancy, the Deputy Medical Director
shall serve as Medical Director until the next selection.
5.4.2. The Deputy Medical Director
5.4.2.1. Qualifications, selection, term of office, resignation and removal from office are
the same as those outlined for the Medical Director.
5.4.2.2. Should the position become vacant, it may be filled by an interim appointment at
the next Executive Committee meeting.
5.4.2.3. The responsibilities and the authority of the position are to perform the duties of
the Medical Director in his absence.
5.4.3. The Heads of the Department
5.4.3.1. Qualifications: A head of department shall possess the following qualifications:

5.4.3.1.1. Active Staff membership in his/her clinical department
5.4.3.1.2. Demonstrated executive and administrative ability through training and
experience
5.4.3.1.3. Current Board certification or demonstrated high level of clinical
competence in the field
5.4.3.1.4. An expressed willingness to discharge faithfully the duties of the office
and work cooperatively with other Medical Staff officers, the Executive Committee and the Hospital
Director.
5.4.3.2. Selection and Appointment Process: The Medical Director, upon
recommendation of the Executive Committee, shall appoint the Head of the Department to be in charge
of each of the Medical Staff departments. He shall serve until he resigns or is terminated. The Hospital
Director shall act on the Medical Director's recommendation by either appointing the appointee, or
notifying the Executive Committee that he will not appoint the appointee.
5.4.3.3. Term of Office: A Head of Department shall serve at the pleasure of the Medical
Director.
5.4.3.4. Resignation: A Head of Department may proffer his resignation to the Medical
Director.
5.4.3.5. Removal From Office: A Head of Department may be removed from office by the
Medical Director. Grounds for removal of a Head of Department from office include, but are not
limited to: failure to perform the duties of the position in a timely manner, failure to support the
Hospital's mission, failure to satisfy the qualifications of the position. Removal from office alone has
no effect on the physician's Medical Staff appointment status or delineated clinical privileges.
5.4.4. The Consultant
5.4.4.1. Either Saudi Board, American Board, or Canadian Fellowship, or MRCP, or

Equivalent
5.4.4.2. Higher qualifications in his specialty, if any.
5.4.4.3. Minimum five (5) years experience Post Qualification
5.4.4.4. Registration in Saudi Medical Council and/or Current license to practice medicine
in Saudi Arabia
5.4.4.5. Additional experience in a sub-specialty
5.4.4.6. Academic affiliation.
5.4.5. The Specialist
5.4.5.1. Saudi Board, Arab Board, either American or Canadian Board (MRCP, American
Board)
5.4.5.2. Higher qualifications in his specialty
5.4.5.3. At least three (3) years experience in his/her specialty
5.4.5.4. Current license to practice medicine in the permanent place of residence
5.4.5.5. Registration in Saudi Medical Council and/or Current license to practice medicine
in Saudi Arabia
5.4.5.6. Additional experience in a sub-specialty.
5.4.6. The Resident
5.4.6.1. Graduate of a recognized Medical School

5.4.6.2. Registration in the Saudi Commission for Health Specialties must be valid and
recent
5.5. Article V. CATEGORIES OF THE MEDICAL STAFF
The Medical Staff shall consist of Administrative, Active, Courtesy (Locum), and Provisional staff.
Specific clinical privileges to admit, attend or to render other services are indicated by the category of
membership as delineated by the Medical Staff.
5.5.1. Active Staff (Permanent/Contracted):

The Active Staff shall consist of those members who have been granted appointments and clinical
privileges in accordance with these Bylaws, frequently use the Hospital facilities, satisfactorily assume
the duties and responsibilities of Active Staff membership and who have been members of the
Provisional Staff for twelve months preceding their advancement to Active Staff, unless such period
is waived on the recommendation of the Credentials and Privileges and Executive Committees. Such
individuals are privileged to admit and/or treat patients in the Hospital as set forth in their delineation
or clinical privileges.
5.5.2. Courtesy Staff:

The Courtesy staff shall consist of members otherwise eligible for Active Staff membership and who
have been granted appointments and clinical privileges in accordance with these Bylaws. Such
individuals are privileged to admit and/or treat for patients defined period of time. Courtesy staff
members are not allowed to be part of the Executive Committee. In the event the Courtesy staff wishes
to be Active member of the Medical staff, he/she may apply.
5.5.2.1. Locum Medical Staff are Medical Staff who are currently on vacation from their
main Hospital/Institution of work, who have Active Staff membership in the said Hospital, and who
have initiated a locum contract with MOH to work during their period of vacation at a Hospital where
he/she is appointed.
5.5.2.2. Visiting Medical Staff are Medical Staff who currently have Active Staff
membership in another Hospital and are rotating at AAGH for a specified period of time.
5.5.2.3. Part Time Medical Staff are Medical Staff who currently have Active Staff
membership in another Hospital and are working part time at AAGH for a few days per week/per
month.
5.5.3. Provisional Staff:

The Provisional staff shall consist of those members who have been granted an initial appointment and
clinical privileges in accordance with these Bylaws. Assignment to the Provisional Staff shall be not
less than twelve months from the date of initial appointment, unless suspended or canceled for due
cause. Such individuals are privileged to admit and/or treat patients as set forth in the delineation of
Clinical Privileges. Provisional staff may also include those members of the Medical Staff who have
been subject to an action to restrict the member’s staff status or clinical privileges as set forth in these
Bylaws. During the provisional appointment period, the performance and clinical competence of the
Medical Staff member shall be reviewed by the responsible Department Head(s). At the
recommendation of the responsible Head(s), such provisional appointment may be, but need not be,
extended for a period not to exceed one additional year. In the event of an adverse decision to appoint
the Medical Staff member to Active or Courtesy status, the membership and clinical privileges of the
Provisional Staff member shall be terminated, upon written notice to him/her by the Medical Director
stating the reasons for the adverse decision.
5.5.4. Administrative Staff:

The Administrative staff shall consist of those Medical Staff members who serve the Hospital in
assuming administrative responsibilities, by employment or contract. They participate fully as
members of the Medical Staff.
5.6. Article VI. THE POSTGRADUATE INTERN
The team shall consist of postgraduate medical or dental interns and in clinical departments, who work
under the supervision of the Heads of the Departments, and in accordance with Hospital and
Department job descriptions. Interns assume responsibilities under such supervision for the safe,
effective and compassionate care of patients on inpatient services and in the outpatient facilities,
consistent with their training and experience. Interns shall be expected to participate in the medical
education programs of the Hospital and the Ministry of Health.
Interns shall comply with ongoing risk management education requirements and adhere to all
applicable policies promulgated by the Ministry of Health and shall agree to be governed by these By
Laws. Interns are not considered part of the Medical Staff.
Interns shall be graduates of, or students of good standing of, approved or recognized schools of
medicine or dentistry.
5.7. Article VII. THE ALLIED HEALTH STAFF
The Allied Health Staff shall consist of those individuals who provide independent clinical services
and who are not physicians or members of the Medical Staff. The Allied Health Staff shall include,
but is not limited to, clinical laboratory directors or practitioners, certified nurse practitioners, certified
nurse midwives, clinical pharmacy practitioners, radiology technicians, physical therapists, dieticians
and optometrists.
Allied Health Staff may exercise judgment within their licensure, certification and/or area of
competence; participate directly in the management of patients under the supervision or direction of a
member of the Medical Staff; record reports and progress notes in the patient's records; and write
orders to the extent established by the appropriate Head of the department and in accordance with
applicable laws.
Allied Health Staff shall agree to be governed by these By Laws.

5.8. Article VIII:
ROLES AND RESPONSIBILITIES OF MEDICAL STAFF MEMBERS
5.8.1. The Medical Director

5.8.1.1. Provide professional medical direction services, but not limited to, implementing,
maintaining and refining approved quality assurance/utilization management programs; keep abreast
of and ensure compliance with government regulations for managed care programs.
5.8.1.2. Manage the functions of the Quality Assurance/Utilization Review Committees.
5.7.1.3. Identify utilization review studies and evaluate adverse trends in hospital
utilization, unusual provider practice patterns, adequacy of benefit/payment components and
comparative differences in utilization trends by healthcare providers.
5.8.1.4. Work collaboratively with member services, medical services, provider relations
and the executive director to prepare, deliver and encourage implementation of recommendations to
provider member for actions which would improve utilization.
5.8.1.5. Participate in the review and assessment, and provide advice on, complex,
controversial and/or unique claims which are outside the realm of medical policy; solicit and evaluate
advice of outside medical consultants and physicians with respect to complex or controversial claims
or experimental and innovative techniques.
5.8.1.6. Provide medical expertise with respect to planning and establishing goals and
policies to improve medical management.
5.8.1.7. Participate in provider network development and new market expansion as
appropriate; participate in the review, assessment and negotiation of provider contracts as appropriate.
5.8.1.8. Collaborate with the Executive Director in the development and implementation
of physician education.
5.8.1.9. Represent the institution on ad hoc committees as appropriate; interface with the
provider community regarding medical review, utilization review and quality assurance issues and
concerns.
5.8.1.10. The Medical Director is responsible and accountable for the clinical performance
of all medical staff and their professional conduct.
5.8.1.11. Participates in any administrative decision making and recommends any
initiatives or program for improvement of the hospital.
5.8.2. The Deputy Medical Director
The responsibilities and authority of the position are to perform the duties of the Medical
Director in his absence.
5.8.3. The Heads of Department

