ESR Required Documents (Policies, Guidelines, Forms)

Region: ……………………………………………………………………………. Hospital Name: ………………………………………………………………..

Date of the visit: ………………………………………………………………. Assessor Name: ………………………………………………………………..

Standard Policy/Plan/List/Form Category Was Your Policy If your Hospital Policy

Considered Met in the did not meet/partially
ESR Survey met the substandard,
did you develop,
revise and update
The hospital has a process for
HR.5.1 The hospital has a written policy o Yes. o Yes.
proper credentialing of staff
HR.5 describing the process used for the verification Policy o No. o No.
members licensed to provide
of credentials. o Partially Met. o In process.
patient care.
Clinical privileges Policy include the following:
Review and update the privileges every two
years.
Medical staff members have o Yes. o Yes.
Identify temporary or emergency privileges
MS.7 current delineated clinical Policy o No. o No.
and not more than 90 days.
privileges. o Partially Met. o In process.
When a new privilege is requested, the
credentials are verified and evaluated prior to
approval.
PC.25.1 There are policies and procedures that
Policies and procedures guide
are developed collaboratively by the blood o Yes. o Yes.
the handling, use, and
PC.25 utilization committee, guiding the handling, Policy o No. o No.
administration of blood and
use, and administration of blood and blood o Partially Met. o In process.
blood products.
products.
 Patients at risk for developing There is a policy for assessing the risk of o Yes. o Yes.
PC.26 venous thromboembolism are developing venous thromboembolism and Policy o No. o No.
identified and managed. Prophylaxis. o Partially Met. o In process.
The hospital has a process to o Yes. o Yes.
There is a process implemented to ensure
QM.17. ensure correct identification Policy o No. o No.
correct identification of patients.
of patients. o Partially Met. o In process.
QM.18.1 There is a process implemented to
The hospital has a process to
prevent wrong patient, wrong site, and wrong o Yes. o Yes.
prevent wrong patient, wrong
QM 18. surgery/procedure during all invasive Policy o No. o No.
site, and wrong
interventions performed in operating rooms o Partially Met. o In process.
surgery/procedure.
or other locations.
IPC.15.6 Transmission-based precaution cards
Facility design and available (isolation signs) are consistent with the o Yes. o Yes.
IPC.15 supplies support isolation patient diagnosis and are posted in Arabic and Policy o No. o No.
practices. English and indicate the type of precautions o Partially Met. o In process.
required.
MM.5.1 There is a written multidisciplinary
plan for managing high-alert medications and
The hospital has a system for o Yes. o Yes.
hazardous pharmaceutical chemicals. It
MM.5 the safety of high-alert Plan o No. o No.
includes identification, location, labelling,
medications. o Partially Met. o In process.
storage, dispensing, and administration of
high-alert medications.
MM.5.2 The hospital identifies an annually
updated list of high-alert medications and o Yes. o Yes.
hazardous pharmaceutical chemicals based on List o No. o No.
its own data and national and international o Partially Met. o In process.
recognized organizations.
MM.5.4 The hospital develops and
implements standard concentrations for all o Yes. o Yes.
Guideline o No. o No.
medications
o Partially Met. o In process.
administered by intravenous infusion.
 The hospital has a system for
MM.6.1 There is a multidisciplinary policy and o Yes. o Yes.
the safety of look-alike and
MM.6 procedure on handling look- alike/sound-alike Policy o No. o No.
sound-alike (LASA)
(LASA) medications. o Partially Met. o In process.
medications.
MM.6.2 The hospital reviews and revises
annually its list of confusing drug names, o Yes. o Yes.
which include LASA medication name pairs List o No. o No.
that the hospital stores, dispenses, and o Partially Met. o In process.
administers.
The hospital has a process for
monitoring, identifying, and
MM.41.1 There is a multidisciplinary policy
reporting significant
and procedure on handling medication errors,
medication errors, including o Yes. o Yes.
near misses, and hazardous situations (e.g.,
MM.41 near misses, hazardous Policy o No. o No.
confusion over look-alike/sound-alike drugs or
conditions, and at-risk o Partially Met. o In process.
similar packaging).
behaviours that have the
potential to cause patient
harm.
MM.41.5 The hospital has a standard format o Yes. o Yes.
Form o No. o No.
for reporting medication errors.
o Partially Met. o In process.
LB.51.1 There are policies and procedures
The blood bank develops a mandating that a sample of blood obtained
process to prevent disease from the donor during blood/ blood o Yes. o Yes.
LB.51 Policy o No. o No.
transmission by component collection is subjected to the
o Partially Met. o In process.
blood/platelet transfusion. following infectious diseases testing:

The hospital ensures that all FMS.9.1 The hospital has a radiation safety o Yes. o Yes.
FMS.9 its occupants are safe from policy and procedure and it is implemented. Policy o No. o No.
radiation hazards. o Partially Met. o In process.
 The hospital and its occupants FMS.24.1 The hospital implements a strict “No o Yes. o Yes.
FMS.24 Policy o No. o No.
are safe from fire and smoke. Smoking” policy.
o Partially Met. o In process.
The hospital ensures proper o Yes. o Yes.
FMS.32 maintenance of the medical There is a policy for Medical Gas System. Policy o No. o No.
gas system o Partially Met. o In process.

List of Policies must be reviewed:

1. Verification of Credentials Policy.
2. Clinical Privilege Policy.
3. The handling, use, and administration of blood and blood products Policy.
4. Informed Consent.
5. VTE Policy.
6. Patient Identification Policy.
7. Surgical Site Verification Policy.
8. Plan for managing high-alert medications and hazardous pharmaceutical chemicals.
9. Policy and procedure on handling look- alike/sound-alike (LASA) medications.
10. Multidisciplinary policy and procedure on handling medication errors, near misses, and hazardous situations (e.g., confusion over
look-alike/sound-alike drugs or similar packaging).
11. Policy and procedure on handling medication errors, near misses, and hazardous situations LB.51.1 There are policies and
procedures mandating that a sample of blood obtained from the donor during blood/ blood component collection is subjected to
the following infectious diseases testing:
12. Radiation safety policy.
13. No Smoking policy.
14. Medical Gas policy.