5.8.3.1. Manage the Department through cooperation and coordination with Hospital
administration;
5.8.3.2. Coordinate planning with respect to Department personnel, equipment, facilities,
and services;
5.8.3.3. Communicate and implement within the Department, actions taken by the
Executive Committee and the Quality Management Committee;
5.8.3.4. Cooperate with other Heads of Department both professionally and
administratively;
5.8.3.5. Correlate and coordinate the medical, nursing, and administrative duties in the
interdepartmental conduct of work;
5.8.3.6. Monitor the competence, professional behavior and medical ethics of Medical
Staff in the Department;
5.8.3.7. Planning and organizing continuous medical education and in-service training
for Medical Staff who provide care within the Department. In-service training shall be based, in part,
on the results of monitoring and evaluation activities;
5.8.3.8. Performs management activities such as interviewing, hiring, termination, and
assessment of clinical competency;
5.8.3.9. Recommends appointments and transfers of staff members;
5.8.3.10. Appoint committees and teams to conduct departmental affairs and appoint a
deputy to represent him during absence;
5.8.3.11. Arrange and chair the monthly departmental meetings;
5.8.3.12. Evaluate and assess the work performance of the Consultants, Specialists and
Residents;
5.8.3.13. Approval of evaluations and recommendations for the Specialists and Residents
done by concerned Consultants;
5.8.3.14. Recommends the type and amount of physical resources to meet the medical
care needs of patients;
5.8.3.15. Ensures compliance with policies and procedures regarding Department
operations, fire, safety and infection controls;
5.8.3.16. Maintain good rapport and a cooperative relationship with departments,
physicians and staff;
5.8.3.17. Resolves personnel concerns at the Departmental level as appropriate;
5.8.3.18. Maintains performance improvement, continuous quality improvement, and
quality control services within the Department;
5.8.3.19. Communicates the mission, ethics and goals of the Hospital as well as the focus
statement of the Department
5.8.3.20. Attends committee, CQI, and management meetings as appropriate;
5.8.4. The Consultants
5.8.4.1. Primary responsible for the whole patient care, plan and management including
emergency and plan operations.
5.8.4.2. Performs at least two rounds daily: morning rounds with main unit and afternoon
rounds with his team.
5.8.4.3. Acts as the decision maker after discussion with other consultants in his unit and
his team doctors.
5.8.4.4. Decides when patient will be discharged.
5.8.4.5. Takes regular on-call duties as planned by the Department Head.
5.8.4.6. Supervision and training of Specialists, Residents, Interns, and update Head of
Department about their progress.
5.8.4.7. Continuously assess Specialists, Residents, Interns and give feedback to the Head
of the Department about his team.
5.8.4.8. Provides time for discussion, teach in daily rounds and train his team in various
skills focusing especially with Saudi/ Arab boards candidates, and interns and sign the logbooks for
them.
5.8.4.9. Supervise and check the clerking, discharge summaries and daily progress notes.
5.8.4.10. For urgent consultation, the consultant shall discuss the case with the referring
consultant.
5.8.4.11. Attends clinic on time and according to the schedule.
5.8.4.12. Attends to other wards to see the referred cases and do follow – up as necessary.
5.8.4.13. Endorse to the On Call Consultant all serious, critically ill patients.
5.8.4.14. Follows–up his patients mortality report, reviews it and discusses in the
Department meeting to be prepared for discussion within the intra department mortality and morbidity
meetings.
5.8.4.15. Participates in hospital teaching program with other departments and presents
periodic lectures.
5.8.4.16. Participate in the Quality Improvement activities in the hospital.
5.8.5. The Specialists
5.8.5.1. Supervises the Residents.

5.8.5.2. Help in the clerking and discharge summaries in case there is no Resident or if
the Resident is attending to other patient.
5.8.5.3. Shares in the planning, work-up and management of the patients performing and
assisting the surgery under the supervision of the Consultant.
5.8.5.4. Covers Specialist Clinic in the Outpatient Department.
5.8.5.5. Communicates and arranges for the procedures or appointment with other
Consultants or hospitals.
5.8.5.6. Arrange for inter-hospital referral and transfer of patients.
5.8.5.7. Takes on-call duty as approved by Head of the Department.
5.8.5.8. Discusses the provisional diagnosis, differential diagnosis, investigations and
plans of management with his resident during the duty calls for each admission from the ER as well
as instruct him regarding results for follow up.
5.8.5.9. Attends the daily ward rounds in the morning and documents it in the file.
5.8.5.10. Supervises the Residents and Interns regarding presentation during the grand
rounds and present the cases in the absence of the Resident of the unit.
5.8.5.11. Sees consultations from other departments and informs the consultants (to see
the case and follow-up)
5.8.5.12. Conducts teaching programs for residents, interns and nurses staff.
5.8.5.13. Ensures a close follow up of their patients and the outcome of management.
5.8.5.14. Writes and presents the morbidity and mortality meetings in the department.
5.8.5.15. Writes medical reports for cases when requested by the Consultants.
5.8.5.16. Endorses each cases and consultations to the incoming team before going off
duty.
5.8.5.17. Participates in the Quality Improvement activities of the hospital.
5.8.6. The Residents
5.8.6.1. Check patient’s blood pressure, pulse and temperature by himself, as appropriate
5.8.6.2. Responsible for clerking, discharge summary, International Classification of
Disease Coding and daily progress notes.
5.8.6.3. Attends two rounds daily (morning and afternoon) with the Consultants.
5.8.6.4. Do evening rounds during the on-calls.
5.8.6.5. Write request for investigations and follow up results of the investigation such
as: Histopathology results, Ultrasounds, X –Rays, etc.
5.8.6.6. Sign results of investigations upon receipt with date and time before inserting it
in the record
5.8.6.7. Present cases admitted in the previous 24 hours during the morning meetings.
5.8.6.8. Present the cases of the unit in the grand rounds.
5.8.6.9. Attends OPD clinics to help the consultant in the absence of Specialist.
5.8.6.10. Informs the Specialists about new arising problems, result of investigations and
critical decision related to patient care.
5.8.6.11. Actively involved in continuous education of the department and hospital
educational programs.
5.8.6.12. Accompany patient during inter-hospital transfer.
5.9. Article IX. GENERAL CONDITIONS OF APPOINTMENT
5.9.1. Under no circumstances shall individuals provide clinical care in an AAGH setting before
being granted privileges by the Credentials and Privileges Committee or by the temporary privileging
process.
5.9.2. The members of the Active Staff and the Courtesy Staff shall have unrestricted license to
practice medicine or dentistry in the Kingdom.
5.9.3. At all times, SCFHS registrations must be maintained, unless granted an exception in
accordance with Hospital policy. The Hospital ensures the registration of all health care professionals
with the Saudi Commission for health Specialties.
5.9.4. At the time of initial appointment and continuously thereafter, members of the Medical
Staff, Interns and Allied Health Professionals shall demonstrate their ability to provide quality patient
care. They shall demonstrate their willingness to abide by the By Laws, policies and procedures of the
Hospital as they currently exist and as amended from time to time and to discharge those Medical Staff
obligations appropriate to their category of membership. Their professional conduct shall comply with
the Hospital's Code of Conduct and generally accepted principles of medical ethics. Their qualification
shall include the absence of the adequate control, of any significant physical or behavioral impairment
that affects or presents a substantial probability of affecting their skill, attitude or judgment in the
fulfillment of their duties. They shall demonstrate that they carry professional liability insurance
coverage. A qualified applicant will not be denied membership and/or clinical privileges on the basis
of gender, race, creed, disability, or national origin.
5.9.5. Appointment to the Medical Staff shall be extended only to clinically competent and fully
licensed physicians who continuously meet the qualifications standard and requirements stated in these
Bylaws, Rules and Regulations.
5.9.6. The appointment to the Medical Staff shall be conferred on the applicant only after the
recommendation of the Credential, Promotion and Privileging Committee
5.9.7. Each applicant shall provide information regarding the following situation, which may
have occurred during any time in their training and/or medical career, when applicable:
5.9.7.1. An investigation and/or suspension of any licensure or registration
5.9.7.2. A voluntary or involuntary relinquishment of licensure or registration
5.9.7.3. A voluntary or involuntary termination of medical staff membership
5.9.7.4. A voluntary or involuntary limitation, reduction, or loss of clinical privileges
5.9.7.5. Any ongoing professional liability, which includes a final judgment and/or
settlement in which he/she is involved.
5.9.8. The initial appointment and/or re contracting are based on the Hospitals’ Policies and
Procedures.
5.9.9.The initial appointment of every member of the Medical Staff shall be provisional for a
probationary period.
5.9.10. Continuation of the Medical Staff member’s contract shall be dependent upon the receipt
of the recommendation from the Chairman of the Department by Human Resources Department. The
Medical Staff member has no right to appeal the termination or modification of his/her clinical
privileges resulting from the assessment of his/her performance during the probationary period.
5.9. Article X. TERMS OF APPOINTMENT

Appointment to the Medical Staff shall be for a period of one (1) year, and renewed annually.
5.9.1. Provisional Appointment Period
Initial appointments to the Active Staff shall include a provisional period of one (1) year.
Members on provisional status are accorded all the rights of the category to which they have been
assigned.
5.9.1.1. Monitoring Performance During the Provisional Period
The Head of the Department shall have the responsibility for monitoring the
appointee's performance during the provisional period. This monitoring shall include , but not be
limited to: evaluation of performance using information available to the Department in its regular
reviews of quality improvement, utilization review, and risk management. Reviews conducted will be
documented and given to the Head of the Department prior to his evaluation of the provisional staff
member's suitability for full staff appointment.
5.9.1.2. Conclusion of Provisional Period
To conclude a provisional period, the Head of the Department must attest to the
Medical Staff member's satisfactory demonstration of clinical abilities. Extensions of provisional
appointments shall be granted if physicians or their Department Head determines that the physician's
clinical activities were insufficient to demonstrate the physician's clinical abilities.
5.9.2. Contract Practitioners
The staff appointment of any Medical Staff whose appointment is solely the result of a
contractual relationship with the Ministry of Health, shall terminate automatically and immediately on
the expiration of the Medical Staff member's contractual relationship with the Ministry of Health.
5.10. Article XI. APPOINTMENT, PROMOTION AND REAPPOINTMENT
5.10.1. Membership Requirements and Criteria:
5.10.1.1. Be a graduate of an accredited medical or dental school

5.10.1.2. Hold a current licensure to practice medicine and/or dentistry in his/her country
of origin or a current and valid License by the Saudi Commission for Health Specialties.
5.10.1.3. Meet the qualification requirements outlined in the job description and as per
the Professional Classification Manual for Health Practitioners of the Saudi Commission for Health
specialties and the Medical Staff Bylaws.
5.10.1.4. Provide evidence of current competency, through relevant training and /or
experience in his/her specialty, and in particular for the specific clinical privileges requested.
5.10.1.5. Provide evidence of a physical and mental health status necessary to meet the
practice requirements, and agree to submit to a physical and mental assessment, if deemed necessary.
5.10.1.6. Provide at least three (3) references from medical professionals with whom they
have recently worked over a reasonable period of time and who can attest to the applicant’s good
standing and adherence to the principles of professional ethics, patient rights, and medical code of
ethics.
5.10.1.7. Report on the application, any voluntary and/or involuntary terminations, and
any limitations, reductions, and/or loss of clinical privileges at another hospital.
5.10.2. Appointment Process:
5.10.2.1. All applications shall be forwarded by the Human Resources Department to the
Department Head for the initial review. The applications will be sent back to the Human Resources
Department with initial recommendations/directives.
5.10.2.2. If the department recommends the application, it shall be forwarded to the
Medical Director.
5.10.2.3. The Medical Director shall forward the application to the Credentials and
Privileging Committee.
5.10.2.4. The Credentials and Privileging Committee, upon receiving the initial application
that is recommended for approval, will examine the evidence of the character, professional
competence, qualifications and ethical standing of the practitioner.
5.10.2.5. The Credentials and Privileging Committee will forward their recommendation
to the Medical Executive Committee for their review and recommendation. The recommendation for
the appointment of a Medical Practitioner to the Medical Staff must specify the vacant post to which
he/she is being appointed
5.10.2.6. The Medical Executive Committee shall forward their recommendation to the
Hospital Director for the final approval.
5.10.2.7. If approved, the Hospital Director's office will send the approved application to
the Human Resource Department for further processing.
5.10.3. Promotion:
5.10.3.1. Medical Staff members seeking promotion have to submit an application with
supporting documents, to the Head of the department for the position that he/she is seeking.
5.10.3.2. The Head of Department after reviewing the application and the supporting
documents will make his/her recommendation.
5.10.3.3. The recommended application will be submitted to the Head of the Credentials
and Privileges Committee.
5.10.3.4. The recommended application will be forwarded to the Hospital Director for final
approval after consulting with the Medical Director.
5.10.3.5. The papers will then be sent to the Human Resources Department for processing,
based on the availability of positions.
5.10.3.6. Salary raises and change of status will be determined by the Human Resources
Department according to the Hospital Bylaws and the Ministry of Health regulations.Once the
promotion has been approved and the Medical Staff has been officially promoted, he/she should apply
for a change in clinical privileges, if necessary. The usual clinical privileging process will be applied.
5.10.4. Reappointments
5.10.4.1. Submission of Request for Reappointment
At least one hundred and twenty (120) days prior to the expiration of the
appointment of a Medical staff, Medical Staff administration shall provide the Staff Member with a
request for evaluation and the appropriate delineation of clinical privileges form. A staff member
seeking reappointment shall submit the related forms, update the information requested, sign the
required documents and return the updated personal file to the Medical Staff administration. The
required documents include, but not limited to the following:
5.10.4.1.1. Annual Evaluation Sheet
5.10.4.1.2. Residence ID (Iqama)/National ID
5.10.4.1.3. Saudi Commission for Health Specialties Classification Certificate
5.10.4.2. Processing of Request for Reappointment
5.10.4.2.1. Upon receipt of a completed request for reappointment, Medical Staff

shall review the application and obtain appropriate verifications and peer recommendations. It shall be
the responsibility and burden of proof of the Medical Staff member requesting the reappointment to
demonstrate compliance with the requisite criteria for reappointment, as well as to resolve any doubts
or inconsistencies, judgment, and clinical and technical skills.
5.10.4.2.2. The Head of the Department shall review the application and make an
appraisal of the individual's professional performance. Factors to be considered in the evaluation
include:
5.10.4.2.2.1. Peer review of clinical performance;
5.10.4.2.2.2. Adherence to the Medical Staff by Laws, Rules and
Regulations, Hospital and Medical Staff policies and procedures including the Code of Conduct, and
any applicable departmental criteria;
5.10.4.2.2.3. Compliance with continuing medical education
requirements
5.10.4.2.2.4. Compliance with Infection Control seminar attendance
requirements
5.10.4.2.2.5. A review of current physical and mental health status as
it impacts on the proper performance of his duties and responsibilities
5.10.4.2.2.6. Attitude, cooperation, and ability to work with others;
5.10.4.2.2.7. Other reasonable indicators of continuing qualifications;
5.10.4.2.3. No request for reappointment shall be reviewed until all information
provided has been verified and documented and the personal file has been deemed complete;
5.10.4.2.4. The Department Head, in consultation with the Credentials and
Privileges Committee, shall review the request for reappointment and related documentation and make
a recommendation concerning the applicant.
5.10.4.3. Decision on Request for Reappointment
The remainder of the reappointment process is the same as for appointment

procedures, including documentation of favorable or adverse recommendations.
5.10. Article XI.
PROCESS OF VERIFICATION OF MEDICAL STAFF CREDENTIALS
(For more details, please refer to APP-HR-05 Policy on Staff Credentialing and Verification)
5.10.1. Verification is defined as verification of the original source of a specific credential to

determine the accuracy of a qualification reported by an individual health care practitioner. Examples
of primary source verification include, but are not limited to, direct correspondence, telephone
verification, internet verification, and reports from credentials verification organizations (Data Flow
and SCFHS).
5.10.1.1. Data Flow Verification Result
5.10.1.2. SCFHS Classification Verification Result
5.10.1.3. HRD Primary Verification Result
5.10.2. If circumstances arise in which it is not possible to obtain verification from the primary
source, information may be solicited from a secondary source if the secondary source obtained the
information from the primary source and the hospital believes the information to be credible and
accurate. It shall include:
5.10.2.1. Government-issued picture identification
5.10.2.2. Immunization status
5.10.2.3. Life support training
5.10.3. Be willing to appear for an interview in regard to his/her application
5.10.4. Authorize the Credentialing and Privileges Committee to consult with members of
Medical Staff of other hospitals with which the applicant has been associated with.
5.10.5. Consent to allow the Credentials and Privileges Committee to inspect all records and
documents that may be material to his/her professional, moral, and ethical qualifications of
competence.
5.10.6. Release from any liability all representatives of Credentials and Privileges Committee
for their actions performed, in good faith and without malice, in connection with evaluating the
applicant.
5.10.7. Submit a completed application, which shall be processed as indicated in the Credentials
and Privileges Committee policies governing the appointment process.
5.11. Article XII. GRANTS AND MAINTENANCE OF CLINICAL PRIVILEGES
(For more details, please refer to APP-MS-07 Policy on Credentialing and Privileging)
5.11.1. No physician shall admit or provide services to patients in the Hospital unless he/she
has been appointed to the Medical Staff and has been granted privileges as provided in these Bylaws
5.11.2. Every member of the Medical Staff shall be entitled to exercise only those approved
clinical privileges.
5.11.3. Process of Temporary Privileging:

5.11.3.1. Definition:
Limited clinical privileges granted by the hospital's Credentialing
and Privileging Committee to a practitioner (eg, a locum physician/visiting physician/support
physician, newly hired staff), to practice medicine for a defined period of time (ninety (90) days).
5.11.3.2. Indications:
Temporary privileges may be granted to the following:
5.11.3.2.1. Locum Medical Staff
5.11.3.2.2. Visiting Medical Staff
5.11.3.2.3. Support Medical Staff
5.11.3.2.4. Applicants for new privileges having complete application that
raises no concerns and is awaiting review and approval by the Credentialing and Privileging
Committee
5.11.3.2.5. An appropriately licensed practitioner who requests for the care
of
one (1) or more specific patients, with specific patient care need.
5.11.3.2.6. An appropriately licensed practitioner who requests for
emergency
coverage of a designated group of patients for a specified, limited period of time.
5.11.3.3. Process:
5.11.3.3.1. Physicians shall complete the special form of application of
clinical privileges on the commencement of their assignment, based on their assessment of their
capabilities and training. The form shall be forwarded to the Head Department.
5.11.3.3.2. The Chairman of the particular department, after consultation with
the Unit Head, shall recommend approval or denial of the requested medical staff privileges.
5.11.3.3.3. Head of Department shall forward his/her recommendation to the
Medical Director who has the authority to grant temporary privileges for one month.
5.11.3.3.4. The Medical Director may renew the temporary privileges up to a
maximum of three (3) months until the physician is granted permanent privileges.
5.11.4. Process of Permanent Privileging:
5.11.4.1. The Medical Director, in consultation with the Department Head, shall
forward the privileging request to the Credentials and Privileges Committee.
5.11.4.2. All recommendations shall be based upon the practitioner’s education and
training, qualifications, professional experience, and the like.
5.11.4.3. The Credentials and Privileges Committee shall review the Department Head's
recommendation and shall recommend privileges valid for up to two (2) years
5.11.4.4. The initial approval of clinical privileges shall be provisional.
5.11.4.5. The clinical privileges to be granted on contract renewal shall be based upon
the Medical Staff member’s record of professional competence and clinical judgment in the treatment
of patients, including an examination of the individual’s pattern of care as demonstrated by peer
review.
5.11.5. Process for Emergency Privileges

5.11.5.1. Definition:
Emergency privileges is a term used to identify a situation where a member
of
the medical and/ or dental staff provides treatment to a patient who is in extremis, as necessary to save
life, limb, or organ, regardless of privileges granted previously.
5.11.5.2. Indications:
5.11.5.2.1. Disaster Privileges are granted only when the emergency
management plan has been activated and the Hospital is unable to meet immediate patient needs.
5.11.5.3. Process:
5.11.5.3.1. The following may grant emergency privileges to licensed
independent practitioners:
5.11.5.3.1.1. the Chairman of the Credentialing and Privileging
Committee
5.11.5.3.1.2. the Medical Director
5.11.5.3.1.3. the Head of the Department requiring emergency
volunteers
5.11.5.3.2. In case a physician who is not a member of the Medical Staff is
required to provide medical services after working hours or during holidays and/or weekends, he/she
shall complete the special form of application of clinical privileges. The Medical Director or his
designee shall authorize the emergency privileges.
5.11.6. Denial of Privileges
5.11.6.1. As discussed previously, the Hospital has the legal right as well as an ethical
duty to the community to keep incompetent practitioners from practicing in the Hospital. This means
that occasionally the Hospital will deny membership and privileges or revoke membership status and
reduce privileges for a practitioner who is incompetent.
5.11.6.2. Due process of law is a legal precedent that refers to the established procedures
outlined in the Medical Staff By Laws that are fair, reasonable and not discriminatory. An important
issue arises when a practitioner vehemently challenges a denial of privileges and seeks court help in
reversing an unfavorable decision by a healthcare organization.
5.11.6.3. The Credentials and Privileges Committee require that the Hospital document
an appeals process for an adverse decision, the Medical Staff By Laws to provide a fair hearing for a
Medical Staff member receiving an adverse decision about membership or clinical privileges. The
goal is to make sure the reason for the decision is available to the Medical Staff member.
5.11.6.4. The following represents some specific guidelines adopted from the By Laws It
is recommended that the Hospital counsel be closely involved with the adverse action process at every
step.
5.11.6.4.1. Identification of a possibly incompetent Medical Staff member:
Any Medical Staff member or Hospital employee who is aware that a Medical Staff member's
incompetence results in injuries to patients or provides unethical or substandard medical care must
request in writing a full investigation.
5.11.6.4.2. Concerns about a Medical Staff member's performance may also
come from the Hospital's monitoring of the performance improvement activities of the Medical Staff
member.
5.11.6.4.3. Inquiry into the charges against the practitioner: The Medical
Executive Committee forms a committee to study the incident reported.
5.11.6.4.4. Report of the inquiry: The completed report includes
recommendations for action deemed appropriate, proposed resolution and the practitioner’s response.
5.11.6.4.5. The Hearing Procedure: The Medical Director appoints three
Medical Staff members to a Hearing Panel
5.11.6.4.6. The Hearing Panel Chairman may decide to use a legal officer to run
the procedure. During the hearing, either party may present evidence determined by the Hearing Panel
Chairman to be relevant
5.11.6.4.7. Within 20 days after final adjournment of the hearing, the Hearing
Panel will make written recommendations and a report justifying the recommendation.
5.12. Article XIII. DISCIPLINARY PROCEDURES
5.12.1. Any person may provide information to the Medical Board, Medical Director, and
Department Head or the Hospital Director about the conduct, performance, or competence of a staff
member. All such complaints shall be forwarded to the Medical Director.
5.12.2. When reliable information indicates that a staff member may have exhibited acts,
demeanor or conduct reasonably likely to be:
5.12.2.1. detrimental to a patient's or anyone's safety.
5.12.2.2. contrary to the Medical Staff By Laws or Rules and/or Regulations or
policies
5.12.3. The Medical Director shall have the discretion to attempt to resolve issues.
5.12.4. A recommendation for an investigation must be submitted to the Medical Board.
5.12.5. The Medical Board shall forward a written report of the investigation to the Medical
Director and Committee.
5.12.6. Despite the status of any investigation, the Medical Board shall at all times retain
authority and discretion to take whatever action.
5.12.7. As soon as possible after the conclusion of an investigation, the Medical Board shall
give notice to the Hospital Director and Department Head, shall take action which may include,
without limitation:
5.12.7.1. Determining no corrective action be taken
5.12.7.2. Deferring action for a reasonable time where circumstances warrant
5.12.7.3. Issuing letters of admonition, warning, reprimand or censure
5.12.7.4. Directing the Medical Staff member to undergo a medical and/or psychiatric
examination by a physician chosen by the Medical Board
5.12.7.5. Recommending the imposition of terms of probation or limitation
5.12.7.6. Recommending reduction, modification, suspension or revocation of
clinical privileges
5.12.7.7. Recommending reduction or limitation of any prerogatives directly related
to membership on the medical staff
5.12.7.8. Recommending suspension, modification, probation or revocation of
medical staff membership
5.12.8. Denial of Medical Staff Membership
5.12.8.1. As discussed previously, the Hospital has the legal right as well as an
ethical duty to the community to keep incompetent practitioners from practicing in the Hospital. This
means that occasionally the Hospital will deny membership and privileges or revoke membership
status and reduce privileges for a practitioner who is incompetent.
5.12.8.2. Due process of law is a legal precedent that refers to the established
procedures outlined in the Medical Staff By Laws that are fair, reasonable and not discriminatory. An
important issue arises when a practitioner vehemently challenges a denial of privileges and seeks court
help in reversing an unfavorable decision by a healthcare organization.
5.12.8.3. The Credentials and Privileges Committee require that the Hospital
document an appeals process for an adverse decision, the Medical Staff By Laws to provide a fair
hearing for a Medical Staff member receiving an adverse decision about membership or clinical
privileges. The goal is to make sure the reason for the decision is available to the Medical Staff
member.
5.12.8.4. The following represents some specific guidelines adopted from the By Laws
It is recommended that the Hospital counsel be closely involved with the adverse action process at
every step.
5.12.8.4.1. Identification of a possibly incompetent Medical Staff member:
Any Medical Staff member or Hospital employee who is aware that a Medical Staff member's
incompetence results in injuries to patients or provides unethical or substandard medical care must
request in writing a full investigation.
5.12.8.4.2. Concerns about a Medical Staff member's performance may
also come from the Hospital's monitoring of the performance improvement activities of the Medical
Staff member.
5.12.8.4.3. Inquiry into the charges against the practitioner: The Medical
Executive Committee forms a committee to study the incident reported.
5.12.8.4.4. Report of the inquiry: The completed report includes
recommendations for action deemed appropriate, proposed resolution and the practitioner’s response.
5.12.8.4.5. The Hearing Procedure: The Medical Director appoints three
Medical Staff members to a Hearing Panel
5.12.8.4.6. The Hearing Panel Chairman may decide to use a legal officer to
run the procedure. During the hearing, either party may present evidence determined by the Hearing
Panel Chairman to be relevant
5.12.8.4.7. Within 20 days after final adjournment of the hearing, the Hearing
Panel will make written recommendations and a report justifying the recommendation.
5.12.9. Appeals
5.12.9.1. When a Medical Staff member has been recommended to be terminated or have
his/her clinical privileges reduced or suspended, he/she should be notified in writing immediately by
the Medical Director. This letter must have an attached a copy of the current Medical Staff By Laws
with the section on appeal rights highlighted.
5.12.9.2. The affected Medical Staff member shall have the right to appeal.
5.12.9.3. The affected Medical Staff member, within seven (7) working days of being
informed of an adverse decision, must inform the Medical Director in writing that he/she wishes to
make an appeal and shall submit the reasons for doing so. If he/she fails to do so within the specified
time, he/she shall be deemed to have waived his/her right of appeal and the action shall stand
5.12.9.4. Within thirty (30) calendar days after the conclusion of the appeal review, the
Credentials and Privileges Committee will make a final recommendation regarding the appeal. The
Hospital Director shall issue the final decision regarding the appeal and its outcome.
5.12.9.5. There is no right to appeal for a physician who is not approved for initial
appointment for continuation following completion of the probationary period or for contract renewal
to the Medical Staff.
5.12.9.6. Within fifteen (15) days of receiving the Hearing Panel’s recommendations, the
Medical Staff member may request an appeal in writing to the Hospital Director. The following are
acceptable grounds for an appeal:
5.12.9.6.1. The Hospital did not follow its By Laws or did not conduct a fair
hearing
5.12.9.6.2. The recommendations were prejudiced.
5.12.9.6.3. The evidence did not support the recommendations.
5.12.9.6.4. New evidence has surfaced.
5.12.9.6.5. The Hospital Director reviews the written request for an appeal.
5.12.9.7. If the Hospital Director decides the grounds for appeal are valid, he or she will
appoint an Appellate Review Body. This Appeal Body includes one member of the Medical Staff and
three members of the Executive Board. The Appellate Review Body examines the original report and
recommendation of the Hearing Panel, but also may accept at its option additional oral or written
evidence. This evidence is also subject to cross examination as at the Hearing Panel proceedings.
5.12.9.8. Within 20 days after the conclusion of the Appellate Review proceedings, a
final decision will be sent to the Hospital Director as well as the Medical Staff member. This decision
is considered to be an action of the governing body and is not subject to further review or appeal.
5.13. Article XIV.
STANDARDS OF PATIENT CARE AND PROFESSIONAL CONDUCT
5.13.1. Admission Process
5.13.1.1. Patients may be admitted to the Hospital as an inpatient ONLY by a qualified

member of the Medical Staff who has been granted the privilege to admit patients to the Abu Arish
General Hospital. All patients are admitted under a Consultant or a Specialist's name, referred to as
Most Responsible Physician.
5.13.1.2. All patients requiring admission will be screened by the Admitting Physician
to decide the urgency, the bed category (ICU/Ward), and necessary investigations to establish a
provisional diagnosis or valid need for admission based on the scope of services.
5.13.1.3. In emergencies, a screening for patients triage will be carried out according
to Categories of Patient’s Conditions Policy.
5.13.1.4. Admissions are accepted 24 hours a day, 7 days a week, irrespective of any
holidays via the Accident and Emergency Department.
5.13.1.5. The Hospital may get patients for admission from other hospitals according
to Acceptance of Patients From Other Hospital Policy.
5.13.1.6. The History and Physical Examination are completed according to the
approved hospital format and any special history or examination requirements will be determined by
the department heads according to the identified needs.
5.13.1.7. If the patient is being admitted to the Intensive Care Unit, the MRP and
Intensivist jointly make the decision to admit the patient. Only those patient who are likely to get
benefit from intensive care will be transferred to ICU in accordance with the ICU Admission Criteria.
5.13.1.8. Routine Admissions
5.13.1.8.1. Routine admissions are made usually through outpatient

department (OPD).
5.13.1.8.2. For OPD patients, the Most Responsible Physician will take the
patient’s history, perform physical assessment and clinical examination, and complete the patient’s
provisional diagnosis in file.
5.13.1.8.3. If the patient needs admission, the Most Responsible Physician

shall write the admission order in the medical record.
5.13.1.8.4. The patient should be educated/ informed by the MRP (and by

nurse, where appropriate). The MRP involves the patient in making informed decision about treatment
offered, by giving them accurate and honest information about:
5.13.1.8.4.1. An explanation about the medical condition and his
illness.
5.13.1.8.4.2. Proposed care and treatment, including procedures
to be carried out, expected length of stay, where it can be anticipated, expected results.
5.13.1.8.4.3. Likelihood of success of treatment.
5.13.1.8.4.4. Potential benefits and risks of complications.
5.13.1.8.4.5. The MRP’s name and other Consultant/Specialist's
names involved in their care.
5.13.1.8.5. Change or transfer of the patient care from one Consultant or
Specialist to another (if applicable).
5.13.1.8.6. If there’s proposed high risk procedure, the MRP shall ask the
patient/relative to sign Informed Consent in accordance to Hospital Consent Policy.
5.13.1.8.7. The MRP will refer the patient to Admission Unit to complete the
admission procedure.
5.13.1.8.8. Patient and/or relatives proceed to Admission Unit with admission
request form and medical record.
5.13.1.8.9. The Admission unit clerk will accomplish the following:
5.13.1.8.1. Take patient’s data
5.13.1.8.2. Check eligibility of the patient for admission.
5.13.1.8.3. If eligible, the clerk will enter the patient data in
computer (MedicaPlus) and generate the admission slip.
5.13.1.8.4. Ask patient to nominate/ identify his designee and
decision maker on his behalf.
5.13.1.8.5. Inform patient and/or relatives regarding patient’s
rights and responsibilities and ask to sign Patient Rights and Responsibilities form.
5.13.1.8.6. Ask to sign General Consent form.
5.13.1.8.7. Inform patient and/or relatives regarding floor and
room number.
5.13.1.8.8. Prepare the file of admission sent to the wards along
with a messenger.
5.13.1.8.10. The orderly will take the patient with accompanied relatives to
the ward.
5.13.1.8.11. The Nurse on Duty will receive the patient along with the
patient’s file, and accompany the patient to his/her room, then will orient the patient and/or relative
regarding the room number, telephone number, and any necessary information that should be known
by the patient and/or relatives. The assigned nurse shall inform the concerned Admitting Physician to
write admission note, and order the diet to kitchen after performing primary nutritional assessment in
accordance with the Nursing Admission Assessment/ Reassessment Policy.
5.13.1.8.12. The Admitting Physician shall write the detailed admission notes
in Admission Sheet and the instructions on Physician Order Sheet that include the provisional
diagnosis, type of diet, required investigations, treatment, and the plan of care.
5.13.1.8.13. The patient must be assessed by the MRP within 24 hours in

accordance with the Patient’s Assessment and Reassessment Policy.
5.13.1.8.14. A comprehensive plan of care shall be planned and documented

(revised and adjusted appropriately according to any change in the patient’s condition) in the Physician
Order Sheer and/or Physician Progress Notes for every newly admitted patient that includes but is not
limited to:
5.13.1.8.14.1. Information on any surgical procedure required.
5.13.1.8.14.2. Any pre-op/postoperative care needed, including
required follow up and referrals to other specialties.
5.13.1.8.14. 3.All patient education provided to the patient on
his/her plan of care and the anticipated outcomes, including the benefits and associated risks (e.g. for
proposed surgery, procedures, treatment, etc.)
5.13.1.8.15. If patient needs referral to other specialty, the consultation

requests shall be sent which states clearly the reason of the consultation, define the services requested
from the consultant; and are handled in a timely and appropriate manner.
5.13.1.9. Urgent and Emergency Admission
5.13.1.9.1. Urgent and emergency admissions are made via Accident and
Emergency Room.
5.13.1.9.2. When the patient arrives to the AED, the AED physician will
evaluate the patient and call the respective specialist or consultant to evaluate the patient who may
need admission.
5.13.1.9.3. If the physician decides to admit the patient the procedure of
routine admission will be followed, with the following exceptions:
5.13.1.9.4. Patient’s relatives/attendants will proceed to admission unit
instead of patient himself.
5.13.1.9.5. The AED Nurse will call the Nursing Supervisor to inform
charge nurse regarding admission and to make the necessary preparation for the patient
5.13.1.9.6. The assigned AED nurse will escort the patient to the specific
ward and endorse the case to the ward/ICU/OR nurse.
5.13.1.9.7. The patient must be assessed by the MRP within 2 hours for
urgent cases, and within 30 minutes for emergencies in accordance to Patient’s Assessment and
Reassessment Policy.
5.13.1.9.8. All AED procedures will be completed before transfer to the
specific ward/OR/ICU.
5.13.1.9.9. If the MRP advices for any radiological investigation, it shall
be performed before transferring the patient to the ward (exception in case of instability of patient’s
status).
5.13.1.9.10. If the patient is hemodynamically unstable, measures for
stabilization shall be started immediately. Patient MUST NOT be transferred till the hemodynamic
stability is achieved.
5.13.1.9.11. For all unconscious patients, airway shall be secured before
transportation.
5.13.1.9.12. All information of the patient including procedures,
investigations and results will be endorsed to the nursing staff of receiving unit and transfer documents
are signed in accordance to the Internal Transfer Policy.
5.13.1.9.13. All treatment and interventions shall be rendered to patient in
the AED, as advised by MRP, until the patient is shifted out to the ward.
5.13.1.9.14. Patient will be continuously monitored during transportation
and his/her bed shall be equipped properly with emergency drugs and CPR kit.
5.13.1.10. Referral Admission
5.13.1.10.1. Within the Kingdom of Saudi Arabia:

5.13.1.10.1.1. Upon receipt of a fax from the concerned
facility/hospital, a Hospital reply via fax will be forwarded the same way in accordance to Patient
Acceptance From Other Hospital Policy.
5.13.1.10.1.2. Within the city or from the areas in vicinity,
patient shall be transported via the transferring hospital ambulance
5.13.1.10.1.3. From remote areas of the kingdom, patient can
be transported through the MEDEVAC (air ambulance).
5.13.1.10.1.4. The patient will be admitted directly to the ward
where appropriate verbal and written endorsements and will be completed.
5.13.1.10.2. Outside the Kingdom:

5.13.1.10.2.1. Upon receipt of a fax via Jazan Directorate of
Health Affairs Office, a Hospital reply via fax will be forwarded through the same channel.
5.13.1.10.2.2. Patient shall be transported through the
government national medical transport system i.e. Medevac (air ambulance).
5.13.1.10.2.3. The AED team, consisting of one physician and
one nurse shall receive the patient from King Abdullah Airport, Jizan. If patient is critical, the ICU
team shall bear the responsibility of transport.
5.13.1.10.2.4. The patient will be admitted to the ward
directly.
5.13.1.11. Handling of Patients When Bed is Not Available

5.13.1.11.1. When there is no available bed in a particular unit and a patient
needs admission the Hospital have to follow the following steps:
5.13.1.11.2. The MRP will try to find bed in another unit in the Hospital
5.13.1.11.3. If there is no available bed in all units of the hospital, the AED
director on-call will be informed and he shall contact another hospital in the area to admit the patient
there.
5.13.1.11.4. When the patient will be referred to another hospital, the
MRP will assess the patient before referral and he will dispense medical report which includes:
5.13.1.11.4.1. History and Physical examination
5.13.1.11.4.2. Diagnosis
5.13.1.11.4.3. Cause of referral
5.13.1.11.4.4. Treatment and Management rendered
5.13.1.11.4.5. Required accompanying Clinical Staff
5.13.1.11.4.5.1. Nurse
5.13.1.11.4.5.2. Doctor
5.13.1.11.4.5.3. Or both
5.13.1.11.4.5.4. No Doctor nor Nurse
5.13.1.11.5. If admission is delayed or not possible due to unavailability of bed
in the ICU, the ICU Medical and Nursing staff will discuss the case, and if appropriate, assist in the
process of alternative specialized care.
5.13.1.12. Admission to Critical Care Units

5.13.1.12.1. ICU provides services that include both intensive monitoring and
intensive treatment for patients with actual or potential vital system failures. During times of high
utilization and scarce beds, patients requiring intensive treatment will have priority over monitoring
(refer to ICU Admission Criteria).
5.13.1.12.2. All admissions will be arranged by consulting the Consultant
Intensivist or ICU specialist before transferring the patient.
5.13.1.12.3. Resuscitation or admission must not be delayed where the
presenting condition is imminently life-threatening (e.g. profound shock or hypoxia).
5.13.1.12.4. Until the patient enters the ICU, his/her medical care will remain
the responsibility of the AED physician.
5.13.1.12.5. If admission is delayed or improbable due to bed unavailability the
ICU staff will discuss and if appropriate, assist in the process of alternative specialized care.
5.13.2. Referral Process
5.13.2.1. Internal Referrals

5.13.2.1.1. All internal referrals and responses shall be in the appropriate
approved Consultation Forms. The Consultation Form shall be completed in legible handwriting and
shall contain clinical and addressograph details
5.13.2.1.2. All internal emergency referrals shall be supplemented by direct
contact between Consultants, if applicable to do so.
5.13.2.1.3. Referrals may only be done by a Consultant (except the AED
Doctor); a Consultant must sign all referrals.
5.13.2.1.4. Only Consultants may respond to referrals from Consultant
colleagues.
5.13.2.1.5. All referrals must bear the signature and stamp of the referring
doctor.
5.13.2.2. Referral by Accident and Emergency Department Doctor (AED Doctor)

5.13.2.2.1. The AED Doctor may refer patients directly to any Specialty on
call team or to the specialty clinics. Where possible, before referring the patient to another specialty,
the Specialist or Consultant in charge of AED should be asked to review the patient. This allows for
more definitive diagnosis and may prevent unnecessary delays for the patient.
5.13.2.2.2. Doctor Communications. This ensures that the patient is
prioritized according to need and that the full information regarding the need for urgent appointment
is known. Once an agreed appointment is made the Central Appointment desk will pull the patient's
Medical file in the case of a new patient to ensure that file is opened.
5.13.2.2.3. Specialist Staff on-Call may not refer patients to the Specialty
Clinics unless such referral are approved by the Consultant on-Call.
5.13.2.2.4. Specialist Staff may not give patients specific dates to the
specialty clinics but Consultants on-Call are at liberty to send patients seen in the AED to the Central
Appointments for specific appointments in their own Specialty Clinics. Where the patient is already
being treated in that specialty, the on-Call Consultant shall treat the emergency condition and send
the patient to the Central Appointments to be booked for the primary treating Consultant. The name
of the primary treating Consultant must be provided.
5.13.2.3. Inter-Specialty Referrals at the Accident and Emergency Department
Where a patient had been referred by an AED Doctor to a Specialist on-Call
belonging to a Specialty, but the Specialist Staff considers that such a case should have been referred
to another Specialty other than his or her own, he/she shall personally contact the On-Call Consultant
staff of the appropriate specialty. However, if there is no agreement between the two Specialist
Staff, the first Specialist Staff shall consult his or her Consultant for resolution of the dispute.
5.13.2.4. Inter-Specialty Referrals of Emergency Cases at the Wards

Inpatients developing emergency conditions and who need referral to other
specialties shall be referred to the Specialist/Consultant on Call of the appropriate specialty. The
Specialist/Consultant on Call of that specialty shall manage the patient during his emergency duty
hours and may continue the patient’s management thereafter with the patient’s MRP if necessary.
5.13.2.5. Emergencies in the Outpatient Clinics

Patients at the Outpatient Department on routine appointment who develop
emergency conditions shall be sent immediately to the AED to be attended by the appropriate
specialty on-call team and the Accident and Emergency Room team. Prior to transfer, resuscitative
measure shall be Instituted, as appropriate.
5.13.2.6. Routine Internal Referrals

5.13.2.3.1. All routine internal referral shall be as stated above.
5.13.2.3.2. All routine referrals, including employees, between specialty clinics
shall be channeled through the Central Appointment Desk.
5.13.2.3.3. All in-patients with non-emergency conditions shall be referred to
the Consultant on-call in the appropriate specialty.
5.13.2.7. External Referrals

5.13.2.7.1. All external referrals shall be seen by a Specialist or Consultant
(exception being that the AED Physician may refer patients directly to the Primary Health Centers for
follow-up or continuation of management of patients treated in the AED).
5.13.2.7.2. All external referrals must be in accordance with the Patient
Transfer Policy and Procedure.
5.13.2.7.2.1. An external referral should not contain abbreviations.
5.13.2.7.2.2. All referrals must be accompanied by copies of the
results of all relevant investigations.
5.13.2.8. Referrals from Primary Health Center (PHC)

5.13.2.8.1. Patients seen in a PHC that require treatment at Abu Arish General
Hospital must have an appropriate Referral Form. The form shall be filled out correctly including all
relevant details of the reason the referral.
5.13.2.8.1. Emergency referrals must be sent to the AED while routine cases
will obtain OPD appointments through their PHC. The PHC will ensure that the patient is aware of
their assigned appointment date at least two days in advance of the scheduled visit. Every attempt
will be made by the PHC to ensure a rational use of the referral system.
5.13.2.8.2. All referrals must have the following information clearly hand-
written or typed.
5.13.2.8.2.1. Full names of patient (four names).
5.13.2.8.2.2. Complete address of patient.
5.13.2.8.2.3. Name and Address of PHC
5.13.2.8.2.4. Full names and signature of referring PHC doctor.
5.13.2.8.2.5. Name of the specialist service patient is being referred
to
5.13.2.8.2.6. PHC medical record number if available.
5.13.2.8.2.7. Details of the sponsor and patient's occupation (Non-
Saudi).
5.13.2.8.3. All referrals must contain full clinical details, including history,
physical examination findings, risk factors, alert medical conditions, medications, investigation
results and provisional diagnosis.
5.13.2.8.4. All female patients must be accompanied by an adult male capable of
decision – making and signing consent for admission and surgical/special procedures. However,
according to Saudi Laws, an adult female of sound mind may sign her consent form.
5.13.3. Transfer Process
5.13.3.1. Intra-Hospital Transfer of Patient

5.13.3.1.1. In Unit Transfer
5.13.3.1.1.1.Transfers within the unit requires no physician
orders.
5.13.3.1.1.2.The Nursing Staff shall coordinate the
relocation/movement of the patient and document the transfer.
5.13.3.1.1.3. After the patient has been relocated/moved the nurse
shall ensure that either the nurse or the ward clerk updates the patients location using the “inpatient
transfer’ conversion on the computer.
5.13.3.1.2. Off Unit Transfer

5.13.3.1.2.1.The physician shall place the order.
5.13.3.1.2.2. Only when there is change of service shall the initial
attending physician cancel all orders and document the transfer order in the paper chart.
5.13.3.1.2.3. The nurse on the units shall complete the Transfer
Information Sheet (Critical Care Transfer Record or Nursing Transfer Summary).
5.13.3.1.2.4. The nurse shall coordinate the transfer of the patient after
the above steps have been completed.
5.13.3.1.2.5. When the patient arrives to the unit, the nurse will ensure
that either the nurse or the ward clerk on the receiving unit shall update the patient’s location.
5.13.3.1.2.6. When a change of service occurs, the nurse on the
receiving unit will update the attending physician.
5.13.3.1.3. In Unit Swap

5.13.3.1.3.1. No physician order is required.
5.13.3.1.3.2. The nurse shall coordinate the move of both patients.
5.13.3.1.3.3. When the patients have been moved, the nurse shall
ensure that either the nurse or the ward clerk updates the patient’s location on the computer.
5.13.3.1.4. Off Unit Swap

5.13.3.1.4.1. Physician order is required.
5.13.3.1.4.2. Only when there is a change of attending physician shall
the initial physician cancel all his orders in the paper chart and chart the transfer order.
5.13.3.1.4.3.The nurse on the both units shall complete the transfer
Information Sheet applicable to their units.
5.13.3.1.4.4. The nurse on both units shall coordinate and collaborate
in moving the patients.
5.13.3.1.5. The manner of transport to other patient care units is either by

wheelchair or stretcher and shall be determined by physicians ordered activity level and patient
condition.
5.13.3.1.6. When the patients have been moved, the nurse on the initiating unit
shall ensure that either the nurse or the ward clerk updates the patient’s locations, on the computer.
5.13.3.1.7. When a change of service occurs for one or both patients, the nurse(s)
on both the initiating and receiving unit(s) shall ensure that the nurse updates they updates the attending
physician.
5.13.3.1.8. Accountability for assuming patient care responsibilities (i.e. initiating
new physician’s orders) at the time a patient is transferred from one nursing care to another rests with
the Registered Nurse on the unit receiving the patients.
5.13.3.1.9. The transferring nurse must verify that patients identification band is in
place.
5.13.3.1.10. The methods by which the RN is assigned care responsibility may vary:
5.13.3.1.10.1. RN assigned to all admissions and transfer
5.13.3.1.10.2. RN assigned to “unoccupied” beds
5.13.3.1.10.3. RN assigned by nurse in charge at time of transfer
5.13.3.1.11. Accountability for assuming patient care responsibilities (receiving

report) when a patient is transferred at change of shift, rests with the shift coming on, to eliminate
double reporting.
5.13.3.1.11.1. The nurse reporting the patient will provide a full verbal
report of patient’s admission, course of treatments and outcome of care to the nurse receiving the
patient.
5.13.3.1.11.2. The nurse transferring the patient will note in the
patient’s medical record by documenting the following:
5.13.3.1.11.2.1.Date, time and room number
5.13.3.1.11.2.2.Mode of transport
5.13.3.1.11.2.3.Any oxygen or special transport
requirement
5.13.3.1.11.2.4. Belongings and valuables
5.13.3.1.11.2.5. Vital signs and intake/output
5.13.3.1.11.2.6. Priority assessments
5.13.3.1.11.2.7. Patient education
5.13.3.1.11.3.The RN must note status of the patient’s
concerns/outcomes as the nursing diagnosis identified on the patient’s plan of care and the Progress
Notes of other disciplines.
5.13.3.1.11.4. Patency/presence of IV’s drainage tubes or catheters.
5.13.3.1.13. All of the patient’s belongings will be transported safely and in a timely
manner from one department or room to another.
5.13.3.1.14. The nurse transferring the patient will notify the family of room number
and location, when they call. If the family cannot be reached the receiving unit will continue to call
on daily basis until a family member is reached or until a family member arrives to visit the patient.
5.13.3.1.15. The nurse receiving the patient shall:
5.13.3.1.15.1. Orient the patient to new room and correct necessary
equipment
5.13.3.1.15.2. Perform nursing assessment noting patient condition,
mode of transfer, patency/location of tubes, drains and catheters.
5.13.3.1.15.3. Note patient belongings.
5.13.3.1.16. Patient will be considered transferred out from the transferring unit
transferred in the receiving unit and will be documented in this way in his/her file by the transferring
and receiving units.
5.13.3.1.17. Transfer of patients to Critical Care:
5.13.3.1.17.1. Communicate directly with Critical Care Nurse via
telephone to obtain a bed assignment if patient is to be transferred directly to unit.
5.13.3.1.17.2. A nurse and physician will accompany the patient to
Critical Care areas.
5.13.3.2. Inter-Hospital Transfer of Patient

5.13.3.2.1. A Saudi patient with a condition treatable at Abu Arish General
Hospital shall not be transferred to another hospital unless the family or patient desires so.
5.13.3.2.2. The treating consultant shall make arrangement at another hospital
by sending a detailed Medical Report by fax to the receiving hospital, along with a copy of patients
identification card.
5.13.3.2.3. An agreement to accept the patient by the receiving consultant
from the other hospital shall be received by fax.
5.13.3.2.4. The PRO who receives a fax must immediately dispatch this to the
concerned ward.
5.13.3.2.5. Upon receiving the fax reply, the treating physician is informed by
the nurse and a written order to transfer the patient is made.
5.13.3.2.6. The consultant in-charge decides whether the patient is fit for
travel and also decides the person who will accompany the patients i.e. a resident doctor and nurse or
only a nurse.
5.13.3.2.7. Unit Head Nurse or Charge Nurse will inform Nursing Supervisor.
5.13.3.2.8. An ambulance request is filled by Unit Charge Nurse and
countersigned by Nursing Supervisor is sent to the PRO.
5.13.3.2.9. The patient must reach the other hospital within the appointed
time.
5.13.3.2.10. Copies of Medical Report, appointment and identification card if
Saudi, or copy of Iqama ID card if non-Saudi, must be arranged. One set of copies is sent to the
receiving hospital along with the patient and one set of copies should be in the patient file.
5.13.3.2.11. The nurse shall ensure the patient’s medical record contain the
following documentation.
5.13.3.2.11.1.Date of transfer
5.13.3.2.11.2.Reason for transfer
5.13.3.2.11.3.Name and location of receiving facility
5.13.3.2.11.4.Acceptance from the receiving hospital
5.13.3.2.11.5.Name of consultant accepting the patient.
5.13.3.2.11.6.Evidence that the patient is sufficiently stabilized
for transfer.
5.13.3.2.11.7.Complete medical information of the patient
which includes histopathology slides for patients who are going for radiotherapy.
5.13.3.2.12. Relative’s of patient should be informed before shifting the
patient. The PRO must make all effort until he informs the patient’s relatives and wait for them to
arrive should they wish to accompany the patient, unless the patient’s condition does not allow so.
5.13.3.2.13. The nurse assigned to transfer the patient must be able to give
complete information and an endorsement to the receiving hospital nursing staff.
5.13.3.2.14. The nurse must be aware of the condition of the patient.
5.13.3.2.15. The unit nurse who is traveling with the patient must document the
time of start of transfer and inform Nursing Supervisor.
5.13.3.2.16. If an escorting nurse is from other unit, the ward charge nurse should
give a verbal report to the escorting nurse.
5.13.3.2.17. If the patient is involved in a police case, police clearance must be
done and a copy of police clearance must be attached to the transfer documentation.
5.13.3.2.18. If the patient is for definite admission and bed is reserved in the other
hospital by documentary evidence, discharge clearance may be done in Admission Office at Abu Arish
General Hospital before patient is transferred to other hospital. Discharge clearance can also be done
after the return of the escort staff and confirmation that patient is admitted.
5.13.3.2.19. Upon arrival staff should inform Nursing Supervisor and give a brief
report about the transfer process.
5.13.3.2.20. The escorting staff shall also document in nurses notes; enter
discharge register and Census Chart.
5.13.3.2.21. Accountability for assuming patient care responsibilities (receiving
report) when a patient is transferred at change of shift at receiving hospital, rests with the shift coming
on, to eliminate double reporting.
5.13.3.2.22. The nurse transporting the patient shall provide a full verbal report
of patient’s admission, course of treatments and outcome of care to the nurse receiving the patient.
5.13.3.2.23. The nurse transferring the patient shall document in the patient’s
medical record the following:
5.13.3.2.23.1. Date, time and room number
5.13.3.2.23.2. Mode of transport
5.13.3.2.23.3. Any oxygen or special transport requirements
5.13.3.2.23.4. Belongings and valuables handed over
5.13.3.2.23.5. Vital signs and intake/output
5.13.3.2.23.6. Priority assessment
5.13.3.2.23.7. Patient education
5.13.3.2.24. The RN must note status of the patient’s concerns/outcomes the
patient’s plan of care and the Progress Notes of other disciplines.
5.13.3.2.25. Patency/presence of intravenous drainage tubes or catheters
5.13.4. Discharge Process
5.13.4.1. The MRP after reviewing the patient and convinced by the stabilization of
the patient decides to discharge the patient.
5.13.4.2. Most Responsible Physician (MRP) or his designee shall update the doctor
progress notes and write a clear order for discharge in the patient file.
5.13.4.3. The assigned nurse prepares the patient’s file for discharge and updates
electronic medical record (MedicaPlus) data.
5.13.4.4. The MRP should complete all documentation with instructions in patient’s
medical record before patient leaves the service area. It will include appropriate information about:
5.13.4.4.1. Post-operative restrictions i.e. diet, activity etc. (if applicable).
5.13.4.4.2. Detailed instructions for the usage and possible food/drug
interactions of prescribed medications that need to be continued at home, and certain home drug
regime, the mode of delivery and any support required.
5.13.4.5. Instructions for follow-up care and patient's needs (i.e. dressing change, refer to
other specialty physician/dentist etc.) and assigning the follow up appointment for the patient.
5.13.4.6. Provide information to the patients about their illness and self –care methods for
activities of daily living.
5.13.4.7. Provide information to the patient about the safe use of medical equipment.
5.13.4.8. Instructions regarding conditions requiring contact with the physician, i.e
excessive drainage or bleeding, pain not controlled by prescribed medication, breathing difficulty etc..
5.13.4.9. Instructions for reaching a physician in case of emergency/urgency (e.g. post-

operative or pro-procedure problems) including phone numbers and way to obtain “urgent” care.
5.13.4.10. The reason the patient needs to be transferred to another institution (if applicable)
5.13.4.11. Involving the family members whenever patients cannot fully understand the
information provided to them (if applicable).
5.13.4.12. If patient will be transferred to another facility/hospital/institution, then the MRP

shall personally discuss the case with the receiving physician.
5.13.4.13. Charge nurse/assigned nurse shall inform the dietitian, physiotherapist,

counseling psychologist, social worker, pharmacist and shall update patient information sheet.
5.13.4.14. Patient's case is reviewed by dietitian, counseling psychologist/social

worker, physiotherapist and shall ensure notes entered by them on their respective sheets.
5.13.4.15. Assigned staff nurse shall return unused medication to pharmacy and obtain
discharge medication(s) through messenger from OPD Pharmacy, by electronic drug prescription
written by the MRP on MedicaPlus.
5.13.4.16. For follow-up OPD Appointment, the nurse fill out the electronic Outpatient
Appointment Form which is sent by assigned nurse to Appointment Section of the Patient
Services Department. The Appointment Section generates computerized appointment slip. The
staff nurse ensures that the correct date is given.
5.13.4.17. For Medico-legal cases there should be final medical report written with
preliminary medical report upon admission.
5.13.4.18. The physician of the concerned team shall write the discharge summary,
countersigned by the attending physician or MRP. Routinely anticipated patient and family
discharge needs are documented in the Patient Discharge Summary. The discharge summary shall
contain:
5.13.4.18.1.Reason for admission
5.13.4.18.2.Significant findings
5.13.4.18.3.Diagnosis
5.13.4.18.4.Brief summary of stay in hospital (therapies, consultations, non-
invasive interventions and results of any important diagnosis procedure/testing).
5.13.4.18.5. Laboratory and radiological investigations’ result
5.13.4.18.6. Details of any surgery/procedure performed
5.13.4.18.7. The outcome of surgery and treatment
5.13.4.18.8. List of medications used
5.13.4.18.9. Other treatment given
5.13.4.18.10. Condition at discharge
5.13.4.18.11. Patient disposition
5.13.4.18.12. Follow-up
5.13.4.18.12.1. Advice about special care the patient requires after
discharge.
5.13.4.18.12.2. Medication to be taken by the patient after
discharge
5.13.4.19. Nurse collects summary, arrange the discharge folder and update discharge track
sheet.
5.13.4.20. Complete accurate discharge documentation before sending file to the discharge
office for the discharge stamp.
5.13.4.21. Contact Discharge Unit about patient’s discharge.
5.13.4.22. Send the file by orderly for discharge to Discharge Unit along with
patient/relative
5.13.4.23. If the patient is under self-finance scheme:

5.13.4.23.1. Final bill is prepared.
5.13.4.23.2. Pending amount is collected from the patient/attendant
5.13.4.23.3. Bill receipt is generated and deposited to Finance and Accounts
Department
5.13.4.24. Discharge slip is given to the patient/orderly and one copy is attached in patient
medical records.
5.13.4.25. Assigned staff nurse will update admission/discharge register and MedicaPlus
data; and send a copy of discharge to ward secretary to type the discharge summary.
5.13.4.26. Inform patient regarding any pending reports and intimate regarding the time and
date of report collection.
5.13.4.27. Check the need for ambulance and inform AED director. Shift the patient in
wheel chair, escorted by orderly
5.13.4.28. In case the patient is discharged against medical advice (DAMA):
5.13.4.29. Patient or Surrogate Decision-Maker signs DAMA form.
5.13.4.30. Physician prepares only one copy of DAMA summary (countersigned by

Specialist on duty), to be kept in the patient medical record. Patient is not entitled to get the copy of
Discharge Summary.
5.13.5. Documentation in Medical Records
5.13.5.1. Purpose
The purpose of complete and accurate patient record documentation is to
foster quality and continuity of care. It creates a means of communication between health care
providers and between health care providers and members about health status, preventive health
services, treatment, planning, and delivery of care.
5.13.5.2. Medical Records Standards

The Hospital medical record standards reflect the importance of
confidentiality and accessibility by authorized users only.
5.13.5.2.1. Keep a unique, individual record for each patient
5.13.5.2.2. Establish an organized record-keeping system to ensure that
medical records are easily retrievable for review and available for use when needed, including at
each patient visit
5.13.5.2.3. Store and maintain medical records in a centralized and secured
location accessible only to authorized personnel and provide equivalent security for electronic
medical records
5.13.5.2.4. Maintain and organize documents within medical records in a
specified order
5.13.5.2.5. Ensure that documents are fastened securely within a paper
medical record
5.13.5.2.6. Provide periodic training in confidentiality and security for
patient information.
5.13.5.3. Documentation of Referral

Whenever a Medical Staff member (other than a patient's Most Responsible
Physician) sees a patient, complete documentation of the encounter must be made available to the
patient's referring MRP.
Promptly accomplishing the records ensures that the Most Responsible
Physician has a complete medical record on file and that the referring physician has the necessary
information.
5.13.5.4. Documentation Standards

The AAGH documentation standards reflect the importance of complete, timely, and accurate health
information. The Hospital expects the following concerning documentation:
5.13.5.4.1. Member identifiers appear on every piece of documentation
5.13.5.4.2. Entries are legible to others and are recorded in black or blue
ink.
5.13.5.4.3. Entries are dated and authenticated by the Most Responsible
Physician or Medical Staff member.
5.13.5.4.4. Documentation is made at the time service is provide.
5.13.5.4.5. Documentation must support all codes submitted.
5.13.5.4.6. Only standard medical abbreviations shall be used in
documentation.
5.13.5.4.7. All patient encounters, including telephone, fax, and electronic
message exchanges are documented.
5.13.5.5. Medical Record Contents:

5.13.5.5.1. Problem list, including significant illnesses and medical conditions
5.13.5.5.2. Medications
5.13.5.5.3. Adverse drug reactions
5.13.5.5.4. Allergies
5.13.5.5.5. Smoking status
5.13.5.5.6. Any history of alcohol use or substance abuse
5.13.5.5.7. Biographical or personal data
5.13.5.5.8. Pertinent history
5.13.5.5.9. Physical exams
5.13.5.5.10. Documentation of clinical findings and evaluation for each visit
5.13.5.5.11. Laboratory and other studies that signify
review
5.13.5.5.12. Working diagnoses consistent with findings and test results
5.13.5.5.13. Treatment plans consistent with diagnoses
5.13.5.5.14. A date for return visits or a follow-up plan for each encounter
5.13.5.5.15. Previous problems addressed in follow-up visits
5.13.5.5.16. A current immunization record
5.13.5.5.17. Preventive services and risk screening
5.13.6. Expected Conduct of Care for all Medical Staff Levels
The Medical Staff shall be organized into the following Hospital Departments:
Anesthesia, General Surgery, Dermatology, Accidents and Emergency, Internal Medicine, Obstetrics
and Gynecology, Ophthalmology, Orthopedic Surgery, Otorhinolaryngology, Pathology, Pediatrics,
Physical Medicine and Rehabilitation, Radiology and Urology.
5.13.6.1. Consultants
5.13.6.1.1. Primarily responsible for the whole patient care plan and
management including emergency and planned operations;
5.13.6.1.2. Performs at least two rounds daily: morning rounds with main unit
and afternoon rounds with his team;
5.13.6.1.3. Act as the decision-maker after discussion with other consultants
in his unit and his team doctors
5.13.6.1.4. Decides discharges of patients;
5.13.6.1.5. takes regular on-call duties as planned by the Head of the
Department;
5.13.6.1.6. Supervision and training of Specialists, Residents, and Interns and
update the Head of the Department about their progress;
5.13.6.1.7. Continuously assess Specialists, Residents and Interns then give
feedback to the Head of the Department regarding his team;
5.13.6.1.8. Provides time for discussions, teach in daily rounds and train his
team in various skills focusing on Saudi Arab Board candidates, Royal College fellowship trainees and
Interns and sign the logbooks for them;
5.13.6.1.9. Supervise the clerking, discharge summaries and daily progress
notes;
5.13.6.1.10. Discuss cases with referring consultants on urgent cases;
5.13.6.1.11. Attends outpatient clinics on time and on schedule;
5.13.6.1.12. Attends to referred cases and do follow-up as appropriate;
5.13.6.1.13. Endorse seriously- and critically-ill cases to the On-Call
Consultants;
5.13.6.1.14. Follow-up patient mortality reports for review and discussion in
the intradepartmental mortality and morbidity meetings;
5.13.6.1.15. Participates in Hospital interdepartmental teaching programs and
present specific topics on lectures;
5.13.6.1.16. Participate in the Quality Improvement activities in the Hospital.
5.13.6.2.Specialists
5.13.6.2.1. Supervises the residents;
5.13.6.2.2. Help in clerking and discharge summaries if Residents are
unavailable;
5.13.6.2.3. Shares in the planning, work-up and management of patients;
5.13.6.2.4. Cover Specialist Clinics at the Outpatient Department;
5.13.6.2.5. Communicate and coordinate procedures or appointments with
other Consultants or Hospitals;
5.13.6.2.6. Coordinate inter-Hospital referrals and transfers of patients;
5.13.6.2.7. Takes on call duties as approved by the Head of the Department;
5.13.6.2.8. Discuss the provisional diagnoses, differential diagnoses;
investigations and plan of management with his/her Residents during duty calls for each ER admission
as well as provide instructions regarding results for follow-up;
5.13.6.2.9. Attend the daily morning rounds and document it in the patient's
charts;
5.13.6.2.10. Supervise the Residents and Interns on presentations during
Grand Rounds and present the cases in the absence of a Unit Resident;
5.13.6.2.11. See, review, and follow-up interdepartmental referrals and inform
the Consultant;
5.13.6.2.12. Conduct teaching programs for the Residents, Interns and
Nursing Staff;
5.13.6.2.13. Ensure close follow-up of patients and management outcomes;
5.13.6.2.14. Write and present the departmental morbidity and mortality
meetings;
5.13.6.2.15. Write medical reports for cases as requested by Consultants;
5.13.6.2.16. Endorse each case and consultation to incoming medical team;
5.13.6.2.17. Participate in the Quality Improvement activities of the Hospital.
5.13.6.3. Residents
5.13.6.3.1. Mainly responsible for clerking, discharge summaries, ICD
coding, and daily progress notes;
5.13.6.3.2. Attend two daily rounds with the Specialists and/or Consultants;
5.13.6.3.3. Do evening rounds during on-call duties;
5.13.6.3.4. Write request for investigations and follow up results, including but
not limited to: histopathology, radiology, ultrasonology results and the like;
5.13.6.3.5. Sign results of investigations with date and time, upon receipt and
before inserting it in the patient's charts;
5.13.6.3.6. Present cases admitted in the previous twenty-four (24) hours during
the morning meetings;
5.13.6.3.7. Present the cases of the unit during the Grand Rounds;
5.13.6.3.8. Attend OPD Clinics to help the Consultant in the absence of the
Specialist;
5.13.6.3.9. Inform the Specialist regarding arising problems, results of
investigations, and critical decisions related to patient care;
5.13.6.3.10. Pursue continuing medical education in intradepartmental and
Hospital educational problems;
5.13.6.3.11. Accompany patient during inter-Hospital transfers.
5.13.7. Professional Conduct of Medical Staff
5.13.7.1. Professional Conduct: Medical Staff must be endorsed with all duties, rules,
regulations needed for adequate fulfillment of Medical Process
5.13.7.1.1. Medical Staff must be made aware of all duties, rules, regulations,
and membership Responsibilities:
5.13.7.1.2. Each Medical Staff member shall provide his/her patients with
care at the highest professional level of quality and efficiency.
5.13.7.1.3. Each Medical Staff member shall abide by the Medical Staff By
Laws, Hospital Policies and Procedures, the Ministry of Health laws, laws of the Kingdom of Saudi
Arabia, and such national and international standards as adopted by the Hospital.
5.13.7.1.4. Each Medical Staff member shall discharge the duties of the
Medical Staff, Department and Committee(s) for which he/she is responsible.
5.13.7.1.5. Each Medical Staff member is responsible to prepare and
complete, in a timely and legible manner, the appropriate medical record and other required records
for all patients to whom he/she provides care.
5.13.7.1.6. Consultant Medical Staff members shall have a strong interest in
teaching and be willing to contribute the necessary time and effort to the relevant educational program.
5.13.7.1.7. Consultant Medical Staff members shall participate in regional
and national scientific societies, associations, meetings, and science clubs as well as in medical
research related to their specialty.
5.13.7.1.8. Medical Staff members shall report practice occurrence variances
and/or incidents, as well as any involvement in professional liability action.
5.13.7.1.9. In an emergency, any Medical Staff member is responsible to
provide any type of patient care necessary as a life-saving measure, or to save patients from serious
harm, regardless of his medical staff status or clinical privileges, as long as the care provided is within
the scope of the individual’s licensure.
5.13.7.2. Ethical Conduct: Ensure the Hospital's commitment to Islamic ethics, Saudi
rules and regulations and cultural obligations and responsible conduct of its employees. The code of
conduct provides guidance to ensure that the hospital's business is conducted in an ethical and legal
manner, and to stress the hospital's ethical responsibility to the patients and community it serves The
Code of Conduct is supplementary to the Hospital values.
5.13.7.2.1. Medical Staff conduct shall be ruled to ensure the hospital's
commitment to the Islamic ethics.
5.13.7.2.2. Medical Staff conduct shall be governed by the rules and
regulations of the Ministry of Health, the Saudi Commission for Health Specialties, and the applicable
ethics of the relevant medical profession.
5.13.7.2.3. All Medical Staff must abide by all ethical policies and regulations
detailed in the Hospital’s ethics documents.
5.13.7.2.4. The Medical Staff shall evaluate practitioner and institutional
performance, through valid and reliable measurement systems based on objective, clinically-sound
criteria, and internationally accepted standards.
5.13.7.2.5. The Medical Staff shall recommend to the Hospitals
Administration the establishment and provision of professional standards.
5.13.7.2.6. The Medical Staff shall conduct or obtain others to conduct and
arrange for Medical Staff participation in education programs, designed to meet the needs of staff
members.
5.13.7.2.7. The Medical Staff shall assure that medical and health care
resources at the Hospitals are appropriately employed for meeting patients' medical, social, and
emotional needs, consistent with sound health care resource utilization practices.
5.13.7.2.8. The Medical Staff shall conduct a systematic review of all
members regarding the quality of care provided by the medical staff.
5.13.7.2.9. The Medical Staff shall analyze the results of review activities in
order to identify problems in the provision of care.
5. RESPONSIBILITIES:
6.1. Heads of Department

6.1.1. ensure the medical staff bylaws are made accessible and communicated to all members
of the medical staff
6.1.2. enforce the medical staff bylaws along with relevant rules and regulations
6.2. Medical Director
6.2.1. ensure the medical staff bylaws are made accessible and communicated to all members
of the medical staff
6.2.2. enforce the medical staff bylaws along with relevant rules and regulations
6.3. Governing Body shall approve the Medical Staff By Laws
Section 6. MATERIALS AND EQUIPMENT:
6.1. Organizational Structure of the Medical Service
Section 7. REFERENCES:
AAGH Medical Staff By Laws
Section 8: ADOPTION
These ByLaws shall become effective and shall replace any previous Bylaws after these have been
adopted by the Medical Executive Committee and approved by the Governing Body.
Adopted by the Medical Executive Committee of AbuArish General Hospital

October 10, 2018
_________________________________________________________________
Dr Abdullah Ghalib Orebi
Chair, AAGH Medical Executive Committee
_________________________________________________________________
Mr Khalid Abdullah Al-Ammar
Director, Quality Management Department
Approved by the Governing Body of Abu Arish General Hospital

October 10, 2018
_________________________________________________________________
Dr Abdullah Ghalib Orebi
Medical Director
_________________________________________________________________
Mr Ahmed Ali Alharbi
Hospital Director
_________________________________________________________________
Dr Abdullah Al-Najmi
General Director

MS ByLaws 2018

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MEDICAL STAFF

9 Section 5. MEDICAL STAFF BY LAWS, RULES AND REGULATIONS

50 Section 6. MATERIALS AND EQUIPMENT:

3.12. Hospital: means Abu Arish General Hospital

3.16. Medical Students/Interns: means an individual enrolled in an undergraduate training

3.26. Warning: a verbal or written communication issued by way of Corrective Action to a

4.5. The Medical Staff By Laws shall address:

5.1. ARTICLE I. Mission, Vision, Values and NAME

5.1.1. AAGH Mission Statement

5.1.2. AAGH Vision

5.1.3. AAGH Values

5.2.2. To promote professional standards among members of the Medical Staff;

5.3.9.1. Medical Executive Committee/Medical Board

5.3.9.2. Blood Utilization Review Committee

5.3.9.3. Cardiopulmonary Resuscitation and Rapid Response Committee

5.3.9.4. Credentialing and Privileging Committee

5.3.9.5. Infection Control Committee

5.3.9.6. Medical Record Review Committee

5.3.9.7. Morbidity and Mortality Committee

5.3.9.8. Operating Room Committee

5.3.9.9. Pharmacy and Therapeutics Committee

5.3.9.10. Tissue Review Committee

5.3.9.11. Utilization Review Committee

5.4.1. The Medical Director

5.4.2. The Deputy Medical Director

5.4.3. The Heads of the Department

5.4.3.1. Qualifications: A head of department shall possess the following qualifications:

5.4.4. The Consultant

5.4.4.1. Either Saudi Board, American Board, or Canadian Fellowship, or MRCP, or

5.4.5. The Specialist

5.4.6. The Resident

5.4.6.1. Graduate of a recognized Medical School

5.5.1. Active Staff (Permanent/Contracted):

5.5.2. Courtesy Staff:

5.5.3. Provisional Staff:

5.5.4. Administrative Staff:

5.6. Article VI. THE POSTGRADUATE INTERN

5.7. Article VII. THE ALLIED HEALTH STAFF

Allied Health Staff shall agree to be governed by these By Laws.

5.8.1. The Medical Director

5.8.2. The Deputy Medical Director

5.8.3. The Heads of Department

5.8.4. The Consultants

5.8.5. The Specialists

5.8.5.1. Supervises the Residents.

5.8.6. The Residents

5.9. Article IX. GENERAL CONDITIONS OF APPOINTMENT

5.9. Article X. TERMS OF APPOINTMENT

5.9.1. Provisional Appointment Period

5.9.1.1. Monitoring Performance During the Provisional Period

5.9.1.2. Conclusion of Provisional Period

5.9.2. Contract Practitioners

5.10.1. Membership Requirements and Criteria:

5.10.1.1. Be a graduate of an accredited medical or dental school

5.10.2. Appointment Process:

5.10.4.1. Submission of Request for Reappointment

5.10.4.2. Processing of Request for Reappointment

5.10.4.2.1. Upon receipt of a completed request for reappointment, Medical Staff

5.10.4.3. Decision on Request for Reappointment

The remainder of the reappointment process is the same as for appointment

5.10.1. Verification is defined as verification of the original source of a specific credential to

5.10.3. Be willing to appear for an interview in regard to his/her application

5.11.3. Process of Temporary Privileging: