Final of Hospital Accreditation SAT

‫االدارة العامة للدعم الفني للمنشآت الصحية‬
‫أداة التقييم الذاتي لمعايير اعتماد المستشفيات‬
‫‪Self assessment tool for GAHAR hospital Accreditation standards Edition 2021‬‬
‫اسم المنشأة‬
‫الجهة التابعة لها‬
‫العنوان ‪/‬المحافظة‬
‫تاريخ عمل التقييم‬
‫اسم المنسق‬
‫اسم مدير المنشأة‬
‫تليفون المنشأه‬
‫تليفون المنسق‬
‫‪andards Edition 2021‬‬
‫اسم المنشأة‬
‫الجهة التابعة لها‬
‫العنوان ‪/‬المحافظة‬
‫تاريخ عمل التقييم‬
‫اسم المنسق‬
‫اسم مدير المنشأة‬
‫تليفون المنشأه‬
‫تليفون المنسق‬
NO
APC.01
2
3
APC.02
3
4
APC.03
APC.04
1
2
APC.05
4
Accreditation Prerequisites
The hospital sustains, ensures and monitors compliance wi
The hospital establishes a process of frequent assessment of complianc
The hospital acts on all feedback and reports received from GAHAR d
The hospital reacts to all GAHAR requirements and reports in a timel
The hospital demonstrates using approved monitoring tools to measur
When a gap is identified, the hospital takes all necessary measures to i
The hospital reports to GAHAR any challenges that affect compliance
The hospital ensures safe medical provision through complying w
The hospital has an approved process for registering all members of th
The hospital assigns a taskforce to ensure complete registration and Id

timeframe.
The process covers all full-time, part-time, visiting, or other types of co

The hospital reports to GAHAR, healthcare authority, and professiona
such as, fake, or misrepresented credentials.
The hospital provides GAHAR with accurate and complete infor
The hospital reports accurate and complete information to GAHAR du
The hospital reports accurate and complete information to GAHAR du

processes
The hospital reports within 30 days any structural changes in the hosp
services by more than 15% (if beds, specialties, staff), building expansi
The hospital provides GAHAR access to evaluation results and reports
The hospital uses the accreditation process to improve safety an
The hospital permits GAHAR to perform on-site evaluations of standa

safety concerns, reports, or regulatory authority sanctions.
The hospital accurately represents its registration and accreditation st
The hospital informs staff and patients on mechanisms to report safety
The hospital maintains professional standards during the surve
During surveys, the hospital reports any conflict of interest to GAHAR
During surveys, the hospital maintains professional standards on deali
During surveys, the hospital ensures that the environment does not po
During surveys, the hospital avoids media or social media releases with
General Admin
‫ أداة التقييم الذاتي لمعايير االعتماد للمستشف‬Self assessment tool for GAHAR hospi
status of preparedness
MET
PARTIAL MET
NOT MET
NOT Applicable
score comments / findings
2
0
N/A
ation.
N/A
2
2
and accreditation process.
1
2
2
General Administration Of Technical Support For Healthc
ment tool for GAHAR hospital Accreditation standards Edition
scoring system
atus of preparedness ‫التقييم‬
MET ‫مطبق بشكل كامل‬
PARTIAL MET ‫مطبق بشكل جزئي‬
NOT MET ‫غير مطبق‬

NOT Applicable ‫غير قابل للتطبيق‬
user guid
Total percentage
Total score
%
Documents
40% Not Met
‫مستند للتقيييم ومستند لنظام‬

‫التقييم‬
‫ الخطة‬- ‫التقارير المستلمة‬

‫التصحيحية‬
‫التقارير المرسلة من المستشفي‬
‫اداة التقييم المستخدمة‬
‫التقارير المرسلة من المستشفي‬
‫‪100%‬‬ ‫‪MET‬‬
‫عملية التسجيل‬
‫أمر التكليف ‪ -‬االطار الزمني‬
‫طريقة التسجيل لجميع العاملين‬

‫التقارير‬
‫‪63%‬‬ ‫‪PARTIAL MET‬‬
‫التقارير بمعلومات صحيحة‬

‫ومكتملة عن المنشأة‬
‫التقارير عن الفترة بين التسجيل و‬

‫االعتماد‬
‫التقارير عن التعديالت االنشائية‬

‫والخدمية‬
‫التقارير التقييم الخارجية‬
‫‪83%‬‬ ‫‪MET‬‬
100% MET
‫الية االبالغ‬
Total chapter Score
77%
port For Healthcare Facilities
s Edition
oring system
score
‫م‬ 2
‫مط‬ 1
N/A
user guide
intertview observation
‫المسئول عن التقييم‬
‫تطبيق المالحظات الواردة‬

‫بالتقارير‬
‫تطبيق التحسين‬
‫االدارة‬
‫المسئول عن التسجيل‬
‫العاملين ( فئات‬
‫مختلفة)‬
‫المسئول‬
‫التقييم الفعلي للمنشأة عن‬

‫طريق الهيئة‬
‫الخدمات المعلنة تتناسب مع‬
‫وضع المؤسسة من االعتماد‬
‫أو التسجيل‬
‫مقابلة مع العاملين‬
‫والمرضي‬
‫وجود تضارب في المصالح‬
‫وجود تعامل غير مهني‬
‫وجود مخاطر فيما يخص‬

‫االمن والسالمة للمراجعين‬
‫نشر اخبار او صور بدون‬

‫موافقة الهيئة‬
percentage%
> = 80%
<80% >=50%
<50%
N/A
Action plan
corrective action responsible person

n plan
Target Date Status
‫غير مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫ي لمعايير االعتماد للمستشفيات‬
Self assessment tool for GAHAR hospital Accre
scoring system
Data APC.01 APC.02
40% 100%
APC
Score
120%
100%
100%
80%
63%
60%
40%
40%
20%
0%
APC.01 APC.02 APC.03
‫أداة التقييم الذاتي لمعايير االعتماد للمستشف‬
or GAHAR hospital Accreditation standards Edition 2021
scoring system
APC.03 APC.04 APC.05 total
63% 83% 100% 77%
APC
Score
100%
83%
77%
63%
APC.03 APC.04 APC.05 total

NO
PCC.01
1
2
PCC.02
PCC.03
1
2
APC.04
4
5
PCC.05
PCC.06
1
2
PCC.07
4
PCC.08
PCC.09
2
3
PCC.10
4
5
PCC.11
6
PCC.12
PCC.13
1
2
PCC14
2
3
PCC15
PCC.16
1
PCC.17
3
4
PCC.18
PCC.19
2
3
PCC.20
PCC.21
1
5
Patient-Centeredness Cultu
. The hospital advertisements are clear and comply with applicabl
The hospital has an approved policy guiding the process of providin

of services.
Advertisements are done in compliance with laws, regulations, and ethic
Patients and their families receive clear, updated, and accurate informat
professionals, and working hours.
Patients and their families are informed of expected costs in a mann
.Patient-centeredculture is developed by interdisciplinary collaboration
The interdisciplinary committee has approved terms of reference.
The committee meets at predefined intervals multiple times a year.
The committee meetings are recorded.
Patient-centered initiatives are supported by the hospital staff and
Staff is oriented, educated, and trained on patient-centered initiatives.

The hospital developed mechanisms to evaluate the patient-centeredness
include patient education activities, patient engagement in making care d
When a staff member or a group of staff demonstrates a patient-centered

lessons from this initiative to improve hospital-wide performance.
Hospital leadership takes action to encourage staff participation in
Patient and family rights are protected and informed to patients a
The hospital has an approved policy guiding the process of defining patie
from a)through k).
All staff members are aware of patients' and families’ rights.
An approved statement on patient rights is posted in all public areas in t

patients, and families.
Patient and family rights are protected in all areas and at all times.
Information about patient rights is provided in writing or in another ma
Patients and families are empowered to assume their responsibiliti
The hospital has an approved policy guiding the process of defining

mentioned in the intent from a) through e).
All staff members are aware of patients' and families’ responsibilities.
An approved statement on patient and family responsibilities is posted in

makes it visible to staff members, patients, and families.
Information about patient responsibilities is provided in writing or i

understands.
Violations against patients’ and families’ rights and responsibilitie
The hospital is responsible for collecting, analyzing, interpreting, and eva

rights and responsibilities
Information about reporting violations to patient and family rights and re
patients, and families in writing or in another understandable manner
Periodical report on violations to patient and familyrights and respon

director
Actions are taken to improve patient centeredness practices based on thos
When ethical dilemmas as conflicting decisions regarding the provisi

evidence of clear discussion and resolution of the situation
Admission consent is obtained from the patient or a legal rep
Admission consent is provided in writing in a language that the patient un
The patient’s medical record includes a record of the patient’s or legal rep
hospitalized
There is a process to address situations when neither a patient nor a legal
Those responsible for obtaining admission consent are able to answer que
.obligations of hospitalization
Patients and families have opportunities to meet with multiple
(including the nurse and medical staff member).
A process is in place to allow patients and families to meet or to talk to he
A process is in place by which patients and families may request additiona

options, etc., and those requests are accommodated
There is a clear process for patients and their families to place que
.healthcare professionals are not present
Tools are used to encourage patients to pose questions
Appropriate patient education materials are available.
The hospital identifies the topics, places, and/or timings for distribut
Patient education materials are readily available during the timings, in th

hospital
Patient education materials contain relevant and evidence-based informat
Patient education materials are appropriate for readers of varying literac
Patient education materials are translated into different languages for for
Patients' and families’ education is provided clearly.
The hospital has an approved policy guiding the process of patient and fa
mentioned in the intent from a)through f
All staff members are aware of patients’ and families’ education process a
Patient education needs, the responsibility of providing education, an

patient’s medical record
Patients receive education relevant to their condition

Patient education activities are recorded in the patient’s medical record
Recorded informed consent is obtained for certain medical proces
The hospital has an approved policy guiding the process of informed cons
intent from a) through d
An informed consent form is available in all relevant areas
Informed consent is obtained in a manner and language that the patient u
Informed consent is recorded and kept in the patient’s medical record
The most responsible physician obtaining the informed consent signs the f
required
Informed consent given by someone other than the patient complies with
Informed consents validity is defined.
The hospital defines validity requirements for informed consent
The hospital defines a list of situations when a new consent is need
All relevant staff members are aware of consent validity
A new consent is obtained when the old consent expires or becomes invali
to f
A new consent is recorded in the patient’s medical record when indicated
Patients and families are informed about their rights and responsi
such as a treatment, a diagnostic procedure, or an intervention.
The hospital has an approved policy guiding the process of informed refu
Staff members receive education to focus on the strengths and empow
Informed refusal form/DAMA form is available in all relevant areas
Informed refusal form/DAMA form contains all required information in t
Informed refusal/DAMA form is recorded and kept in the patient’s medic
Informed refusal/DAMA form given by someone other than the patient co
Patients and families are informed and supported through the
Financial and/or patient relations staff members are available to assist pa

.managing billing (or other administrative) processes
Cost estimation documents and tools are available

A process is in place to ensure periodic education and support of patients
administrative) process
The hospital identifies patients whose conditions might require higher cos
them periodically
Patient-centered waiting spaces are available for various services.
Waiting spaces are lit, ventilated, clean, and safe
Waiting spaces are planned to accommodate the expected number of pati
Waiting spaces provide access to satisfy basic human needs such as
Patients receive information on how long they may wait
During hospitalization, the patient's stay is comfortable.

Patients are allowed to control the environment of their space, such as ven
Comfortable spaces and equipment are available for patient use
Healthy food is available for patients and their companions 24 hours a da
Visiting hours are convenient for patients and their families
The hospital identifies, communicates, and honors patient emo
Clinical staff members assess and reassess patients’ emotional, religious, a

file
Plans of care are modified to honor emotional, religious, and spiritual nee
Cleaning, food, and other services assess and reassess patient and family p
Traditional schedules are modified to honor patient preferences
Patient’s dignity, privacy, and confidentiality are protected during
Patient’sprivacy is respected for all clinical interviews, examinations, proc
Confidentiality of patient information is maintained according to laws and
Patients are allowed to decide who can attend their screening, assessment
The hospital’s responsibility towards the patient’s belongings is de
Thehospital has an approved policy guiding hospital responsibilities for p

.)from a) through e
Staff members are aware of the hospital’s policy

Information about the hospital's responsibility for belongings is given to t
The patient’sbelongings are protected and returned
Lost and found items are recorded, protected, and returned when possibl
items are not returned within a defined timeframe
The hospital improves provided services based on measured patien
The hospital has an approved policy guiding the process of patient a

mentioned in the intent from a) through c
.There is evidence that the hospital has received, analyzed, and inter
There is evidence that interpreted feedbacks have been shared with conce
improvement
.There is evidence that patients’ and families’ feedback is used to imp
Patients and families are able to make oral or written compl

The hospital has an approved policy guiding the process of managing pati
the intent from a) through d)
The hospital allows the complaining process to be publically available
Patients and families are allowed to provide suggestions and complaints
Complaints and suggestions are investigated and analyzed by the hospital
Patients and families receive feedback about their complaints or suggestio

Genera
‫أداة التقييم الذاتي لمعايير االعتماد للمستش‬ Self assessment tool for GAHAR ho
MET
PARTIAL MET
NOT MET
NOT Applicable
f the healthcare professionals' syndicates
N/A
2
2
2
2
1
1
1
er discussing the patient’s needs and obligations
0
0
2
2
N/A
N/A
N/A
N/A
N/A
s.
N/A
N/A
N/A
N/A
2
nuing a step(s) in the medical care process
1
1
esses.
1
1
1
1
other preferences.
1
1
reening, assessments, care, and treatments.
0
2
N/A
d process.
2
1
General Administration Of Technical Support For H
ssment tool for GAHAR hospital Accreditation standards Edition2021
scoring system
status of preparedness ‫التقييم‬

user
Total percentage% Total score
Documents
67% PARTIAL MET
‫السياسة‬
‫‪100%‬‬ ‫‪MET‬‬
‫شروط االنعقاد‬
‫محاضر االجتماعات‬
‫‪100%‬‬ ‫‪MET‬‬
‫برامج التدريب والتهيئة‬

‫الية التقييم (تثقيف و مشاركة‬
‫المرضي و‪)...‬‬
‫‪90%‬‬ ‫‪MET‬‬
‫تقارير جمع و تحليل و تقييم‬

‫انتهاكات حقوق المريض‬
‫تقارير اإلبالغ‬
‫التقارير الدورية‬
‫اإلجراءات التصحيحية‬
‫توصيات باالجتماعات‬
‫‪38%‬‬ ‫‪Not Met‬‬
‫نموذج اقرار الدخول‬
‫الملف الطبي‬
‫‪25%‬‬ ‫‪Not Met‬‬
‫‪100%‬‬ ‫‪MET‬‬
‫المواد التثقيفية للمرضى‬

‫المواد التثقيفية للمرضي‬
‫والدليل العلمي‬
‫‪100%‬‬ ‫‪MET‬‬
‫إقرار الموافقه‬
‫متطلبات صالحية اإلقرارات‬
‫قائمة بمدة صالحية االقرارات‬
‫وثائق تثقيف العاملين‬
‫النموذج‬
‫وثائق تقدير التكلفة واالدوات‬

‫المرفقة‬
50% PARTIAL MET
50% PARTIAL MET

‫تقييم المريض‬
‫خطة الرعاية‬
‫تعديل الجداول‬
50% PARTIAL MET
63% PARTIAL MET
‫دفتر المفقودات‬
‫‪100%‬‬ ‫‪MET‬‬
‫وثائق تثبت تحليل التغذية‬

‫الراجعة من المرضي‬
‫محاضر االجنماعات‬
‫إجراءات التحسين‬
‫‪90%‬‬ ‫‪MET‬‬
‫فحص و تحليل الشكاوي‬

‫والمقترحات‬
‫التغذية الراجعة للمرضى و‬

‫ذويهم‬
‫‪Total chapter Score‬‬
‫‪67%‬‬
upport For Healthcare Facilities
dition2021
ng system
score
2
‫م‬ 1
0
N/A
user guide
intertview observation
‫مالحظة طريقة االعالن‬
‫ومطابقتها للوائح والقوانين‬
‫المرضي و ذويهم‬
‫وسائل اإلعالن عن تكاليف‬

‫الخدمات‬
‫العاملين‬
‫العاملين ‪ -‬المرضي‬
‫االجراءات المتخذة‬
‫جميع العاملين‬
‫لوحات ارشادية لحقوق‬

‫المرضي باالماكن العامة‬
‫بالمنشأة‬
‫حماية حقوق المرضي‬

‫معلومات عن حقوق‬
‫المرضي‬
‫المريض‬
‫لوحات ارشادية لمسؤوليات‬

‫المرضي باالماكن العامة‬
‫معلومات عن مسئوليات‬
‫المرضي‬
‫المريض‬
‫العاملين ‪ -‬المرضى و‬
‫ذويهم‬
‫مدير المنشاة‬
‫تطبيق اإلجراءات‬
‫مقدمي الخدمة الطبية‬
‫العاملين ‪ -‬المرضي‬
‫العاملين‬ ‫تطبيق اإلجراء‬
‫المسئول عن الحصول‬
‫علي االقرار من‬
‫المريض‬
‫مقدمي الخدمة ‪-‬‬
‫تطبيق االجراء‬
‫المرضى و ذويهم‬

‫المرضي وذويهم‬ ‫تطبيق االجراء‬
‫االدوات المستخدمة لتشجيع‬

‫مقدمي الخدمة‬
‫المرضي‬
‫موجودة ومتاحة ومستخدمة‬

‫مالئمة المواد التثقيفية‬
‫المستخدمة لجميع الفئات‬
‫المواد التثقيفية مترجمة‬

‫الكثر من لغة‬
‫المرضي ‪ -‬مقدم الخدمة‬

‫توافر اقرارات الموافقة‬
‫بجميع االقسام‬
‫المرضي‬

‫المرضى‬
‫النماذج متوفرة بجميع‬

‫االقسام‬
‫الموظف المسئول‬
‫المرضي وذويهم‬ ‫تطبيق اإلجراء‬
‫العاملين ‪ -‬المرضى‬
‫اماكن االنتظار‬
‫اماكن االنتظار‬
‫اماكن االنتظار ( حمام ‪ -‬مياة‬

‫للشرب)‬
‫المرضي‬
‫المرضي وذويهم‬
‫اماكن تواجد المرضي‬
‫المرضي وذويهم‬ ‫أماكت تحضير الطعام‬
‫المرضي والفريق‬
‫الطبي‬
‫المرضي وذويهم‬ ‫النظافة ‪ ,‬الطعام ‪ ,‬الخدمات‬

‫خصوصية المرضي أثناء‬
‫تلقي الخدمة‬
‫سرية بيانات المرضي‬
‫خصوصية المرضي أثناء‬

‫المرضي‬
‫تلقي الخدمة‬
‫طريقة الحفظ لمتعلقات‬

‫المرضي‬
‫االعاملين‬
‫المسئول‬ ‫طرق التواصل‬

‫اماكن تلقي الشكاوي واتاحة‬
‫االجراءات‬
percentage%
> = 80%
<80% >=50%
<50%
N/A
Action plan
corrective action responsible person

n plan
Target Date Status
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Data PCC.01 PCC.02 PCC.03
67% 100% 100%
120%
100% 100%
100%
90%
80%
67%
60%
40%
20%
0%
PCC.01 PCC.02 PCC.03 PCC.04

‫عتماد للمستشفيات‬
Self assessment tool for GAHAR hos
sco
PCC.04 PCC.05 PCC.06 PCC.07 PCC.08 PCC.09
90% 50% 50% 38% 25% 100%
100% 100%
90%
75
50% 50%
38%
25%
03 PCC.04 PCC.05 PCC.06 PCC.07 PCC.08 PCC.09 PCC.10 P

‫أداة التقييم الذاتي لمعايير االعتماد للمستشفيات‬
t tool for GAHAR hospital Accreditation standards Edition 2021
scoring system
PCC.10 PCC.11 PCC.12 PCC.13 PCC.14
100% 75% 70% 50% 50%
PCC Score
100%
75%
70%
50% 50% 50% 50% 50%
PCC.10 PCC.11 PCC.12 PCC.13 PCC.14 PCC.15 PCC.16 PCC

PCC.15 PCC.16 PCC.017 PCC.18 PCC.19 PCC.20
50% 50% 50% 50% 63% 100%
100%
90%
67%
63%
50% 50% 50% 50%
PCC.15 PCC.16 PCC.017 PCC.18 PCC.19 PCC.20 PCC.21 Total

PCC.21 Total
90% 67%
90%
67%
PCC.21 Total
NO
ACT1
1
ACT2
3
4
NSR.01 ACT3
5
6
ACT4
ACT5
1
ACT6
4
ACT7
ACT8
2
3
NSR.07 ACT9
ACT10
1
ACT11
1
2
ACT12
1
2
ACT13
1
2
ACT14
1
2
ACT15
2
3
ACT16
2
3
ACT17
4
Access,Continuity,Tra
. The hospital grants patients access to its services according to ap

The hospital has an approved policy granting access to patients th
through c).
Patients are made aware of available services, including oper

relevant), and access path.
The hospital defines a system for informing patients and families

and is available at points of contact and public areas
Patients are referred and/or transferred to other healthcare

hospital scope of service.
. The hospital ensures a safe, effective and comfortable registration
The hospital has an approved policy for matching patient healthc

elements mentioned in the intent from a) through c).
All staff members involved in patient registration and flow pa
The registration process and patient flow information are availab

first contact and in public areas.
Patient registration and flow processes are uniform to all patients
. Accurate patient identification through at least two identifiers to
The hospital has an approved policy and procedure for patient id

intent from a) through f).
All healthcare professionals are aware of hospital policy.
The patient's identification occurs according to the policy.
The patient's identifiers are recorded in the patient’s medical rec
The hospital tracks, collects, analyzes, and reports data on the pa

The hospital acts on improvement opportunities identified in its p
The hospital ensures a safe, effective and comfortable hospi
The hospital has an approved policy and procedure for hospit

mentioned in the intent a) through e).
All staff members involved in patient registration and flow pathw
When patient care is required during the hospitalization process,

record.
When a patient bed is not available, the patient stays in a safe and
The hospital works in collaboration with other community s

A needs assessment analysis is performed to identify patient need
The hospital ensures safe access through multiple means of t
The hospital’s services are accessible for patients with various typ
Appropriate and clear wayfinding signage are used to help p
. All hospital areas are identified with signs
.Wayfinding signs are used in all relevant places to reduce patient
.When color-coded signage is used, clear instructions on what
.Signs are visible and lit during all operating times

The hospital has an approvedrisk assessment and manageme
There is a risk assessment for patient flow that addresses all hospi
Relevant stakeholders participate in performing the risk assessme
Bottlenecks and crowded places are identified
Actions are taken to improve patient flow
The hospital ensures safe, effective and clear responsibilities
The hospital has an approved policy and procedure for assign

elementsmentioned in the intent from a)through d
.The patient's medical record identifies the physician responsible f

.The clear handover process is performed in cases of transfer of ca
A standardized approach to hand over communications,
.The hospital has an approved policy that addresses all elements m
All healthcare professionals are aware of hospital policy
.Handover communications are recorded and available when requ
.The hospital tracks, collects, analyzes, and reports data on th
.The hospital acts on improvement opportunities identified in
Second opinion processis available, safeand effective.

.All medical staff members involved in a second opinion are aware
.Second opinions are provided if possible
When second opinions cannot be provided by the hospital, Pa

alternatives
The process of requesting, communicating, and responding to

medical record
The consultation process is available, safe and effective.
The hospital has an approved policy that addresses all elements m

Healthcare professionals who are involved in the consultation are
Consultations are obtained based on patient needs
Consultations are obtained within a defined timeframe
Information exchange between consultation requestor and respond

condition and important information, and recorded in the patient’
Multidisciplinary management process is safe, effectivean

.All medical staff members are aware of the hospital policy
.Multidisciplinary management meetings are obtained based on pa
Multidisciplinary management meetings occur according to the po
Information exchange between multidisciplinary management

important findings, and recorded in the patient’s .medical record
Transportation of patients is coordinated, safe, and in an ap

.All staff members involved in the transportation of patients are aw
.Only competent staff members are allowed to lift, handle, and tra
Transportation of patients occurs in a safe, appropriate mann
Requirements for transporting patients in critical conditions are id

record
The hospital grants access to intensive care and speciali
. The hospital has an approved policy that addresses all elements m

All staff members involved in the admission and discharge of
aware of the approved criteria
.Only competent staff members are allowed to admit and discharg
.Admission and discharge of patients from critical and specialized
Processes of transfer outside the hospital, referral, tempo
All staff members involved in discharge,temporary discharge, refe

policy
The discharge,temporary discharge,referral,and/or transfer out
record
.The reason for the discharge,temporary discharge, referral, and/o
.The referral and/or transfer feedback is reviewed,signed, and rec
Discharge summaries are complete.
All staff members involved in the discharge of patients are aware o
There is evidence of identification and provision of required

Discharge summaries are recorded using all the required elements
.A copy of the discharge summary is kept in the patient’s medical
Referral/transfer sheets are complete.
.All staff members involved in the referral/transfer of patients are
.There is evidence of identification and provision of required
.Referral/transfer sheets are recorded using all the required eleme
.A copy of the referral/transfer sheet is kept in the patient’s medic

General
‫ أداة التقييم الذاتي لمعايير االعتماد للمستشفيات‬Self assessment tool for GAHAR
MET
PARTIAL MET
NOT MET
NOT Applicable
riteria
2
1
1
th his/her plan of care
1
1
sy physical access.
2
nside the hospital.
1
2
N/A
N/A
o questions, is implemented.
1
1
1
1
eeds
1
1
0
1
based on clear criteria.
2
0
fined.
N/A
N/A
N/A
N/A
N/A
N/A
N/A
2
General Administration Of Technical Support For He
ssessment tool for GAHAR hospital Accreditation standards Edition
scoring sy
Total
Total score
percentage%
63% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
88% MET
100% MET
50% PARTIAL MET
60% PARTIAL MET

40% Not Met
50% PARTIAL MET
40% Not Met
25% Not Met
50% PARTIAL MET
100% MET
100% MET
Total chapter Score

66%
ation Of Technical Support For Healthcare Facilities
Accreditation standards Edition
scoring system
‫مطبق بشكل كامل‬
‫مطبق بشكل جزئي‬
‫غير مطبق‬
‫غير قابل للتطبيق‬
user guide
Documents intertview
‫نموذج االحالة أو النقل‬ ‫مقدمي الخدمة‬
‫العاملين المسئولين عن االجراء‬
‫جميع اإلجراءات المتعلقة بالمريض‬
‫تقارير تتبع و جمع وتحليل البيانات‬

‫إجراءات التحسين‬ ‫الجودة ‪ -‬مقدمي الخدمة‬
‫جميع العاملين المسئولين عن‬

‫االجراء‬
‫خطة الرعاية بالملف الطبي‬

‫تحليل تقييم االحتياجات‬
‫وثائق تقييم المخاطر‬
‫المشاركين بتقييم المخاطر‬
‫إجراءات التحسين‬
‫تحديد الطبيب المسئول بالملف‬

‫الطبي‬
‫الملف الطبي‬ ‫مقدمي الخدمة‬
‫جميع مقدمي الخدمة‬
‫تقارير تتبع و جمع وتحليل البيانات‬
‫إجراءات التحسين‬ ‫الجودة ‪ -‬مقدمي الخدمة‬

‫المريض و ذويهم‬
‫احتياجات المريض بالملف الطبي‬ ‫مقدمي الخدمة‬
‫تحديد وقت طلب و تنفيذ االستشاره‬

‫بالملف الطبي‬
‫االجتماعات بناء على احتياجات‬

‫المريض‬
‫اجتماعات فريق متعدد‬

‫التخصصات‬
‫ملف العاملين ‪ -‬سجالت التدريب‬
‫ملفات العاملين (االمتيازات الطبية)‬
‫نموذج ملخص الخروج‬
‫نسخة من نموذج ملخص الخروج‬

‫نموذج االحاله ‪ /‬النقل‬
‫نسخة من نموذج االحاله ‪ /‬النقل‬

ities
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
de Acti
observation corrective action

‫اللوحات االرشاديه و قائمه األسعار‬
‫مناطق الدخول‬
‫معلومات متاحه لجميع المرضى بمناطق‬

‫الدخول‬
‫مناطق الدخول‬
‫تعريف المريض عن طريق جميع‬

‫المتعاملين مع المريض‬
‫تطبيق إجراءات التحسين التحسين‬
‫اماكن انتظار المرضي في حالة عدم وجود‬

‫اسرة‬
‫سالمه الوصول‬
‫سهولة الوصول للخدمة للمرضي ذوي‬

‫االحتياجات الخاصة‬
‫توافر عالمات ارشادية وتعريفية‬
‫عالمات ارشاديه واضحة و مميزة‬
‫تعليمات واضحة‬
‫توافر عالمات مرئية و مضيئة‬

‫أماكن الزحام والتجمعات‬
‫تطبيق التحسين في أماكن الزحام‬

‫والتجمعات‬
‫تطبيق إجراءات التحسين التحسين‬
‫نقل المرضي بطريقة أمنة وصحيحة‬
Action plan
responsible person Target Date Status

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Data ACT.01 ACT.02 ACT.03
63% 50% 50%
120%
100% 100%
100%
80%
63%
60%
50% 50%
40%
20%
0%
ACT.01 ACT.02 ACT.03 ACT.04 ACT.0
Self assessment tool for GAHAR hospital Accreditation standards Editi

scoring system
ACT.04 ACT.05 ACT.06 ACT.07 ACT.08 ACT.09
100% 100% 50% 88% 100% 50%
ATC Score
100% 100% 100%
88%
60%
50% 50%
40%
ACT.04 ACT.05 ACT.06 ACT.07 ACT.08 ACT.09 ACT.10 ACT.11

‫أداة التقيي‬
ation standards Edition 2021
ACT.10 ACT.11 ACT.12 ACT.13 ACT.14 ACT.15
60% 40% 50% 40% 25% 50%
100% 100%
66%
50% 50%
40% 40%
25%
.10 ACT.11 ACT.12 ACT.13 ACT.14 ACT.15 ACT.16 ACT.17 To

ACT.16 ACT.17 Total
100% 100% 66%
00% 100%
66%
ACT.16 ACT.17 Total

NO
ICD1.
1
ICD.2
3
4
ICD.3
5
ICD.4
ICD.5
1
2
ICD.6
4
ICD.7
ICD.8
1
2
ICD.9
3
4
ICD.10
NSR.5 ICD.11
1
2
NSR.6 ICD.12
1
6
NSR.10 ICD.13
5
ICD.14
ICD.15
1
2
ICD.16
1
2
ICD.17
2
3
NSR.2 ICD.18
5
ICD.19
ICD.20
1
2
ICD.21
3
4
ICD.22
5
ICD.23
ICD.24
2
3
ICD.25
3
4
ICD.26
5
ICD.27
ICD.28
1
2
ICD.29
3
4
NSR.11 ICD.30
4
5
ICD.31
4
5
ICD.32
4
5
ICD.33
4
5
NSR.8 ICD.34
4
5
NSR.4 ICD.35
4
5
ICD.36
5
NSR.9 ICD.37
ICD.38
1
5
integrated care
Care delivery is uniform when a similar service is needed re

Clinical guidelines/protocols, life-saving measures, patient safety
consents, rational use of assessment, diagnostic, ancillary, and
needs and without discrimination.
Quality reviews, satisfaction questionnaires, and medical audi

regardless of patient background.
Potential discrimination events are reported and investigated.
. Patient care processes are collaborative
The hospital has an approved policy that covers all elements men
All staff members involved in patient care are aware of the hospit
When a conflict occurs between healthcare professionals, acti

Collaborative care is demonstrated in the patient’s medical recor
. Pre-hospital services are delivered according to applicable laws a
The hospital has an approved policy that covers all elements men
Emergency staff members are aware of the hospital policy.
Drills are performed to ensure continuous readiness.
Pre-hospital care records are complete and kept in the patient’s m
There is a process of recording and monitoring of response times.

Urgent and emergency services are delivered according to ap
The hospital has an approved policy for emergency services as me
Competent staff members offer emergency servicesaccording
Patients and families are informed of their priority level and expe
member.
Evidence of registration of all emergency patients treated in the e
Emergency plan of care is recorded in the patient’s medical recor
Clinical care standards for emergency care are adopted and/or ad
Clinical guidelines and protocols are adopted and adapted for at

(when applicable).
Evidence of staff members training on relevant clinical guidelines
Evidence that clinical guidelines/protocols were consulted during
Evidence of monitoring compliance of healthcare professionals to
. Emergency care is recorded in the patient’s medical record
Emergency assessment and reassessment by emergency care st

recorded in the patient’s medical record
.The plan of care developed by emergency and non-emergenc
.Departure order is recorded and timed
.Watches, clocks, digital clocks, and timers used for time recording
. Outpatient care services are effective
The hospital has an approvedpolicy to guide initial assessment and

elements from a) through j) in the intent
.Healthcare professionals are qualified and aware of the componen
.Initial medical assessments are performed within 24 hours of hosp
.All examinations, investigations and results done before hospitaliz
.Medical reassessments are performed recorded in the patient’s m
. Initial medical assessment and subsequent reassessments are per
The hospital has an approvedpolicy to guide initial assessment and

elements from a) through j) in the intent
.Healthcare professionals are qualified and aware of the componen
.Initial medical assessments are performed within 24 hours of hosp
.All examinations, investigations and results done before hospitaliz
.Medical reassessments are performed recorded in the patient’s m
. Initial nursing assessments and subsequent reassessments are per
The hospital has an approved policy to guide nursing initial a

.content as per the elements from a) through g) in the intent
Nurses are qualified and aware of the elements of nurse assessmen
Initial nursing assessments are performed within 24 hours of hosp

Nursing reassessments are performed and recorded in the patient’
Patient’s healthcare needs are identified according to defined scre
The hospital has an approved policy including elements in the inte

healthcare needsto define its content and .timeframe based on
. Healthcare professionals are qualified and aware of the elements
.All screens are completed and recorded within an approved timef
.Patients are referred for further assessment by the specific service
Patient’s risk of falling is screened, assessed, periodically reassesse
The hospital has an approved policy to guide screening for patient’s risk f
guidelines. Policy includes all elements in the intentfrom a) through f).
Healthcare professionals, are qualified and aware of the elements of appr
Patients who have higher level of fall risk and their families are aw
All fall risk screens are completed and recorded within an app
General measures and tailored care plans are recorded in the patient’s m
All fall risk reassessments are done within an approved timeframe.
.Patient’s risk of developing pressure ulcers is screened, assessed, p

The hospital has an approved policy to guide screening for patient’s press
guidelines. Policy addresses all elements mentioned in the intent from a) t
Healthcare professionals, are aware of the elements of the pressure ulcer s
Patients who have higher level of pressure ulceration risk and their
All pressure ulcer risk screens are completed and recorded within an app
General measures and tailored care plansare recorded in the patient’s me
All pressure ulcer risk reassessments are done within an approved timefra
Patient’s risk of developing venous thromboembolism (deep ve
managed .safelyand effectively
The hospital has an approved policy to guide screening for patient

)based on guidelines. Policy addresses all elements .mentioned
.Healthcare professionals, are aware of the elements of the V
.Patients who have higher level of VTE risk and their familie
.All VTE risk screens are completed and recorded within an
.There is evidence thatcompliance to guideline is monitored

.An individualized plan of care is developed for every patient
There is evidence that plan of care is developed by all relevant disc

elements mentionedin the intent from a) through g).
There is evidence that plan of care is developed with the participation of p
Plan of care is changed/updated based on a reassessment of patient chang
. The clinical practice guidelines development process is defined
.The hospital has an approved policy that guides all the elements m
.All medical and nursing leaders are aware of the hospital policy
. Training programs are implemented to communicate and train s
.At least three clinical guidelines are developed/adopted in the hos
.Clinical practice guidelines are implemented uniformly to all pati
. GAHAR clinical care standards are used when applicable to pati
. All clinical staff members are aware of the clinical care standard
. Staff members have access to approved clinical care standards w
.Compliance to clinical care standards is used for privileging, perf
The hospital implements GAHAR mandated clinical standards rel

supervision of hospital leaders
Hospital leaders measure compliance of GAHAR clinical care stan

quarterly
. Information is available to support medical staff members’order
.All medical staff members are aware of the full order requiremen
.Medical orders follow all the required elements

.There is a process to follow when medical orders lack one or
. Verbal or telephone orders are communicated safelyand effective
The hospital has an approved policy to guide verbal communicatio

)elements mentioned in the intent from a) through d
.Healthcare professionals, are aware of the elements of the policy
.All verbal orders and telephone orders are recorded in the patien
.The hospital tracks, collects, analyzes, and reports data on verbal
.The hospital acts on improvement opportunities identified in

. Inpatients and outpatients are screened for pain, assessed whenev
The hospital has an approved policy to guide pain management processes

through d).
All staff members are aware of the policy.
All inpatients and outpatients are screened for pain using a valid and app
Pain assessment, reassessment, and management plans are recorded in th
Qualified Individuals are responsible for managing the pain and recordin
record.
. Patients’ special nutritional needs are assessed and managed

All inpatient medical and nursing staff members are aware of the
Qualified healthcare professionals are responsible for the assessm
Patient’s nutritional needs are assessed and managed according t
Patient’s nutritional needs assessment and management is record
. Patients’ special psychosocial needs are assessed and managed
The hospital has an approved policy that addresses all the elements menti
All inpatient medical and nursing staff members are aware of the hospita
Competent individuals are responsible for the assessment and manag

Patient’s psychosocial needs are assessed and managed according to polic
Patient’s psychosocial needs assessment and management is recorded in t
. Patients’ special functional needs are assessed and managed
The hospital has an approved policy that addresses all the elemen
Competent individuals are responsible for the assessment and
Patient’s functional needs are assessed and managed.
Patient’s functional needs assessment and management is recorde

.Special screening, assessment, reassessment, and care compone
Special patient population needs are assessed and managed.
Special patient populations’ needs assessment and management is
. For women in la
The hospital has an approved policy that guide childbirth process
All involved staff members are aware of the process.

Childbirth process is assessed and managed.
Checklists, protocol, or other tools are used successfully for every
Childbirth process assessment and management is recorded in th
There is evidence of monitoring the implementation process
. Clinical guidelines are used to define the assessment and car
The hospital has an approved assessment and care management of

)mentioned in the intent from a) throughf
All staff members involved in pediatric patient careare aware

population policy
.Competent individuals are responsible for the assessment and

Children are assessed and managed safely
.Children assessment and care management is recorded in the pati
. Terminally-ill patients needs are assessed and managed
All staff members involved in terminally ill care are aware of the hospital
Competent individuals are responsible for the assessment and manag
Terminally ill patients are assessed and managed safely.
Terminally ill patients’ assessment and management is recorded in the pa

. Mental health patients’ rights during assessments, and care plans
All staff members involved with mental healthcare are aware of the hospi
Competent individuals are responsible for the assessment and manageme
Mental health patients are assessed and managed safely
Mental health patients’ assessment and management is recorded in th
. Restraintand seclusion are used safely, appropriately and in a ma
All staff members involved in restraint and seclusion are aware of the hos
Competent individuals are responsible for the use of restraint and seclusio
Restraint and seclusions are used safely
Restraints and seclusions are recorded in the patient’s medical record
. Victims of drug abuse and addiction are assessed and mana
All staff members involved in care of victims of drug abuse or addiction p
Competent individuals are responsible for the assessment and manageme

Victims of drug abuse and addiction patients are assessed and managed sa
Victims of drug abuse and addiction patients’ assessment and managemen
. Critical results are communicated timely, accurately and safely
The hospital hasan approved policy to guide critical results communicatio

mentioned in the intent from a) through d).
Healthcare professionals, are aware of the elements of the policy.
All critical resultsare recorded in the patient’s medical recordwithin a

through vii).
The hospital tracks, collects, analyzes, and reports data on critical results
The hospital acts on improvement opportunities identified in critical resu
.Chemotherapy and/or radiotherapy services are provided acc
All staff members involved in chemotherapy or radiotherapy services are
Competent individuals are responsible for the management and use of che
Management and use of chemotherapy and/or radiotherapy occurs safely

Management and use of chemotherapy and/or radiotherapy isrecorded in
.Dialysis services are provided and managed according to laws and
All staff members involved in dialysis services are aware of the hospital po
Management and use of dialysis services occurs safely.
Management and use of dialysis services isrecorded in patient’s medical r

There is a process for safety and prevention of seroconversion for patients
machines).
.Critical Care services are provided according to laws, regula
All staff members involved in critical care services are aware of the hospit
Competent individuals are responsible for the management and prov
Management and use of critical care services is safe.

Management and use of critical care arerecorded in the patient’s medical
The hospital has an approved policyand procedure for manag
All staff members using devices with critical alarms are aware of the hosp
Competent individuals are responsible for the management and use of cri
Management and the use of critical alarms is safe.

Management and use of critical alarms are recorded according to policy i
company, schedule, agreed settings, evidence of function, reporting of m
.Systems are implemented to prevent catheter and tubing misconn
All staff members using tubes and catheters are aware of the hospital poli
Competent individuals are responsible for the management and use of tub
Management and the use of tubes and catheters is safe.

Management and use of tubes and catheters are recorded in the patient’sm
.Emergency equipment and supplies are available and functioning
All staff members involved in life-threatening conditions management are
Management of medical emergencies and cardio-pulmonary arrests occur
Management of medical emergencies and cardio-pulmonary arrestsis reco
Equipment and supplies are checked daily and replaced after use.
.The hospital has an approved policy and proceduresto ensure hos
All staff members involved in direct patient care are aware of the hospital
Competent individuals are responsible for the recognition of and re
Recognition of and response to clinical deterioration occurssafely.
Recognition of and response to clinical deteriorationare recorded in the p
.Response to medical emergencies and cardio-pulmonary arrestsin

All staff members involved in medical emergencies and cardiopulmon
Competent individuals are responsible for the management of medic
Management of medical emergencies and cardio-pulmonary arrests occur
Management of medical emergencies and cardio-pulmonary arrestsar

Gene
‫أداة التقييم الذاتي لمعايير االعتماد للم‬ Self assessment tool for GAHAR
MET
PARTIAL MET
NOT MET
NOT Applicable
care
2
1
1
1
2
rvice
2
2
2
2
2
N/A
N/A
1
1
1
2
tively
1
1
ned, assessed, periodically reassessed, and
1
1
1
N/A
N/A
N/A
N/A
2
N/A
N/A
N/A
N/A
2
2
2
2
2
2
1
1
1
2
2
2
1
1
2
gulations
N/A
N/A
N/A
N/A
1
1
d clinical guidelines/protocols
1
1
1
1
1
1
1
1
0
0
N/A
N/A
N/A
N/A
N/A
2
N/A
2
erioration
c patients
2
2
General Administration Of Technical Support F
ssment tool for GAHAR hospital Accreditation standards Edition
scoring
tatus of preparedness ‫التقييم‬
Total percentage
Total score
%
67% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
100% MET
100% MET
63% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
50% PARTIAL MET
58% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET

100% MET
100% MET
100% MET
100% MET
60% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
75% PARTIAL MET
100% MET
100% MET
100% MET
100% MET
Total chapter Score
73%
ration Of Technical Support For Healthcare Facilities
reditation standards Edition 2021
scoring system
user guide
‫أدلة العمل االكلينيكية ‪ /‬بروتوكول‬
‫تقارير مراجعة الجودة ‪ -‬استبيان‬

‫رضا المنتفعين‬
‫سياسة‬
‫سياسة‬
‫العاملين بالطوارئ‬
‫ملف المريض‬
‫تسجيل ومتابعة االستجابة‬

‫سياسة‬
‫تقييم الكفاءات ‪ -‬ملف العاملين‬
‫سجل الطوارئ‬
‫‪clinical care standards‬‬

‫تدريب علي البرتوكوالت‬ ‫مقدمي الخمة ‪-‬مسئول التدريب‬
‫تقارير المعاييرة‬ ‫مسئول الصيانة‬

‫سياسة‬
‫موظفين العيادات‬
‫الملف الطبي‬ ‫مقدمي الخدمة‬
‫سياسة‬
‫سياسة‬
‫التمريض‬
‫التقييم التمريضي‬
‫سياسة‬
‫مقدمين الخدمة‬
‫سياسة‬
‫سياسة‬
‫سياسة‬
‫ملف المريض‬ ‫المرضى و ذويهم‬
‫سياسة‬
‫األطباء والتمريض‬
‫خطة التدريب ‪ +‬ملف الموظفين‬ ‫المسئول‬
‫‪Clinical‬‬
‫‪guidelines/protocols‬‬
‫ملفات العاملين ‪ -‬تقييم االداء ‪-‬‬
‫مراجعة النظراء‬
‫االتقارير‬
‫سياسة‬
‫سياسة‬
‫تقارير جمع وتحليل البيانات‬ ‫الجوده‬
‫خطة تحسين األداء‬ ‫الجوده‬

‫سياسة‬
‫ملف المريض‬ ‫المسئول‬
‫سياسة‬
‫ملف الموظف‬
‫ملف المريض‬ ‫اخصائية التغذية‪-‬التمريض‬
‫سياسة‬
‫شخص مؤهل‬
‫سياسة‬
‫شخص مؤهل‬
‫سياسة‬
‫سياسة‬
‫قائمة التحقق ‪ -‬البروتوكول ‪-‬‬

‫األدوات‬
‫تقارير‬ ‫المسئول‬
‫سياسة‬
‫ملف العاملين‬
‫تقييم األطفال‬
‫سياسة‬
‫سياسة‬
‫التقيم‬
‫سياسة‬
‫سياسة‬
‫سياسة‬
‫تقارير جمع وتحليل البيانات‬

‫خطة تحسين األداء‬ ‫الجودة‬
‫سياسة‬
‫سياسة‬
‫سياسة‬
‫سياسة‬
‫سجل التوثيق‬
‫سياسة‬
‫سياسة‬
‫قائمة المحتويات لعربة الطوارئ‬

‫سياسة‬
‫سياسة‬
Facilities
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
de Act

‫اإلجراءات المتخذه‬
‫الساعات‬
‫التقييم المبدئي‬
‫مشاركة المريض‬
‫إجراءات منع السقوط‬

‫إجراءات منع قرح الفراش‬
‫تطبيق االجراءات‬
‫تطبق االجراءات‬
‫العالج الكميائي و االشعاعي‬

‫خدمة غسيل الكلى‬
‫منطقة مخصصة‬
‫خدمات الرعاية الحرجة‬

‫التعامل مع االنظارات الحرجة‬
‫استخدام القساطر و الوصالت‬

Action plan

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Data ICD.01 ICD.02 ICD.03
67% 50% 50%
120%
100% 100%
100%
80%
67%
60%
50% 50%
40%
20%
0%
ICD.01 ICD.02 ICD.03 ICD.04 ICD.05
ICD.04 ICD.05 ICD.06 ICD.07 ICD.08 ICD.09
100% 100% 63% 100% 100% 50%
% 100% 100% 100%
63%
58%
50% 50% 50%
CD.04 ICD.05 ICD.06 ICD.07 ICD.08 ICD.09 ICD.10 ICD.11 ICD.12

‫العتماد للمستشفيات‬
Self assessment tool for GAHAR hosp

scori
ICD.10 ICD.11 ICD.12 ICD.13 ICD.14 ICD.15
50% 58% 50% 50% 50% 50%
100% 100% 100% 100%
50% 50% 50% 50%
CD.11 ICD.12 ICD.13 ICD.14 ICD.15 ICD.16 ICD.17 ICD.18 ICD.19

tool for GAHAR hospital Accreditation standards Edition 2021

scoring system
ICD.16 ICD.17 ICD.18 ICD.19 ICD.20 ICD.21 ICD.22
100% 100% 100% 100% 60% 50% 50%
ICD SCORE
100% 100% 100% 100% 100%
60%
50% 50% 50%
7 ICD.18 ICD.19 ICD.20 ICD.21 ICD.22 ICD.23 ICD.24 ICD.25 IC

2021
ICD.23 ICD.24 ICD.25 ICD.26 ICD27 ICD.28 ICD.29
100% 100% 50% 100% 100% 50% 50%
% 100% 100%
50% 50% 50% 50% 50% 50%
CD.24 ICD.25 ICD.26 ICD27 ICD.28 ICD.29 ICD.30 ICD.31 ICD.32

ICD.30 ICD.31 ICD.32 ICD.33 ICD.34 ICD.35 ICD.36
50% 50% 50% 50% 75% 100% 100%
100% 100% 100% 100%
75% 73%
50% 50% 50%
ICD.31 ICD.32 ICD.33 ICD.34 ICD.35 ICD.36 ICD.37 ICD.38 To

ICD.37 ICD.38 Total
100% 100% 73%
0% 100%
73%
ICD.37 ICD.38 Total

NO
DAS.01
1
DAS.02
1
DAS.03
3
4
DAS.04
4
5
DAS.05
5
6
DAS.06
6
DAS.07
DAS.08
1
NSR.25 DAS.09
3
4
DAS.10
3
4
DAS.11
3
DAS.12
5
6
DAS.13
4
5
DAS.14
4
5
DAS.15
3
4
DAS.16
2
3
DAS.17
2
3
DAS.18
3
4
DAS.19
3
4
DAS.20
3
4
DAS.21
4
5
DAS.22
5
6
DAS.23
5
NSR.26 DAS24
DAS.25
1
DAS.26
3
4
DAS.27
DAS.28
1
DAS.29
3
4
DAS.30
3
4
DAS.31
2
3
DAS.32
2
3
DAS.33
1
2
5
Diagnostic and Anci
Medical Imaging services are planned, operated, and provid

Medical Imaging services provided either onsite or through outsid
All related licenses, permits and guidelines are available
Medical Imaging list of services meets the scope of clinical services
Medical Imaging services are provided in a uniform manner regar
The hospital demonstrates evidence of monitoring of the quality an
There is evidence of annual evaluation of the medical imaging serv

and presented to the governing body.
Medical imaging services are performed by licensed compete

regulations and assessed competencies.
The hospital has an approved policy that addresses all the mention
e) in the intent.
Privileges are granted for performing each medical imaging servic
Competency assessment is performed annually and recorded in m
There is a mechanism to grant privileges temporarily in emergenc
Performance of medical imaging studies and procedures is s
The medical imaging service has a written procedure for each stud
Procedure manuals are readily available in the medical imaging d

elements from a) through f) in the intent.
Staff are trained and knowledgeable of the contents of procedure m

The procedures are consistently followed.
Authorized staff members review the procedures on predefined in
Medical imaging pre-examination process is effective.
The hospital has an approved policy to guide the medical imaging

f) in the intent
Medical imaging service provides referrers and patients with infor

imaging techniques, manual is distributed to all users and availabl
Medical imaging service staff member ensures that a patient perfo

patient identity
Medical imaging service staff member ensures that a patient has c

for the procedure that is being performed.
Actions are taken when a request is incomplete, illegible, or not cli
ensure patient safety.
When an additional or substituted examination is called for, medic

referrers and record in patient’s medical record.
A medical imaging quality control program is developed.
The hospital has an approved procedure describing the quality con

elements in the intent from a) through g).
Medical imaging service staff members involved in quality control
All quality control processes are performed according to quality c
All quality control processes are recorded.
Responsible authorized staff member reviews quality control and

Corrective action is taken whenever targets are unmet.
Medical imaging examination is consistent, safe and effective
Medical imaging protocols are documented and they address radio

aftercare according to the relevant examinations and/or modalitie
Where specific tasks are delegated to members of the medical ima

circumstances under which healthcare professionals shall seek fur
Medical imaging staff members are aware of examination protoco
Examinations requiring sedation of the patient are not undertaken

available to immediately attend the patient, and the safety require
Radiographic factors, positioning, sterile tray set-up, and aftercar
Imaging protocols for pediatric patients are optimized to obtain th

radiation dose possible and with minimal use of sedation and anes
Medical Imaging investigations are reported within approve
Staff members involved in interpreting and reporting results are c
Results are reported within approved timeframe
The hospital tracks, collects, analyzes, and reports data on its repo
The hospital acts on improvement opportunities identified in its m
Delays in reporting medical imaging studies are notified to referre
Copies of medical Imaging results are recorded in the patien

There is a process to complete medical imaging reports that addre
f).
All medical imaging staff involved in result reporting are aware of
Complete medical imaging reports are recorded in the patient’s m
When reports are not complete, there is a process to inform report
Radiation safety program is developed and implemented.
The hospital has an approved radiation safety program for patien

hazards encountered in the hospital in addition to all elements men
Identified radiation safety risks are mitigated through processes a
Staff members involved in medical imaging are aware of radiation

training for new procedures and equipment
Radiation doses measured and monitored for patients and does no
Radiation doses for patients in all radiology areas are recorded in
The radiation safety program is part of the hospital environment a
Laboratory services are planned, provided, and operated ac
Laboratory services meet applicable national guidelines, standard
Laboratory services are available to meet the needs related to the
Scope of services defined and documented in the hospital Laborato

The plan for services is periodically reviewed and modified as the
The designated laboratory area is available and separate from any
Presence of dedicated area for sample collection.
Licensed, competent healthcare professionals are assigned to
The hospital has an approved policy and procedure that address a
Competency assessment is performed annually and recorded in lab
Privileges are granted for performing each laboratory function ba

Reagents and other laboratory supplies are managed effectiv
The hospital has an approved policy that addresses all the mention
List of all reagents and supplies that are used for all testing proces
Reagents and other supplies are inspected and accepted or rejecte
Reagent quality is checked before use.
Reagents and supplies are accurately recorded and labeled.

Reagents are requested, issued, and dispatched effectively.
Referral laboratory services are selected and monitored effe
There is a written agreement between the two laboratories describ

the intent from i) to viii).
Referral laboratory meets the selection criteria.
Referral laboratory is evaluated based on a predefined criteria an

Records of send-out tests support compliance.
Minimum retesting interval is utilized to assist in appropriat
The hospital has an approved policy to guide the process of minim

through j).
Medical staff members are educated on appropriate tests are requ
Hospital approved rules are implemented in the laboratory to rem
Requests to repeat tests are restricted to a particular grade or leve

Medical staff members explain reasons to override a rule.
Utilization management measures are developed.
Laboratory pre-examination process is effective.
The hospital has an approved policy to guide the pre-examination
There is a laboratory service manual distributed to all users and a
All staff involved in requesting laboratory tests are aware of the p

Preparation of specimen collection and labeling requirements are
Specimens are handled and transported safely
Specimens are disposed safely.
Specimen reception, tracking, and storage processes are effe
The hospital has an approved policy that addresses all elements in
All staff involved in receiving specimens are aware of the policy re

All received and accepted specimens are recorded including date a
person receiving the sample.
Records for specimen rejection and specimens referred to other la

in the intent.
Evidence of traceability of all portions of the primary sample to th
Samples are stored in appropriate conditions during all pre-exami
Verified/validated analytical test methods are selected and p
The laboratory has an approved policy to guide the selection of the

laboratory.
The laboratory follows verification/validation methods endorsed b

The responsible authorized staff member demonstrates competenc
test.
Records of verification and /or validation results fulfilling accepta
There is recorded evidence of reverification/revalidation whenever
Instructions for performing test methods and procedures ar
The laboratory has a written procedure for each analytical test me
The technical laboratory procedures are readily available when ne
Each procedure includes all the required elements from a) throug

Staff are trained and knowledgeable of the contents of procedure m
The procedures are consistently followed.
Authorized staff member review the procedures on predefined int
An individualized internal quality control program is develo
The hospital has an approved procedure describing the internal qu

elements in the intent from a) through h).
Laboratory staff members involved in internal quality control are
All quality control processes are performed according to the intern

All quality control processes are recorded.
Responsible authorized staff member reviews quality control and
Corrective action is taken when indicated.
External quality assessment program or its alternatives is de
The laboratory subscribes to an external proficiency-testing progr

the laboratory and available from the provider, as well as the com
Evidence that the samples are tested along with the laboratory’s re
routinely perform the laboratory test(s) using routine methods.
The laboratory is consistent in testing and reporting results within

A review of returned reports includes the requirements of element
Records of all processes, including testing, reporting, review, conc
Evidence of proficiency testing alternative procedures used accord

available
Laboratory post-examination process is developed and imple
The hospital has an approved policy to guide the post-examination

from a) through e).
The laboratory defines the authorized staff member who review an
The retention process of a final laboratory report is implemented w
The procedure of specimen storage and retention is implemented.

Required specimens are easily retrieved.
Laboratory results are reported within the acceptable turna
The hospital has approved policy and procedures defining each lab
measuring it.
Turnaround times are reviewed and monitored for laboratory test
Cases of unacceptable turn-around time are investigated, and prop
The hospital tracks, collects, analyzes, and reports data on its repo
The hospital acts on improvement opportunities identified in its la

Delays in turnaround time are notified to requestors.
STAT results are reported within safe and effective timefram
The hospital has an approved policy to guide ordering, collection,
The laboratory has a STAT List of tests with acceptable STAT rep
STAT tests turnaround times are reviewed and monitored for labo
Cases of unacceptable STAT turn-around time are investigated, an
Delays in STAT turnaround time are notified to requestors.

A comprehensive documented laboratory safety program is
A written program that describes safety measures for laboratory s

in the intent from a) to i).
Laboratory staff are trained on the safety program
Laboratory risk assessment is performed and safety reports are is

and facility safety committee.
Spill kits, safety showers and eye washes are available, functioning
Safety precautions are implemented.
The hospital tracks, collects, analyzes and reports data on laborato

opportunities.
Point-of-care testing is monitored for providing accurate and

The laboratory assigns a competent responsible staff member for s
Staff members who are responsible for performing point of care te
There is a defined process for performing and reporting point of c
Quality control procedures for POCT are recorded and implemen
Blood transfusion services are planned, operated and provid
There is an approved quality manual that addresses all elements m

a) through j).
All blood transfusion staff members are aware of the quality manu
Blood transfusion services have suitable space, environment, equip

Blood transfusion services are monitored by a licensed qualified m
Blood is accepted only from voluntary, non-remunerated, lo
The hospital has an approved policy that describes all elements me
Blood bank staff are aware of the hospital policy.
Blood donors are selected safely
Blood donors receive pre-donation counselling.
Blood donor selection and counselling is recorded.
Processes of collection, handling, testing of blood, and blood

national guidelines.
Blood bank staff are aware of the hospital’s policy
Blood and/or blood components are collected and handled as elem
Blood and/or blood components are tested and prepared as elemen
Blood and blood components are labelled, stored in the blood
There is a system is in place to ensure that blood/blood component

seronegative according to serological investigation
Labels of blood and/or blood components include all elements in th
There is a system in place to trace blood and blood products from

transfusion, discard or transfer
Blood and/or blood components are stored under access-controlled
An alarm system and a provision for alternate power supply is ava
Expired blood or blood components are managed effectively.
Obtaining blood from a blood bank outside the hospital has
There is a written agreement between the two blood banks describ

the intent from i) to xiii).
Contracted blood bank meets the selection criteria.

Contracted blood bank is evaluated based on predefined criteria.
Blood bank staff members involved in receiving blood or blood com

predefined acceptance criteria.
Records of inspecting received blood and blood components suppo
Requesting blood and/or blood component services occurs in
Blood bank staff members are aware of the hospital policy.

Indication for transfusion is recorded in the patient’s medical reco
Blood bank staff members receive information about indication of

information of the patient and whether the request is needed on em
Blood sample label and blood transfusion request are completed w

cross-checked before issuing blood or blood components
Blood and/or blood components are distributed from the blo
Blood bank staff members are aware of the hospital policy.

Cross matching reports show recipient and donor data.
Standard compatibility test is completed promptly.
If discrepancy in the result is noted, the concerned healthcare prof

transfusion.
Special situations are managed safely.
Blood and/or blood components are transfused safely.

Healthcare professionals involved in blood and/or blood componen
Blood or blood component bags are visually checked before transf
Monitoring of patient condition during transfusion is recorded in
A system is implemented to prevent and to manage transfusion com

Gen
‫ أداة التقييم الذاتي لمعايير االعتماد للمستشفيات‬Self assessment tool for GA
MET
PARTIAL MET
NOT MET
NOT Applicable
lations, and clinical guideline /protocol.

2
are assigned according to applicable laws and

1
1
1
1
1
1
1
1
2
2
2
N/A
N/A
1
0
licable guidelines.
1
0
1
1
2
1
1
1
2
1
N/A
N/A
N/A
N/A
N/A
N/A
2
N/A
2
2
2
2
2
2
1
1
and release of verified laboratory tests.
1
1
1
1
2
2
2
1
lations and clinical guideline /protocol.
2
2
N/A
N/A
y.
1
quirements.
1
1
1
1
1
2
1
1
0
1
N/A
assessment tool for GAHAR hospital Accreditation standards Edi
scoring s
Total
Total score
percentage%
58% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
100% MET
100% MET
42% Not Met
33% Not Met
50% PARTIAL MET
58% PARTIAL MET
50% PARTIAL MET
25% Not Met
50% PARTIAL MET
67% PARTIAL MET
100% MET
100% MET
100% MET
58% PARTIAL MET
50% PARTIAL MET
58% PARTIAL MET
100% MET
83% MET
50% PARTIAL MET

75% PARTIAL MET
100% MET
50% PARTIAL MET

42% Not Met
50% PARTIAL MET
60% PARTIAL MET
42% Not Met
38% Not Met
Total chapter Score
62%
nistration Of Technical Support For Healthcare Facilities
ital Accreditation standards Edition
scoring system
user guide
‫اللوائح والقوانين‪ -‬ادلة العمل‪-‬‬
‫السياسات‬
‫التراخيص و أدلة العمل ‪-‬سياسات‬

‫القسم‬
‫قائمة الخدمات‬ ‫مسئول االشعة ‪ -‬االدارة‬
‫التقاريرو التقييم‬
‫تقرير التقييم السنوي‬

‫سياسه‬
‫ملف العاملين ‪ -‬تقييم الكفاءة‬

‫واالمتيازات‬
‫ملف العاملين‬ ‫مسئول الموارد البشريه ‪ -‬مسئول‬

‫االشعه‬
‫السياسة ‪ -‬ادلة التشغيل‬
‫ادلة اإلجراءات‬
‫وثائق التدريب‬ ‫العاملين بالقسم‬

‫تقارير المراجعه‬ ‫مسئول االشعة‬
‫سياسه‬
‫التقارير‬ ‫مقدمي الخدمة‬
‫‪-‬ملف المريض‬ ‫مقدمي الخدمة‬
‫ملف المريض‬ ‫مقدمى الخدمه ‪ -‬المرضى‬

‫طلب اجراء الفحص‬
‫طلب اجراء الفحص‪-‬ملف المريض‬
‫البرنامج‬
‫ملف العاملين‬ ‫المسئولين عن االجراء‬
‫تقارير‪ -‬التوثيق‬
‫تقارير الجودة واالداء‬ ‫العضو المكلف‬

‫خطه تصحيحه‬
‫البروتوكوالت‬
‫مقدمي الخدمه‬
‫سياسه‬
‫ملف العاملين‬ ‫مقدمي الخدمه‬
‫ملف المريض ‪ -‬سجل النتائج‬
‫تقاريرجمع وتحليل البيانات‬ ‫االداره ‪ -‬مسئول القسم‬
‫مشاريع التحسين‬
‫تقارير‪ -‬االخطار‬
‫تقارير ‪ -‬ملف المريض‬
‫‪-‬تقارير ‪ -‬ملف المريض‬ ‫مقدمي الخدمه‬
‫تقييم المخاطر‬
‫العاملين بالقسم‬
‫جرعات االشعة المستخدمة‬
‫للمرضى‬
‫خطه السالمه‬
‫اللوائح والقوانين ‪ -‬سياسات‬ ‫مسئول المعمل‬

‫المعمل‬
‫قائمة الخدمات‬
‫تقييم وتحديد الخدمات المطلوبة‬ ‫مسئول المعمل ‪ -‬االدارة‬
‫سياسه‬
‫ملف العاملين ‪ -‬تقييم الكفاءة‬
‫مسئول الموارد البشريه ‪-‬‬

‫االمتيازات‪ -‬ملف العاملين‬ ‫مسئول المعمل‬
‫سياسه‬
‫قائمه المستلزمات والكيماويات‬
‫اشتراطات قبول ورفض الكيماويات‬ ‫رئيس القسم ‪-‬المسئول‬
‫تقارير فحص‬
‫السجالت و التقارير‬
‫سياسه‬
‫عقد اتفاق‬
‫معايير تقيييم واختيار‬ ‫مدير المعمل‬
‫تقييم‬
‫سياسه‬
‫وثائق التدريب‬ ‫مقدمي الخدمه‬
‫قائمه بالمسموح لهم‬

‫الطاقم الطبي‬
‫تقارير ادارة االستخدام‬ ‫مدير المعمل‬
‫سياسه‬
‫دليل خدمات المعمل‬
‫اإلجراءات‬
‫سجالت المعمل‬
‫سياسه‬
‫تقارير التحقق‬
‫سجل ‪ -‬التقارير‬
‫سجل ‪ -‬التقارير‬
‫االجراءات المكتوبة لطرق التحليل‬
‫مدير المعمل‬
‫وثائق التدريب‬ ‫مقدمي الخدمه‬
‫تقارير المراجعه‬ ‫مدير المعمل ‪ -‬المسئول‬
‫ملف العاملين ‪ -‬التدريب‬ ‫مقدمي الخدمة‬

‫تقارير‪ -‬سجل التوثيق‬
‫تقارير الجودة واالداء‬ ‫المسئول‬
‫الخطه التصحيحه‬
‫تقارير‬ ‫مقدمي الخدمه‬
‫تقارير‪ -‬السجالت‬
‫تقارير‬
‫تقارير‪ -‬السجالت‬
‫تقارير‬ ‫مدير المعمل‬
‫سياسه‬
‫قائمة المصرح لهم مراجعة واعتماد‬

‫النتائج‬
‫سياسه‬
‫ملف المريض‪ -‬تقارير‬
‫تحليل ‪ -‬اجراءات تصحيحية‬ ‫مدير المعمل‪ -‬االداره‬
‫تقارير‬
‫خطة التحسين‬
‫تقارير االبالغ‬
‫سياسه‬
‫قائمه‬
‫ملف المريض‪ -‬تقارير‬
‫تحليل ‪ -‬اجراءات تصحيحية‬ ‫مدير المعمل‪ -‬االداره‬
‫تقارير‪-‬اخطارات‬ ‫مقدمي الخدمه‬

‫برنامج‬
‫وثائق التدريب‬ ‫العاملين بالمعمل‬
‫تقارير السالمة ‪ -‬تقييم المخاطر‪-‬لجنة‬

‫السالمة‬
‫تقارير‪ -‬الخطة التصحيحية‬

‫امر التكليف‬
‫المؤهالت العلميه ‪ -‬الخبرات ‪-‬‬

‫السياسة‪-‬تقارير‬
‫التوثيق والتقارير‬ ‫الشخص المكلف‬
‫ادليل جودة‬
‫المؤهالت العلميه ‪ -‬الخبرات ‪-‬‬ ‫مسئول بنك الدم‬
‫سياسه‬
‫المتبرعين ‪ -‬مقدم الخدمة‬
‫تقارير والتسجيل‬
‫سياسه‬
‫فني الصيانه‪-‬مقدمي الخدمة‬
‫سياسه‬
‫االتفاقات‬
‫‪-‬محددات وضوابط‬ ‫االداره‬

‫معايير التقييم‬
‫تقارير‬
‫سياسه‬
‫العاملون‬
‫طلب نقل الدم ‪ -‬ملف المريض‪-‬‬

‫قائمه التحقق‬
‫سياسه‬
‫تقارير التطابق ‪ -‬ملف المريض‬
‫ملف المريض ‪ -‬التقارير‬ ‫مقدمي الخدمه‬
‫سياسه‬
are Facilities
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
de Ac

‫الخدمات المقدمة داخليا او بالتعاقد‬
‫مطابقة‬
‫الخدمات تقدم في جميع االوقات واالماكن‬

‫بنفس الجودة‬
‫متوفر ومتاح‬
‫تطبيق االجراء وتوفير المعلومات‬

‫لجميع المستخدمين‬
‫تطبيق البروتوكول‬
‫تطبيق االجراءات التصحيحية‬
‫اجهزه القياس و الواقيات الشخصية و‬
‫التحاليل الدورية للعاملين‬
‫تحديد جرعات االشعة‬
‫مطابق و متوفر‬
‫المعمل ومطابقة للمواصفات‬
‫منطقه سحب العينات‬

‫تعريف وتخزين الكيماويات‬
‫تطبيق االجراء طبقا للسياسة‬
‫تطابق المعمل للمعايير‬

‫تطبيق القواعد طبقا للسياسة‬
‫االلتزام بالقائمه‬
‫دليل الخدمات المعمل متوفر وموزع‬
‫للمستخدمين‬
‫نقل العينات والتعامل معها طبقا‬

‫للسياسة‬
‫التخلص من العينات طبقا للسياسة‬

‫شروط التخزين‬
‫تطبيق االجراءات طبقا للسياسة‬
‫تطبيق االجراءات طبقا للسياسة‬
‫تطبيق االجراءات طبقا للبرنامج‬

‫تطبيق الخطه التصحيحه‬
‫أماكن تخزين السجالت‬

‫توافر كفاءة حقائب االنسكابات و غاسله‬
‫االعين و الدش‬
‫تطبيق احتياطات السالمه‬
‫توافر مكان مناسب ‪ -‬توافر‬

‫المستلزمات و االدوات‬
‫تميز اكياس الدم و مشتقاتة‬
‫النظام المتبع‬
‫تخزين الدم و مشتقاتة‬
‫االنذارات الحرجة ‪ -‬مصدر كهرباء‬

‫ثانوي‬


‫تطبيق السياسه‬
Action plan

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Data DAS.01 DAS.02 DAS.03
58% 50% 50%
120%
100%
80%
60% 58%
50% 50% 50% 50%
40%
20%
0%
DAS.01 DAS.02 DAS.03 DAS.04 DAS.05

DAS.04 DAS.05 DAS.06 DAS.07 DAS.08 DAS.09
50% 50% 50% 100% 100% 42%
100% 100%
58
50% 50% 50% 50%
42%
33%
DAS.04 DAS.05 DAS.06 DAS.07 DAS.08 DAS.09 DAS.10 DAS.11 D

‫لذاتي لمعايير االعتماد للمستشفيات‬
Self assessment tool for GAHAR hospital Accredi
scoring system
33% 50% 58% 50% 50% 50%
DASSCore
100% 100%
67%
58%
50% 50% 50% 50%
DAS.11 DAS.12 DAS.13 DAS.14 DAS.15 DAS.16 DAS.17 DAS.18

‫اأداة التقييم الذاتي لمعايير االعتماد للم‬
HAR hospital Accreditation standards Edition 2021
scoring system
67% 100% 100% 100% 58% 50%
DASSCore
100% 100% 100% 100%
83%
58% 58%
50%
16 DAS.17 DAS.18 DAS.19 DAS.20 DAS.21 DAS.22 DAS.23 DAS.24

DAS.22 DAS.23 DAS.24 DAS.25 DAS.26 DAS.27 DAS.28
58% 100% 83% 50% 75% 100% 50%
100% 100%
83%
75%
50% 50% 50%

42%
22 DAS.23 DAS.24 DAS.25 DAS.26 DAS.27 DAS.28 DAS.29 DAS.30

DAS.29 DAS.30 DAS.31 DAS.32 DAS.33 Total
42% 50% 60% 42% 38% 63%
60% 63%
50%
2% 42%
38%
DAS.29 DAS.30 DAS.31 DAS.32 DAS.33 Total

NO
SAS.01
1
SAS.02
4
5
SAS.03
5
SAS.04
NSR.17 SAS.05
2
3
NSR.18 SAS.06
3
4
NSR.19 SAS.07
SAS.08
1
NSR.20 SAS.09
4
5
SAS.10
SAS.11
1
2
SAS.12
2
3
SAS.13
4
SAS.14
5
6
SAS.15
SAS.16
1
SAS.17
3
4
SAS.18
SAS.19
1
SAS.20
3
SAS.21
SAS.22
1
2
SAS.23
5
SAS24
SAS.25
3
SAS.26
SAS.27
3
4
Surgery, Anesthesia,
Provision of surgery and invasive procedure services is acco

All units providing surgery and invasive procedure services have a
including medical gases, and well maintained.
All units providing surgery and invasive procedure services have a

medication.
All staff performing surgery and invasive procedure services are c
Booking of surgeries and invasive procedures is effective and
The hospital has an approved policy to guide the booking process

a) through d).
All physicians booked or performed procedures are permitted to d
There is an ongoing process for booking all elective procedures an
There is an ongoing process for analysis of postponed or canceled

Punctuality of the procedural unit is maintained and recorded star
procedure.
Patient assessment is performed by a medical staff member(
A complete medical assessment is performed for all patients going
Complete nursing assessment is performed for all patients going fo
Results of investigations are available for healthcare professionals
the identified risks of the patient’s conditions are documented in th
Action is taken for the management of the risk factors before surg
Patient assessment is performed by a medical staff member(
A focused medical assessment is performed for patients going for l
The risk classification of the patient's condition is determined befo
The focused assessment is documented in the patient’s medical rec
The plan of care is performed on time for those patients
Precise site where a surgery or invasive procedure shall be p
The hospital has an approved policy for site marking in the hospit
Staff are trained on the implementation of site marking.

Site marking is a unified mark all over the hospital and performed
invasive procedure.
Site marking is performed before the patient enters the operation
The hospital tracks, collects, analyzes and reports data on site mar
The hospital acts on improvement opportunities identified in its si
Documents and equipment needed for procedures and anest

the patient.
The hospital has an approved policy for preoperative verification
There is recorded evidence of preoperative verification of all need

invasive procedure.
The hospital tracks, collects, analyzes and reports data on preoper

The hospital acts on improvement opportunities identified in its pr
Correct patient, procedure, and body part is confirmed preo
The hospital has an approved policy to ensure the correct patient,
Time out is implemented before all surgery and invasive procedur

invasive .procedure.
The surgery or invasive procedure team is involved in the time out

performing physician, the nurse, and the anesthesiologist when ap
The hospital tracks, collects, analyzes and reports data on time ou
The hospital acts on improvement opportunities identified in time
Procedure details are recorded immediately after the proced

The procedure report is readily available for all patients who unde
The report includes at least a) through h) in the intent.
The report is kept in the patient’s medical record.
Accurate counting of sponges, needles, and instruments pre
Counting of sponges, needles, towels, or instruments is done pre, d

or invasive procedure by two staff as the second one is acting as a
There is a record for the preoperative, intraoperative and postope
The performing physician confirmed the process and signed the co
The hospital tracks, collects, analyzes and reports data on the coun
The hospital acts on improvement opportunities identified in the c
Surgically removed tissue is sent to the hospital laboratory s

pathological examination.
There is a clear pathway of any surgically removed tissue.
There is a list of exempted tissue from pathological examination.
Surgically removed tissues are sent for pathological examination, a

patient’s medical record within the defined time frame.
System for recall of implantable devices is developed, implem
There is a list of implantable devices used in the hospital.

There is a process for the retrospective tracing of any implantable
The procedure report includes the details of any used implantable
There is a process for the recall of a patient who has an implantab
Postoperative care plan is determined and recorded before
There is a postoperative care plan for all patients performing the p
The postoperative care plan is documented in the patient’s record

The postoperative care plan is implemented.
Provision of anesthesia and sedation services is according to
The provision of anesthesia service meets the applicable profession

national laws, and regulations.
The provision of sedation service meets the applicable professiona

national laws, and regulations.
Minimum setup shall be available, which includes equipment, med

and medical gases.
Appropriate number of anesthesia staff members are available.

Anesthesia and sedation services are performed under the di
There is a competent, qualified leader for the anesthesia and sedat
There is a clear, specific job description for the anesthesia and sed
The anesthesia and sedation leader determines the structure neede
The anesthesia and sedation leader follows up with the processes o
The anesthesia and sedation leader evaluates the outcome of provi

The anesthesia and sedation leader evaluate anesthesiologists and
Anesthesia and sedation services are uniform throughout the
The provision of anesthesia services is uniform all over the hospita
The provision of sedation services is uniform all over the hospital.
Anesthesia and sedation services are readily available 24 hours, se

needs.
Anesthesia techniques and management of serious anesthesia

hospital approved protocols are implemented for anesthesia techn
hospital approved protocols are implemented for the management
The equipment, medications, and medical supplies needed during

readily available in the hospital.
Patients’ anesthesia plan is performed after pre-anesthesia a
There is performed pre-anesthesia for patients before receiving an
There is developed detailed anesthesia plan for patients after perfo
Pre-anesthesia assessment and the anesthesia plan development is

The pre-anesthesia assessment and the anesthesia plan are recorde
Immediate pre induction assessment is performed by anesthesiolog
A competent anesthesiologist performs continuous monitorin
The patient physiologic status is monitored before and during ane

approved clinical practice guidelines.
The monitoring of patient physiologic status is performed by a qua
The results of the monitoring are recorded in the patient’s medica

clinical guidelines/protocols
Patient care during anesthesia is safe.

Anesthesia care is performed safely based on approved anesthesia
The implemented anesthesia care is recorded in the patient’s medi

standard
A copy of the anesthesia record is kept in the patient’s medical rec
Post-anesthesia care unit is equipped according to applicable
There is a post-anesthesia care unit for each department where su
Laws, Regulations, Clinical guidelines and professional standards

units are equipped properly.
The post-anesthesia care unit is equipped with the required equipm

A competent clinical practitioner performs continuous moni
discharge/transfer from the post anesthesia care unit is mad
Post-anesthesia care is performed by a competent practitioner.
The patient physiologic status is monitored during the post-anesth
Patient physiologic status shall be recorded in the patient’s medica
The provided post-anesthesia care from a) to k) in the standard is
A qualified anesthesiologist makes the decision of patient transfer/

other practitioner according to defined criteria
Sedation techniques and management of complications of se
There is hospital approved protocols for sedation techniques used

There is hospital approved protocols for the management of comp
The equipment, medications, and medical supplies needed during
Determining the patients’ sedation plan is performed after p
There is a performed pre-sedation assessment for patients before r
There is a developed sedation plan for patients after performing th
Pre-sedation assessment and the sedation plan development is perf
The pre-sedation assessment and the sedation plan are recorded in
Patient re-assessment by a competent physician is performed imm

practitioner according to defined criteria.
A competent clinical practitioner performs continuous moni
physiological status before and during sedation
Patient physiologic status is monitored before and during sedation
Monitoring of patient physiologic status is performed by a compet
Monitoring results are recorded in patient’s medical record accord
Patient’s care during sedation is recorded.
Sedation care is performed safely based on approved sedation tech
The sedation record including all elements in the intent from a) th
A copy of sedation record is kept in the patient’s medical record.

Post sedation care is performed by a qualified healthcare pr
appropriately equipped place
There is a post-sedation care unit for each department where surg
The post-sedation care unit is equipped with the required equipme
Post-sedation care is provided by a qualified healthcare profession
A competent clinical practitioner professional continuously m

physiological status during post sedation care.
The patient physiologic status is monitored during the post-sedatio

every 15 minutes.
Monitoring of patient physiologic status is performed by a compet
The provided post-sedation care from a) to g) in the intent is recor

A competent physician decides on the patient's transfer/discharge
criteria.
‫اإل‬
1 ‫ أداة التقييم الذاتي لمعايير االعتماد للمستشفيات‬Self assessment tool for
MET
PARTIAL MET
NOT MET
NOT Applicable
clinical guidelines/protocols.
N/A
1
1
ocedure.
1
ocedure.
with patient’s involvement.
1
1
orrect, and properly functioning before calling for
1
1
or invasive procedure (time out).
2
0
1
1
esent in the list of exempted tissues from the
1
1
1
1
uideline/protocol.
1
0
1
0
, seven days a week.
N/A
N/A
clinical protocols.
N/A
N/A
2
2
nd during anesthesia
2
2
col.
1
he post-anesthesia care unit and the decision of the
itioner according to established criteria.
1
1
etent physician.
2
2
0
2
N/A
2
2
General Administration Of Technical Suppo
f assessment tool for GAHAR hospital Accreditation standards Ed
scoring sy
us of preparedness ‫التقييم‬
Total
Total score
percentage%
50% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET

50% PARTIAL MET
100% MET
67% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET

50% PARTIAL MET
38% Not Met
25% Not Met
50% PARTIAL MET
100% MET
100% MET
100% MET
100% MET
67% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET

100% MET
100% MET
33% Not Met

67% PARTIAL MET
83% MET
Total chapter Score
64%
dministration Of Technical Support For Healthcare Facilities
spital Accreditation standards Edition
scoring system
user guide
‫سياسة‬
‫االمتيازات الطبيه‬ ‫األطباء‬
‫لستة العمليات‬
‫آلية لتحليل العمليات المءجله او‬

‫الملغية‬
‫سجيل لتسجيل دقه وقت االجراءات‬ ‫المرضي‬
‫تقييم الطبي‬
‫التقييم التمريضي‬
‫اإلجراءات التصحيحية‬ ‫العاملين‬

‫تقييم المريض‬ ‫العاملين‬
‫تحديد المخاطر‬
‫خطة الرعايه‬
‫سياسة‬
‫وثائق تدريب‬ ‫األطباء والتمريض‬

‫تقارير جمع وتحليل البيانات‬ ‫الجوده‪ /‬رئيس العمليات‬
‫تحسين األداء ‪ -‬تقارير‬
‫سياسة‬
‫ملف المريض‬ ‫األطباء والتمريض‬

‫سياسة‬

‫تقرير االجراء‬
‫محتوى التقرير‬
‫تقرير العد‬
‫األطباء‬

‫‪CLINICAL PATHWAY‬‬
‫قائمة باالنسجة‬
‫قائمة باالجهزه التي يمكن زرعها‬

‫تقرير االجراء‬
‫خطة الرعاية بعد العملية‬
‫مؤهالت العاملين‬
‫الهيكل التنظيمي للقسم‬ ‫رئيس القسم‬
‫توصيف وظيفي‬
‫تقارير المتابعه‬
‫تقييم الخدمة‬
‫تقييم كفاءة مقدمي الخدمة‬
‫جدول التخدير‬ ‫فريق التخدير‬
‫بروتوكول التخدير ‪ /‬ملف المريض‬ ‫مقدمي الخدمة‬
‫تقييم ماقبل التخدير‬
‫خطة التخدير‬ ‫أطباء التخدير‬
‫مؤهالت أطباء التخدير‬

‫تقييم المريض قبل واثناء التخدير‬
‫مؤهالت أطباء التخدير‬ ‫طبيب التخدير‬
‫بروتكول معتمد‬ ‫طبيب التخدير‬
‫‪Clinical guidelines‬‬
‫مؤهالت طبيب التخدير‬
‫‪Clinical guidelines‬‬ ‫مقدم الخدمة‬
‫االمتيازات الطبيه ‪ /‬ملف المريض‬
‫برتوكول معتمد‬
‫برتوكول معتمد‬
‫تقييم قبل التخديرالملف الطبي‬
‫خطة التخديرالملف الطبي‬
‫االمتبازات الطبيه‬ ‫طبيب التخدير‬
‫اعادة التقييم‬ ‫طبيب التخدير‬

‫ادلة العمل ‪-‬الملف الطبي‬
‫االمتيازات الطبيه ‪/‬تقييم الكفاءات‬ ‫مقدمي الخدمة‬
‫سياسات‬
‫تقرير التخدير‪ -‬الملف الطبي‬
‫تقييم الكفاءات ‪ /‬االمتيازات الطبيه‬ ‫مقدمي الخدمة‬
‫ملف ‪clinical practice‬‬

‫اـل ‪-‬‬ ‫مقدمي الخدمة‬
‫‪guidelines‬اـلطبي‬
‫االمتيازات الطبيه ‪ /‬تقييم الكفاءات‬
‫االمتيازات الطبيه ‪ /‬تقييم الكفاءات‬
thcare Facilities
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
de A

‫تجهيزات واشتراطات اماكن االجراء‬
‫التداخلي‪/‬الجراحي‬
‫االجهزة ‪،‬المستلزمات واالدوية‬

‫االجراءات التداخلية‪/‬الجراحية‬
‫تطبيق خطة الرعاية‬
‫مكان االجراء‬
‫تطبيق حطة الرعاية‬
‫خدمات التخدير‬
‫خدمات التهدئه‬
‫تجهيز مكان االجراء‬
‫عدد العاملين‬
‫العمليات و مكان االجراء‬
‫تطبيق البروتوكوالت‬
‫تطبيق البروتوكوالت‬
‫توافر المعدات‬
‫التقييم قبل التخدير‬
‫خدمات التخدير‬
‫تطبيق رعاية مابعد التخدير‬
‫تجهيز غرفة االفاقه‬

‫مالحظة المريض باالفاقه‬
‫وحدة مابعد االفاقه‬
‫تجهيز الوحدة‬
Action plan
responsible person Target Date

Status
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
st nu. SAS.01 SAS.02 DAS.03
50% 50% 50%
120%
100%
80%
60%
50% 50% 50% 50%
40%
20%
0%
SAS.01 SAS.02 DAS.03 SAS.04
Self assessment
SAS.04 SAS.05 SAS.06 SAS.07 SAS.08 SAS.09
50% 50% 50% 100% 67% 50%
100%
67%
% 50% 50% 50% 50% 50% 50%
03 SAS.04 SAS.05 SAS.06 SAS.07 SAS.08 SAS.09 SAS.10 SAS.11

Self assessment tool for GAHAR hospital Accreditation standards Edition 20

scoring system
50% 50% 50% 38% 25% 50%
SAS Score
100% 100% 100%
50% 50% 50% 50%

38%
25%
AS.10 SAS.11 SAS.12 SAS.13 SAS.14 SAS.15 SAS.16 SAS.17 SAS.18

standards Edition 2021
100% 100% 100% 100% 67% 50%
0% 100% 100% 100% 100% 100%
67%
50% 50%
S.16 SAS.17 SAS.18 SAS.19 SAS.20 SAS.21 SAS.22 SAS.23 SAS.24

SAS.22 SAS.23 SAS.24 SAS.25 SAS.26 SAS.27 Total
50% 100% 100% 33% 67% 83% 64%
100% 100%
83%
67% 64%
33%
2 SAS.23 SAS.24 SAS.25 SAS.26 SAS.27 Total

NO
MMS.01
1
2
MMS.02
2
3
MMS.03
2
3
NSR.14 MMS.04
3
4
MMS.05
4
NSR.15 MMS.06
NSR.16 MMS.07
1
MMS.08
1
MMS.09
2
3
NSR.13 MMS.10
3
4
MMS.11
4
MMS.12
MMS.13
1
2
MMS.14
3
4
MMS.15
5
MMS.16
MMS.17
1
MMS.18
2
3
Medication M
Medication organization, management, and usage are aligne

of services to meet patients’ needs according to the applicabl
The hospital develops medication management and safety program

all elements from a) through h) in the intent.
The hospital has a clear structure for pharmacy services, and a lic
activities.
The hospital has a drug and therapeutic committee (DTC) with a c

ongoing evaluation of the medication management and safety prog
Updated and appropriate medication-related information sources

involved in medication management.
The hospital selects and monitors process and outcome indicators
There is an annual documented review of the medication managem

intent as appropriate.
Antimicrobial stewardship program is developed and implem

prescription and usage of antimicrobials.
The antimicrobial stewardship program is a hospital priority with
The hospital has an approved interdisciplinary antimicrobial stew

(CDC) core elements and the law, regulations, and guidelines.
The hospital educates staff, patients, and their families about antim
The antimicrobial stewardship program uses hospital-approved in
The hospital tracks, collects, analyzes, and reports data on its anti
The hospital acts on improvement opportunities identified in its an
Hospital medications are selected, listed, and procured based
The hospital (represented by the drug and therapeutic committee)

procurement of medications according to the applicable laws and
provided to ensure uninterrupted availability of medication supply
The hospital has an approved list of the approved medications (oft

the intent.
A controlled printed and/or electronic formulary copy of the appr
involved in medication management.
Medication list (formulary) is monitored, maintained, and updated
The hospital has an approved process to guide the addition/deletio
The hospital has an approved process on proper communication a

professionals.
Medications are safely and securely stored in stores, pharma
Medications are safely and securely stored under manufacturer/m

organized.
Psychotropic, controlled, and narcotic medications are stored acco
The hospital has an approved process for the use and storage of m
The hospital has a clear process to deal with an electric power outa
Medications in stores, pharmacies, and patient care areas are peri

storage conditions.
Medications, medication containers, other solutions, and the comp

original packages or boxes) with the name, concentration/ strength
Emergency medications are available, accessible, and secure
The hospital has an approved policy to guide emergency medicatio

addresses at least all elements mentioned in the intent from a) thro
Emergency medications are uniformly stored in all locations.
Emergency medications are appropriately available and accessible
Emergency medications are replaced within a predefined timefram

High-Alert medications and concentrated electrolytes are ide
and dispensed in a way that assures that risk is minimized.
The hospital provides initial and ongoing training to the healthcar

concentrated electrolytes.
The hospital has an approved list(s) of high-alert medications that
High-alert medications and concentrated electrolytes are safely sto
The hospital implements a process to prevent inadvertent adminis
The hospital tracks, collects, analyzes, and reports data on manage

improvement opportunities identified are acted upon.
Look-alike and sound-alike medications are identified and st

There is a list of LASA medications that is updated at least annual
The hospital provides initial and ongoing training to the healthcar
LASA medications are stored, segregated, and labeled safely and u
LASA medication are checked properly upon dispensing.
The hospital tracks, collects, analyzes, and reports data on manage

upon.
When indicated, Medications are recalled safely.

The hospital has an approved policy to guide the drug recall proce
Staff members involved in drug recall process are aware of the po
Recalled drugs are retrieved, labeled, separated, and disposed of (
Expired, outdated, damaged, dispensed but not used, and/or conta
Expired, outdated, damaged, dispensed but not used, and/or conta
Management of nutrition products and medications that req
The hospital has an approved policy to guide use of these medicati
Staff members involved in managing these medications demonstra

Contrast media and radiopharmaceuticals are received, identified
Medications brought by patients are received, identified, labeled, s
Breast milk received, identified, labeled, stored, and administered
Effects and potential adverse effects of these medications are moni
Medications are reconciled across all interfaces of care in th
The hospital has an approved policy for medication reconciliation
Staff responsible for reconciling medications are trained to take th
Medication reconciliation occurs on admission, during the transiti

Medication prescribers compare the list of current medications wi
on the comparison.
Reconciled medications are clearly recorded, and related informat

patient’s medication prescribing
Patients and families are involved in medication reconciliation.
Medication ordering, prescribing, and transcribing processe
The hospital has an approved policy to guide the processes of orde

mentioned in the intent from a) through e).
The hospital is responsible for identifying those healthcare profess

and job description to order, prescribe, and transcribe medication
Staff members involved in medication prescription, dispensing and

which medications, locations of prescription, complete prescription
Medication transcription process is implemented and permitted un

Complete medication prescription elements are defined.
Complete medication prescriptions and orders include elements fr
Psychotropic, controlled, and narcotic medications are safely pres
Medication prescriptions are safe and complete, and are recorded
Special types of orders, such as weight-based dosing, titration, tap
Incomplete, illegible, or unclear prescriptions are managed safely.
Medication prescriptions are reviewed for accuracy and app
Patient-specific information and its source are available and acces

Healthcare professionals permitted to perform appropriateness re
Each prescription is reviewed for appropriateness by a licensed ph

intent, using current and updated resources.
When an on-site licensed, competent pharmacist is not available, a

review of critical elements f) through h) in the intent using current
There is a process to contact the prescriber when questions or con
Medications are prepared safely.
Medications are prepared safely in clean, uncluttered, and separat

adhering to the applicable laws, regulations, and professional stan
The hospital identifies those healthcare professionals authorized to
The hospital has a system for safely providing medications to meet

The hospital implements a process to guide the compounding and
All medications prepared in the hospital are correctly labeled in a
Medications are safely and accurately dispensed according t
The hospital is responsible for identifying those healthcare profess

and job description to dispense medications.
The hospital has a uniform medication dispensing and distribution
Psychotropic, controlled, and narcotic medications are dispensed a
Medications are dispensed in the most ready-to-administer form a
Hospital pharmacy has a process for the provision of medication e

families, especially on patients’ discharge, and the patients are giv
Medications are safely and accurately administered accordin
regulations
The hospital identifies those healthcare professionals, by law and r

authorized to administer medications and admixtures, with or wit
Medication administration includes a process to verify the medica

elements from a) to h) in the intent.
Psychotropics, controlled, and narcotic medications are administe
Patients are informed about the medications that they are going to
other concerns about administering medication and are given a ch
Medications administered, refused, or omitted is recorded in the p
The hospital implements a process that guides the safe and accura
person who is not a staff member (If allowed) and addresses traini
Medication effects on patients are monitored.

The patient’s response to his/her medication is monitored accordin
The hospital implements a process for monitoring the response to

direct care of the hospital.
Actual or potential medication adverse drug effects on patients are

to be taken in response.
Adverse drug events (ADEs) are reported in a manner consistent w
The hospital implements a process informing the prescriber when
Medication errors, near misses, and medication therapy pro

reported, and acted upon.
The hospital has an approved policy to guide the process of definin

and medication therapy problems based on national/international
The hospital implements a process for detecting, reporting to bodi

near misses, and medication therapy problems.
The hospital utilizes reported medication errors, near misses, and
programs.
General Administr
‫ أداة التقييم الذاتي لمعايير االعتماد‬Self assessment tool for GAHAR hospita
MET
PARTIAL MET
NOT MET
NOT Applicable
2
1
N/A
2
2
2
2
2
2
N/A
N/A
N/A
2
and administration errors.

2
2
N/A
2
2
2
2
2
2
2
2
2
2
2
1
N/A
2
2
2
2
General Administration Of Technical Support For Healthcare F
l for GAHAR hospital Accreditation standards Edition
scoring system

Total percentage
Total score
%
90% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
60% PARTIAL MET
100% MET
100% MET
Total chapter Score
97%
nical Support For Healthcare Facilities
standards Edition
scoring system
user guide
‫برنامج ادارة الدواء‬

‫الهيكل التنظيمي ‪ -‬التراخيص‬ ‫الصيدلي االول‬
‫شروط االنعقاد‪ -‬محاضر‬

‫اجتماعات لجنه الدواء‬
‫مرجع علمي لالدويه‬
‫مؤشرات االداء‬
‫تقارير مراجعه البرنامج‬ ‫الصيدلي االول‬
‫البرنامج و اعتماده‬
‫قرار تشكيل لجنة متابعة‬

‫استخدام المضادات الحيوية‬ ‫الصيدلي االول ‪ -‬العاملين‬
‫برامج التدريب‬ ‫العاملين ‪ -‬المرضى و ذويهم‬
‫بروتوكول معتمد‬
‫تقارير متابعة البرنامج‬ ‫الصيدلي االول‬
‫تقارير بتحسين االداء‬ ‫الصيدلي االول‬
‫آلية معتمدة‬
‫قائمه باالدويه المعتمده‬

‫قائمه االدويه و تعديالتها‬
‫الصيدلي االول‬
‫طرق التواصل‬ ‫األطباء‬
‫الصيدلي االول‬
‫آلية معتمدة للتعامل مع األدوية‬

‫متعددة االستخدام‬
‫تقارير المرور‬ ‫الصيدلي االول ‪ -‬العاملين‬
‫سياسه‬
‫سياسه‬
‫الصيدلي االول ‪-‬مقدمي‬

‫برامج التدريب‬ ‫الخدمة‬
‫قائمه االدويه عاليه الخطوره و‬

‫التركيز‬
‫تقارير االخطاء الدوائية‬ ‫مقدمي الخدمة‬
‫تقارير جمع وتحليل البيانات و‬

‫خطط التحسين‬
‫سياسه‬
‫قائمه االدويه المتشابه في الشكل‬

‫و النطق‬
‫برامج التدريب‬ ‫الصيدلي االول ‪-‬مقدمي‬

‫الخدمة‬
‫تقارير جمع وتحليل البيانات و‬

‫خطط التحسين‬
‫سياسه‬
‫المسئولين‬
‫الصيدلي االول ‪ -‬رؤساء‬

‫االقسام ‪ -‬العاملين‬
‫سياسه‬
‫العامون ذوي الصلة‬
‫العامون ذوي الصلة‬
‫الصيدلي االول ‪ -‬مقدمي‬

‫تقارير االثار الجانبيه‬ ‫الخدمة‬
‫سياسه‬
‫برامج التدريب‬ ‫المسئول‬
‫االطباء‬
‫سياسه‬
‫قائمة المسموح لهم وصف‬

‫وطلب وكتابة االدوية‬
‫نماذج وصف الدواء‬
‫نماذج وصف و صرف األدوية‬ ‫الصيادلة و األطباء و التمريض‬

‫المخدرة‬ ‫ذوي الصلة‬
‫األطباء‬
‫الصيادلة و األطباء و التمريض‬

‫ذوي الصلة‬
‫تقييم كفاءة‬ ‫مسئولي المراجعة‬
‫الوصفة الطبية ‪ -‬الملف الطبي‬
‫برناج التدريب‬ ‫المسئول عن المراجعة في‬

‫الحاالت الطارئة‬
‫الصيادله ‪ -‬االطباء‬
‫القوانين و اللوائح و المعايير‬

‫المتبعة‬
‫قائمة المسموح لهم تحضير‬

‫االدوية‬
‫التمريض‪ -‬الصيادله ‪ -‬االطباء‬

‫المسئول عن تحضير الدواء‬
‫المؤهالت ‪ -‬الخبرات ‪ -‬التدريب‬

‫‪ -‬التوصيف الوظيفي‬ ‫الصيادلة‬
‫نظام الصرف مطابق للوائح و‬

‫القوانين‬
‫المؤهالت ‪ -‬الخبرات ‪ -‬التدريب‬
‫‪ -‬التوصيف الوظيفي‬ ‫مسئولي اعطاء الدواء‬
‫آلية اعطاء الدواء‬
‫المريض‬
‫التوثيق والتدريب‬ ‫‪-‬المريض وذوية‬

‫آلية حقن الدواء ألول مرة‬ ‫مقدم الخدمه‬
‫‪Adverse drug events‬التقارير‬

‫)‪(ADEs‬‬
‫آلية االبالغ‬ ‫مقدم الخدمه‬
‫سياسه‬
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
Action plan

‫متابعة المؤشرات‬
‫استخدام المضادات الحيويه‬

‫طبقا للبرنامج وللقوانين و‬
‫اللوائح‬
‫نسخه من قائمة االدويه‬
‫المعتمده متاحة لكل مقدمي‬
‫الخدمة‬
‫قائمة االدوية محدثة‬
‫القائمة مطابقة لالدوية‬

‫الموجودة (االضافة والحذف)‬
‫تخزين الدواء‬
‫االدوية المخدرة و النفسية‬
‫اتباع االجراءات مع االدوية‬

‫متعددة الجرعات‬
‫طرق لتعامل مع انقطاع التيار‬
‫الكهربائي‬
‫تعريف االدويه و الحاويات و‬

‫المحاليل المستخدمه‬
‫بالتحضير‬
‫توحيد تنسيق أدوية الطوارئ‬

‫بجميع االقسام‬
‫توافر أدويه الطوارئ بجميع‬

‫االقسام‬
‫استكمال ادوية الطوارئ في‬

‫اطار زمني محدد طبقا للسياسة‬
‫توزيع القوائم على كافة أماكن‬
‫تواجد الدواء بالمستشفى‬
‫تخزين و تعريف االدويه عاليه‬

‫الخطوره و التركيز‬
‫توزيع القوائم على كافة أماكن‬
‫تواجد الدواء بالمستشفى‬
‫تخزين و تعريف و فصل‬

‫االدويه المتشابهه في الشكل و‬
‫النطق‬
‫التاكد من االدوية المتشابهة‬

‫قبل الصرف طبقا للسياسة‬
‫التعامل مع االدوية‬
‫‪ Recall‬المستدعاة‬
‫تخزين االدوية منتهية‬

‫الصالحية و التالفةو التي تم‬
‫صرفها بدون استخدامها و‬
‫الملوثة‬
‫التخلص من االدوية منتهية‬
‫الصالحيةو التالفةو التي تم‬
‫صرفها بدون استخدامها و‬
‫الملوثة‬
‫طرق التعامل و التخزين‬
‫االدوية التي احضرها المرضي‬

‫معهم‬
‫التعامل مع لبن االم( االستالم‬

‫‪ -‬التعريف ‪ -‬الحفظ ‪-‬‬
‫االستخدام)‬
‫التطبيق‬
‫اكتمال نماذج وصف األدوية‬
‫اكتمال نماذج وصف األدوية‬
‫اتاحة بيانات المرضى‬

‫مراجعة الوصفة الطبية‬
‫مراجعة الوصفة الطبية‬
‫مراجعة الوصفة الطبية في‬

‫الحاالت الطارئة‬
‫اماكن تحضير الدواء‬
‫تعريف الدواء المحضرة طبقا‬

‫للسياسة‬
‫طريقة الصرف‬
‫االدوية المصروفة للمرضي‬
‫‪ medication education‬انشطة‬
‫‪and counseling‬‬
‫إعطاء األدوية‬
‫ اعطاء‬Psychotropics,
controlled, and narcotic
medications
‫االجراء المتخذ‬
‫تطبيق االجراءات التصحيحه‬
Action plan
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Data MMS.01 MMS.02 MMS.03 MMS.04
90% 100% 100% 100%
120%
100% 100% 100% 100%

100%
90%
80%
60%
40%
20%
0%
MMS.01 MMS.02 MMS.03 MMS.04 MMS.05
Self assessment tool for GAHAR hospital Accreditation standards Editi
scoring system
MMS.05 MMS.06 MMS.07 MMS.08 MMS.09
100% 100% 100% 100% 100%
EMS Score
100% 100% 100% 100% 100% 100% 100% 100%
4 MMS.05 MMS.06 MMS.07 MMS.08 MMS.09 MMS.10 MMS11 MMS.12

‫أداة التقييم الذاتي‬
creditation standards Edition 2021
em
MMS.10 MMS11 MMS.12 MMS.13 MMS.14 MMS.15 MMS.16
100% 100% 100% 100% 100% 100% 60%
100% 100% 100% 100% 100% 100% 100%
60%
.10 MMS11 MMS.12 MMS.13 MMS.14 MMS.15 MMS.16 MMS.17 MMS.018

MMS.17 MMS.018 Total
100% 100% 97%
0% 100% 97%
MMS.17 MMS.018 Total

NO
EFS.01
1
EFS.02
2
3
NSR21 EFS.03
4
5
EFS.04
4
NSR.22 EFS.05
NSR.23 EFS.06
1
2
NSR.24 EFS.07
1
2
EFS.08
2
3
EFS.09
5
6
NSR.27 EFS.10
5
6
NSR.28 EFS.11
5
6
EFS.12
EFS.13
1
2
5
Environmental an
Hospital facilities comply with laws, regulations, fire, and na

The hospital leadership complies with environmental safety laws, r
The hospital maintains basic requirement for development of envi
The hospital has a committee overseeing environmental safety with
Environment and facility safety committee meets regularly and m
The hospital's leadership ensures compliance with external inspec

timeframe.
Hospital environment and facility safety program is continu
The hospital ensures availability of qualified staff that matches the
The hospital builds capacity to support environmental and facility

The hospital ensures that interdisciplinary environment and facili
and services at least twice annually.
There is a biannual report submitted to the hospital’s governing b

and facility surveillance rounds with corrective actions taken or ne
Fire and smoke safety plan addresses prevention, early detec

and safe evacuation in case of fire and/or other internal eme
the hospital has an approved fire and smoke safety plan that inclu
The hospital fire alarm, firefighting and smoke containment system

requirements.
Inspection, testing and maintenance of fire alarm, firefighting and
The hospital provides education for fire response and evacuation t

The hospital guarantees safe evacuation processes for all occupant
The fire and smoke safety plan is evaluated annually and, wheneve
The hospital clinical and non-clinical areas are smoking-free
The hospital has an approved policy for a smoking-free environme
Staff, patients and visitors are aware of the hospital policy.
Occupants, according to laws and regulations, do not smoke in all
The hospital monitors compliance to smoking-free policy.

Fire drills are performed in different clinical and non-clinic
at least one unannounced drill annually.
Fire drills are performed based on a predefined time interval.
Staff members participate in fire drills at least once annually.
Fire drill results are recorded from a) through e) in the intent.
Fire drill results evaluation is performed after performing each d
The hospital plan a corrective action, whenever indicated.
The hospital plans safe handling, storage, usage and transpo
The hospital develops hazardous material and waste management

The hospital ensures staff safety when handling hazardous materia
Waste disposal occurs according to laws and regulations.
The hospital ensures safe usage, handling, storage, and labeling of
The hospital has an approved document for spill management, Inv

hazardous materials
The plan is evaluated and updated annually with aggregation and
A safe work environment plan addresses high-risk areas, pro

mitigation requirements, tools, and responsibilities
The hospital has an approved plan to ensure a safe work environm

Staff are aware of safety measure pertinent to their job
Safety measures are implemented in all areas
Safety instructions are posted in all high-risk areas.
Safety management plan is evaluated and updated annually with a
The hospital performs a pre-construction risk assessment wh
The hospital performs a pre-construction risk assessment before a
All affected departments are involved in the risk assessment.

The hospital plans corrective actions whenever indicated.
If a contractor is used, contractors' compliance is monitored and e
Security plan addresses security of all occupants and proper

and isolated areas with risk mitigation, control measures, too
The hospital has an approved security plan that includes items a) t
Security plan education is provided on at least annually to all staff
Security measures are implemented including identification of occ
Occupants are protected from harm, such as violence, aggression,
Restricted and isolated areas are protected and secured.

Security plan is evaluated and updated annually with aggregation
Medical equipment plan ensures safe selection, inspection, te
The hospital has an approved medical equipment management pla
The hospital have qualified individuals to oversee medical equipm
Staff are educated on the medical equipment plan at least annually
Records are maintained for medical equipment inventory, user tra

contact, testing on installation, periodic preventive maintenance, c
The hospital ensures that only trained and competent people hand
Essential utilities plan addresses regular inspection, mainten
There is a hospital approved plan for utility management that incl
The hospital has qualified staff members to oversee utility systems
Staff are educated on the utility systems plan at least annually.
Records are maintained for utility systems inventory, testing, perio
Critical utility systems are identified and back up availability is en

Water services are safe and effective
The hospital has an approved policy that addresses all the element
The hospital has available continuous water supply.
Regular chemical and microbiological analyses for water services
The hospital conducts appropriate corrective actions when needed
Emergency preparedness plan addresses responding to disas

potential of occurring within the geographical area of the ho
There is approved hospital emergency preparedness plan that incl

Staff training is performed, tested, and evaluated.
The hospital performs at least one drill annually that includes item
The hospital demonstrates preparedness for identified emergencie
The plan is evaluated regularly with aggregation and analysis of n

General A
‫أداة التقييم الذاتي لمعايير االعتم‬ Self assessment tool for GAHAR ho
MET
PARTIAL MET
NOT MET
NOT Applicable

0
2
2
2
2
2
2
2
2
2
2
2
2
2
2
nt.
2
2
2
2
2
2
2
General Administration Of Technical Support For Health
ol for GAHAR hospital Accreditation standards Edition2021
scoring system
Total percentage
Total score
%
70% PARTIAL MET

100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
100% MET
92% MET
100% MET
50% PARTIAL MET
100% MET
Total chapter Score
93%
Technical Support For Healthcare Facilities
n standards Edition2021
scoring system
user guide
‫اللوائح والقوانين سالمة البيئة‬
‫وكود البناء والرسومات‬
‫برنامج السالمة‬
‫اعضاء اللجنة وشروط االنعقاد‬

‫‪ -‬لجنة السالمة‬
‫تقارير المرور الخارجية ‪ -‬الخطة‬ ‫مسئول السالمة واالدارة‬

‫المؤهالت ‪ -‬ملف العاملين‬ ‫مسئول السالمه‬
‫مسئول السالمه ‪ -‬العاملين توثيق لتدريبات و دورات تأهيليه‬

‫تقارير مرور جوالت ترصد متعدد‬
‫التخصصات علي االقل مرتين‬
‫سنويا‬
‫اتقارير المرور ‪ -‬الخطة‬ ‫االدارة‬

‫خطه الحريق معتمده‬
‫تقارير صيانه لمعدات الكشف‬ ‫مسئول السالمه ‪ -‬مسئول‬

‫المبكر و مكافحه االطفاء‬ ‫الدفاع المدني ‪-‬مسئول‬
‫الصيانة‬
‫توثيق لتدريبات و دورات تأهيليه‬ ‫العاملين‬

‫تقيمات و تعديالت الخطه‬
‫سياسه منع التدخين‬
‫العاملين‪ -‬المرضى ‪ -‬الزائرين‬
‫تقارير قياس االلتزام‬

‫أوقات تجارب المحاكاة‬
‫واالشتراطات‬
‫اسماء المشاركين بتجارب‬

‫االخالء‬
‫تسجيل تجارب المحاكاة‬ ‫مسئول السالمه ‪ -‬العاملين‬
‫تقييم نتيجة تجارب المحاكاه‬ ‫مسئول السالمه‬
‫خطه تصحيحه‬ ‫مسئول السالمه‬
‫خطه النخلص االمن من النفايات‬

‫و المواد الخطر‬
‫شهاده تداول النفايات‬
‫تقارير االنسكابات‪ -‬تقارير الواقعه‬
‫خطه السالمه‬
‫تقيمات و تعديالت الخطه‬ ‫مسئول السالمه‬
‫تقييم المخاطر ما قبل االنشاءات‬
‫رؤساء االقسام المعنية‬

‫خطه تصيحه‬
‫تقييم المقاول‪-‬تصاريح العمل‬
‫خطه االمن‬
‫تدريب العاملين‬ ‫العاملين‬
‫مسئول السالمه ‪ -‬مسئول‬

‫االمن‬
‫خطه االجهزه الطبيه‬
‫المؤهالت‬ ‫مسئول صيانه االجهزه الطبيه‬
‫تدريبات استخدام االجهزه‬ ‫العاملين ‪ -‬المسئول‬
‫حصر باالجهزه ‪ -‬عقود الصيانه ‪-‬‬

‫شهادات الضمان ‪ -‬محاضر‬
‫مسئول صيانه االجهزه الطبيه التركيب و التدريب و التشغيل ‪-‬‬
‫سجل صيانه االجهزه ‪ -‬المعايره‬ ‫‪ -‬العاملين‬
‫‪ -‬الصيانه الدوريه و الوقائيه‬
‫خطه المرافق‬
‫المؤهالت‬ ‫مسئول صيانه‬
‫تدريبات العاملين‬
‫تقارير ‪ -‬حصر بالمرافق ‪-‬‬

‫التجارب ‪ -‬محاضر الصيانه‬
‫الوقائيه و الدوريه ‪ -‬تاريخ صيانه‬ ‫مسئول الصيانه‬
‫المرافق‬
‫تقارير و تجارب انظمه الطواريء‬

‫سياسه‬
‫فنى الصيانه‬
‫نتائج تحاليل المياه‬
‫خطه تصحيحيه‬
‫خطه الطواريء‬
‫تدريبات و التقييم‬ ‫مسئول السالمه ‪ -‬العاملين‬
‫تجارب‬

es
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
Action pla

‫تطبيق اللوائح والقوانين وكود‬
‫البناء‬
‫مطابقة االجراء‬
‫نظام االكتشاف المبكر ‪-‬‬
‫معدات مكافحه الحريق‬
‫مطابقة االجراء‬
‫تطبيق التعديالت‬
‫التدخين بالمنطقه المخصصه‬

‫للتدخين فقط‬
‫منع التدخين بالمستشفى‬

‫غرفة النفايات ‪-‬تطبيق االجراء‬
‫تطبيق تعديالت الخطه‬

‫تطبيق اجراءات السالمه‬
‫ارشادات و بوسترات السالمه‬

‫باالماكن عالية الخطورة‬
‫مشاركة االقسام المعنية‬

‫اتباع اساليب السالمه‬
‫باالعمال االنشائيه‬
‫متطلبات االمان‬
‫اجراءات حماية المتواجدين‬

‫بالمبني‬
‫تأمين المناطق المنعزله‬

‫كروت التعريف ‪ -‬الصيانه‬

‫الوقائيه و الدوريه‬
‫استخدام االجهزه من قبل‬

‫العاملين المدربين‬
‫المرافق‬
‫توافر مياه نقيه بالمنشأه‬

‫االستجابه في حاالت‬
‫الطواريء المختلفه‬

Action plan

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫شفيات‬
Self assessment tool for GA
Data EFS.01 EFS.02 EFS.03 EFS.04
70% 100% 100% 100%
120%
100% 100% 100% 100% 1
100%
80%
70%
60%
40%
20%
0%
EFS.01 EFS.02 EFS.03 EFS.04 EFS.05
sessment tool for GAHAR hospital Accreditation standards Edition 2021

scoring system
EFS.05 EFS.06 EFS.07 EFS.08 EFS.09
100% 100% 100% 100% 100%
EFS SCore
100% 100% 100% 100% 100% 100% 100% 1

92%
50%
EFS.04 EFS.05 EFS.06 EFS.07 EFS.08 EFS.09 EFS.10 EFS11 EFS.12

Edition 2021
EFS.10 EFS11 EFS.12 EFS.13 Total
92% 100% 50% 100% 93%
100% 100%
93%
50%
10 EFS11 EFS.12 EFS.13 Total

NO
IPCD.1
1
IPC..2
2
3
IPC.3
3
4
IPC.4
NSR.03 IPC.5
1
IPC.6
2
3
IPC.7
IPC.8
1
IPC.9
3
4
IPC.10
IPC.11
1
2
IPC.12
2
3
IPC.13
2
3
IPC.14
1
2
IPC.15
1
6
IPC.16
5
6
IPC.17
IPC.18
1
IPC.19
1
2
IPC.20
2
3
IPC.21
IPC.22
1
4
Infection Preve
.The IPC team leader is a competent healthcare professional

There is an assigned dedicated IPC team
The IPC team leader is a competent healthcare professional.
The IPC Team members are qualified through certification and e
The IPC team leader and each member has a defined job descrip
The IPC team member(s) has the ability to communicate with the
. A comprehensive infection prevention and control program is de
The program describes the scope, objectives, expectations, and su
The program includes all areas of the hospital and covers patient
The program is based on IPC risk assessment, current scientific k
regulations.
The program includes a training plan for all healthcare professio
The hospital tracks, collects, analyzes, and reports data on its infe
The hospital acts on improvement opportunities identified in its i
.The hospital establishes a functioning multidisciplinary IPC comm
There are clear terms of reference for the infection control comm
All relevant disciplines are represented in the committee.
The committee meets at least monthly.

The committee meetings are recorded.
Implementation of the decisions taken by the committee at the en
The hospital identifies the procedures and processes that are
The hospital identifies departments and services with increased p
The hospital has defined and implemented policies and procedure
The hospital tracks, collects, analyzes, and reports data on its infe
The hospital acts on improvement opportunities identified in its i
Evidence-based hand hygiene guidelines are adopted and im

Hospital has approved Hand Hygiene policies and procedures bas
Healthcare professionals are trained on these policies and proced
Hand hygiene posters are displayed in required areas and hand h
The hospital tracks, collects, analyzes, and reports data on hand h
The hospital acts on improvement opportunities identified in han
Personal protective equipment is available and used correctl
.Choice of PPE to be purchased is based on standardized products
.The hospital provides PPE that is easily accessible and appropriat

.Proper selection and use of PPE according to the patient’s suspec
.PPEs are stored in appropriate areas that are easily accessible
Soap, washing detergents, antiseptics, and disinfectants are a
.Choice of purchased detergents, antiseptics, and disinfectants is b
The hospital provides detergents, antiseptics, and disinfectants tha
Proper selection and use of antiseptics and disinfectants according

procedure occurs
.Antiseptics and disinfectants are stored in appropriate areas that
Respiratory hygiene is implemented as an element of standa

.Respiratory hygiene /cough etiquette posters are displayed at app
Resources such as tissues and surgical masks are available in num
.Hospital designate space for patients with suspected respiratory in
.Patients with suspected respiratory infections are identified and p
Injection practices are safe.
.Hand hygiene facilities are available
.the Intravenous bottles/bags are not used interchangeably betwee
.Use of single-dose vials versus multi-dose vials follows regulations

.The hospital ensures single use of the fluids infusion /administrati
Environmental cleaning activities are aligned with current e
.Cleaning activities and times are listed for each area and include a
Staff members involved in environmental cleaning activities are tr
.Cleaning technique and disinfectant of choice matches the require
.Blood/body fluid spills are properly managed and spill kits (disinf
Current evidence-based aseptic techniques are followed duri
.Healthcare professionals are trained and educated on aseptic tech

.All medical procedures are performed in environment, that don’t
Items that are used for medical procedures are not contaminated i
.Various aseptic techniques are performed in the hospital accordin
Patients with clinically suspected and/or confirmed commun
.The hospital has an approved policy to guide transmission-based
.Healthcare professionals are trained and educated on approved p

.The hospital has one or more standardized isolation room(s) acco
Patients with suspected/ confirmed clinical communicable diseases

separated in separate assigned areas/room.
Healthcare professionals caring for patients with a suspected comm

practices according to the type of .isolation
A safe and protective environment is provided to immunoco
.The hospital defines conditions that require transmission-based p
.Healthcare professionals are trained on transmission-based preca

The hospital ensures the availability of a protective environment if
healthcare facility
.Facility design supports the provision of a safe environment for im
Signage is positioned prominently outside the room of a patient in

precautions.
.Transmission-based precautions are performed when required
Patient care equipment are disinfected/sterilized based on ev
The hospital has an approved policy to guide the process of disinfe

)through g
.Healthcare professionals are trained on approved policy.
.The hospital has at least one functioning pre-vacuum class B steri
The laws and regulations, Spaulding classification, and manufactu

.disinfection
.There are a least three physically separated areas for cleaning, pa
Clean and sterile supplies are properly stored in designated storag

.temperature extremes
A disinfection/sterilization quality control program is develo

The hospital has an approved policy describing the quality control
)the intent from a) through e
Quality of packaging material, as well as chemical and biological i

specifications
.Healthcare professionals involved in sterilization/disinfection are
.Quality control tests for monitoring sterilization and high-level di
.Quality control processes are recorded
.Corrective action is taken whenever results are not satisfactory

Laundry service and healthcare textile management are saf
The hospital has an approved policy to guide the safe laundry and
)the intent from a) through e
.Staff members involved in laundry and health textile managemen
.Contaminated textile are collected, stored and transported safely
.There is at least one functioning washing machine
.There are a least three physically separated areas for sorting, was
.A quality control program, including water temperatures, is impl
Infection risks during demolition, renovation, or constructio
.The hospital has an approved policy for infection risk assessment
.Infection risk assessment of renovations, or new constructions has
.Staff members involved in demolition/construction/renovation are
.There is a mechanism, such as work permission, to empower infec
Infection prevention measures, considerations and recommendatio

.projects
Healthcare-associated infections surveillance process is effec

.The hospital has an approved policy to guide the surveillance pro
.Healthcare professionals are trained on approved policy
.The hospital tracks, collects, and analyzes data on its surveillance
The hospital reports data on its surveillance program to stakehold
.The hospital acts on improvement opportunities identified in its su
Outbreaks are investigated and managed effectively.
. The hospital has an approved process for outbreak investigations

.There is a reporting system of patients with suspected communica
.Outbreak investigation and management occur through multidisc
.Outbreak management includes immediate control measures, gen
.The hospital tracks, collects, analyzes, and reports data on its outb
.The hospital acts on improvement opportunities identified in its o
Multi-Drug resistant organisms (MDROs) are controlled.
The hospital has an approved policy for MDRO spread control.
Healthcare professionals are trained on approved policy.

Measures are taken to control MDRO infection spread.
.Food services are safe and effective
Staff members involved in food services are aware of approved po
There are separate areas for receiving, storage, and preparation o
There are measures to prevent the risk of cross-contamination.
The hospital prepares and distributes food using proper sanitatio
.Postmortem care is safe

Staff members involved in postmortem care are aware of approve
Safe postmortem care practices are implemented according to cu
Standard and transmission based precautions are applied on dead

General Admi
‫أداة التقييم الذاتي لمعايير ا‬ Self assessment tool for GAHAR hospita
MET
PARTIAL MET
NOT MET
NOT Applicable

N/A
1
1
1
1
thcare-associated infections.
2
1
1
re standards.
2
2
1
1
1
1
obable mode(s) of transmission.
1
1
2
1
ns.
1
2
0
1
N/A
N/A
N/A
N/A
2
N/A
N/A
2
N/A
2
2
2
2
1
1
1
1
1
General Administration Of Technical Support For Healt
ool for GAHAR hospital Accreditation standards Edition2021
scoring sys
Total
Total score
percentage%
63% PARTIAL MET

67% PARTIAL MET
50% PARTIAL MET
100% MET
80% MET
50% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET

60% PARTIAL MET
50% PARTIAL MET
33% Not Met
50% PARTIAL MET
100% MET
100% MET
100% MET
100% MET
67% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET

Total chapter Score
69%
Of Technical Support For Healthcare Facilities
ation standards Edition2021
scoring system
user guide
‫أمر التكليف للفريق‬
‫ملف مسئول مكافحة العدوي ‪-‬‬

‫الشهادات والخبرات‬
‫ملفات العاملين ‪ -‬التدريب‬
‫التوصيف الوظيفي‬
‫مستندات التواصل مع االدارة‬ ‫أعضاء الفريق ‪ -‬االدارة‬
‫برنامج مكافحة العدوي‬
‫برنامج مكافحة العدوي‬

‫خطة التدريب‬ ‫العاملين ‪ -‬المرضي‬
‫مهام االنعقاد‬
‫تشكيل اللجنة‬
‫التوصيات‬
‫السياسات واالجراءات‬
‫خطة تصحيحية‬
‫سياسة‬
‫تقارير جمع وتحليل البيانات‬ ‫الجوده‬
‫خطة تحسين األداء‬
‫مواصفات لمهام الحماية الشخصية‬

‫مواصفات المطهرات‬
‫تحديد أماكن المرضي المشتبه‬
‫باالمراض التنفسية‬
‫‪ -clinical guidelines‬السياسة‬
‫وثائق التدريب‬ ‫مسئولي النظافة‬
‫وثائق التدريب‬ ‫مقدمي الخدمة الطبية‬

‫‪evidence-based guidelines‬‬
‫سجالت التدريب‬ ‫مقدمي الخدمة الطبية‬

‫مقدمي الخدمة الطبية‬
‫االشتراطات‬
‫التدريب‬ ‫الفريق الطبي‬

‫اللوائح والقوانين ‪ -‬اشتراطات‬

‫الشركة المصنعة‬
‫االشتراطات‬
‫ملفات العاملين ‪ -‬التدريب‬ ‫الفريق الطبي‬
‫اختبارات الجودة‬
‫سجل الجودة‬
‫خطة تصحيحية‬
‫العاملين بالقسم‬
‫برنامج الجودة والتوثيق‬ ‫مسئول القسم‬
‫التدريب‬ ‫العاملين المشاركين‬
‫تصاريح العمل‬ ‫االدارة ‪ -‬المسئول‬

‫محاضر اجتماع اللجنة‬
‫الية االبالغ‬ ‫االدارة ‪ -‬المسئول‬
‫التدريب‬
‫‪ - evidence-‬اللوائح والقوانين‬
‫‪based guidelines‬‬
ies
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
de Actio

‫متابعة التنفيذ‬

‫توافر بوسترات غسيل األيدي ‪/‬‬
‫مستلزمات غسل األيدي‬
‫توفر الواقيات الشخصية المناسبة لكل‬

‫إجراء‬
‫استخدام العاملين للواقيات بطريقة‬
‫صحيحة‬
‫تخزين الواقيات الشخصية‬
‫متاحة ومالئمة‬
‫استخدام العاملين للمطهرات بطريقة‬

‫صحيحة‬
‫التخزين الصحيح للمطهرات‬

‫توافر البوسترات‬
‫توافر المناديل والمسكات الجراحية‬
‫أماكن المرضي المشتبه باالمراض‬

‫التنفسية‬
‫أماكن المرضي المشتبه باالمراض‬

‫التنفسية‬
‫توافر تجهيزات غسل االيدي‬
‫‪ spill kits‬توافر‬
‫غرف العزل‬
‫االلتزام بالواقيات الشخصية المناسبة‬

‫العالمة‬
‫‪functioning pre-vacuum class‬‬
‫‪B sterilizer‬‬
‫االلتزام وتطبيق االجراء‬
‫اماكن مفصولة‬
‫التخزين طبقا لالشتراطات‬

‫غسالة واحدة علي االقل تعمل‬
‫فاصل مادي بين مناطق العمل الخاصة‬

‫اجراءات مكافحة العدوى‬



‫اماكن منفصلة لتلقي تخزين واعداد الطعام‬
Action plan

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Data IPC.01 IPC.02 IPC.03
63% 67% 50%
120%
100%
100%
80%
67%
63%
60%
50%
40%
20%
0%
IPC.01 IPC.02 IPC.03 IPC.04
Self assess
IPC.04 IPC.05 IPC.06 IPC.07 IPC.08 IPC.09
100% 80% 50% 100% 100% 50%
IPC
100% 100% 100%
80%
50% 50% 50% 50% 50%
IPC.03 IPC.04 IPC.05 IPC.06 IPC.07 IPC.08 IPC.09 IPC.10 IPC.11

Self assessment tool for GAHAR hospital Accreditation standards Ed

scoring system
50% 50% 60% 50% 33% 50%
IPC SCore
100% 100% 100%
60%
50% 50% 50% 50%
33%
IPC.10 IPC.11 IPC.12 IPC.13 IPC.14 IPC.15 IPC.16 IPC.17 IPC.18

‫أداة التقييم‬
ditation standards Edition 2021
100% 100% 100% 100% 67% 50%
% 100% 100% 100%
67% 69%
50% 50%
PC.16 IPC.17 IPC.18 IPC.19 IPC.20 IPC.21 IPC22 Total

IPC22 Total
50% 69%
69%
2 Total
NO
OGM.01
1
OGM.2
2
3
OGM.3
4
5
OGM.4
OGM.5
2
3
OGM.6
4
5
OGM.7
OGM.8
2
3
OGM.9
4
OGM.10
OGM.11
1
OGM.12
1
2
OGM.13
2
3
OGM.14
5
6
OGM.15
4
5
OGM.16
OGM.17
1
2
OGM.18
2
3
OGM.19
5
OGM.20
6
Organization Governance
. The hospital has a defined governing body structure

The governing body structure is represented in the hospital’s cha
Members of the governing body are identified by title and name
Governing body members are diverse and represent community i
The governing body meets on predefined intervals, and minutes o
The governing body evaluates its performance annually versus th
.The governing body works with the hospital leaders to set the hos
The hospital has a mission statement approved by the governing b
The mission statement is aligned with national healthcare initiativ

The mission statement is evaluated annually.
The mission statement is visible in public areas to staff, patients a
Governing body responsibilities and accountabilities are identified
The governing body has defined its responsibilities and accountab

allocation that includes clear criteria for selection and prioritizat
The strategic plan is approved, monitored, and updated by the go
Operational plan and budget are approved, monitored, and upda
Quality improvement and patient safety and risk management pr

governing body
Community assessment and involvement program is approved, m
The hospital leaders ensure effective communication with th
There is a defined process of communication between the governi

leaders
The governing body members and hospital leaders are aware of t

communication channel.
The governing body submits feedback reports to the hospital dire
A full-time qualified director is appointed by the governing b
There is a full-time qualified director managing the hospital
There is an appointment letter for hospital director according to

There is a job description for the hospital director covering the st
The hospital director has appropriate training and/or experience

description
There is evidence that the director assumes his/her assigned respo

employee.
There is a clear process for coordination and communication
The hospital has at least the committees mentioned in the intent a
Each committee had terms of reference
Committees are meeting regularly.
Committees’ minutes of the meetings are recorded and communic

There is an announced process of coordination and communicatio
committees/ structures
A strategic plan is developed under oversight and guidance o
The hospital has a strategic plan with goals/desired outcomes and
Participation of staff, hospital leaders, community, and other iden
There are progress review reports to monitor the strategic plan at
Operational plans are developed to achieve the strategic plan

stakeholders
The hospital has operational plans that include a) to e) in the inten
Staff are involved in designing the related operational plans.

Operational plans progress/analysis reports.
The plans are communicated throughout the hospital.
Leaders evaluate the operational plans annually, and lessons learn
The responsibilities and accountabilities of the hospital leade
There is a job description for each hospital leader to identify the r
.The responsibilities of the hospital leaders include at least a) throu
.Hospital leaders understand their responsibilities
.Hospital leaders perform their responsibilities and present report

A designated qualified staff member is assigned to supervise
responsibilities
There are job descriptions for each departments/ services supervis

responsibilities.
There is a supervisor for each department of the hospital who is qu
The responsibilities of the Departments/ services supervisor includ
Departments and services heads understand their responsibilities.
Departments and services heads perform their responsibilities and
The hospital defines supply chain management processes.

A policy addresses all elements from a) through e
Supply chain process is recorded, monitored, and evaluated at leas
Suppliers are monitored and evaluated at least annually
Actions are taken to ensure that critical supplies are available whe
The hospital manages its storage, stock, and inventory.
The hospital has an approved policy for managing storage, stock, a

least from a) through d) in the intent
As required by laws and regulations, basic information is recorded
)through h
There is an inventory control system that includes identification of

monitoring of out-stock events.
The hospital identifies its critical resources and ensures their conti
The hospital has at least one efficient utilization improvemen
.The hospital identifies high frequency and high-cost processes, e w
The hospital participates in at least one efficient utilization improv

waste and redundancies
Improvement results are monitored to ensure sustainability
The hospital manages the patient billing system.
The hospital has an approved policy for billing patients accurately
There is an approved price list.
Patients are informed of any potential cost pertinent to the planne
The hospital uses accurate and approved codes for diagnoses, inter
In the case of a third-party payer (or health insurance), the timelin

Billing staff is oriented on various health insurance processes.
The hospital implements a process for selection, evaluation,

monitoring contracted services
There is a list of all contracted services, including clinical and non
There are selection criteria for each service
Head of departments/services participate in the selection, evaluatio
There are performance measures for monitoring contracted servic

Each contract is evaluated at least annually to determine if it shou
Leaders create a culture of safety and quality within the fac
.Leaders participate in safety rounds
.Leaders support quality and patient safety initiatives, monitoring
.Leaders creates a just culture to encourage reporting errors and n
The hospital ensures positive workplace culture.
The hospital has an approved policy for positive workplace cultur

The workplace is clean, safe, and security measures are implemen
Measures of workplace violence, discrimination, and harassment a
There are communication channels between staff and hospital lead
Staff feedback and staff satisfaction are measured
The hospital ensures ethical management.
The hospital has an approved policy for ethical management that a
Staff members are aware of the policy

Ethical issues are discussed and managed according to the approv
Solved ethical issues are used for education and staff professional
The hospital ensures that there are spaces matching require
Staff rest areas are ventilated, lit, and clean.
Staff rest areas are not overcrowded.
Staff rest areas are reachable through communication tools
Staff rest areas are secured and not readily-accessible for non-staf
The staff has access to healthy food and water supply

. The hospital has an approved staff health program that is monito
There is an approved hospital’s staff health program according to

intent
There is an occupational health risk assessment that defines occu
Staff members are educated about the risks within the hospital en
medical examination.
All staff members are subject to the Immunization program and

approved hospital guidelines
All test results, immunizations, post-exposure prophylaxis and in
There is evidence of taking action and informing employees in cas

Gener
‫أداة التقييم الذاتي لمعايير االعتماد ل‬ Self assessment tool for GAHAR
MET
PARTIAL MET
NOT MET
NOT Applicable

2
1
1
1
1
able laws and regulations.
2
2
pital committees/ structures.
2
1
from staff, service providers, and other
N/A
2
N/A
1
.
1
1
1
1
1
1
2
0
N/A
N/A
N/A
N/A
N/A
N/A
2
2
2
2
2
gulations
N/A
1
sment tool for GAHAR hospital Accreditation standards Edition 2
scoring sy
s of preparedness ‫التقييم‬
ARTIAL MET ‫مطبق بشكل جزئي‬
OT Applicable ‫غير قابل للتطبيق‬
Total
Total score
percentage%
70% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
100% MET
100% MET
60% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET

50% PARTIAL MET
33% Not Met
33% Not Met
50% PARTIAL MET
100% MET
100% MET
100% MET
100% MET
80% MET
Total chapter Score

71%
inistration Of Technical Support For Healthcare Facilities
Accreditation standards Edition 2021
scoring system
user guide
‫هيكل الهيئة الحاكمة‬
‫الهيكل التنظيمي‬
‫مستند تشكيل مجلس االدارة‬ ‫مدير المنشأة‬
‫مدير المنشأة ‪/‬ممثل الهيئة‬

‫التقرير السنوى‬
‫الحاكمة‬
‫رسالة المنشأة معتمدة‬
‫محتوى الرسالة‬ ‫مدير النشأة ‪-‬قادة المنشأة‬

‫التقييم السنوى‬
‫مهام مجلس االدارة‬
‫‪-‬الخطة االستراتيجية‬
‫‪-‬الخطة التشغيلية‬
‫‪-‬برنامج تحسين الجودة‬

‫برنامج المشاركة المجتمعية‪-‬محاضر‬
‫االجتماعات‬
‫سبل التواصل‬
‫قادة المنشأة ‪ -‬مجلس االدارة‬
‫تقارير‬ ‫مدير المنشأة‬
‫مدير المنشأة‬
‫قرار تعيين مدير المنشأة‬

‫التوصيف الوظيفى لمدير المنشأة‬
‫ملف مدير المستشفي‬
‫قرارات التكليف بأعمال‬
‫قرار تشكيل اللجان‬
‫شروط االنعقاد‬
‫محاضر اجتماعات اللجان‬
‫محاضر اجتماعات اللجان‬ ‫قادة المنشأة‬

‫التقارير ‪-‬القرارات االدارية‪-‬محاضر‬
‫مدير المنشأة‪-‬قادة المنشأة‬
‫االجتماعات‬
‫‪-‬الخطة االستراتيجية‬ ‫مدير المنشأة‬
‫محاضر االجتماعات‬ ‫مدير المنشأة‪-‬القادة‪-‬العاملين‬
‫التقرير السنوى‬ ‫مدير المنشأة‬
‫الخطة التشغيلية‬
‫محاضر االجتماعات‬ ‫العاملين‬

‫تقارير المتابعة‬ ‫مدير‪-‬قادة المنشأة‬
‫التقاريرالسنوية‬
‫مهام القيادات بالمستشفي‬
‫قادة المنشأة‬
‫قرار التكليف‬
‫مهام المشرف علي القسم‬
‫رؤساء االقسام‬
‫سياسة‬
‫التقارير السنوية ‪ -‬التسجيل‬
‫التقييم السنوي للموردين‬
‫االجراءات التصحيحية‬ ‫االدارة ‪-‬المسئول‬
‫تسجيل المعلومات االساسية‬ ‫مسئول المخازن‬
‫نظام التحكم بالمخزون‬
‫ق´´ائمة‪critical resources‬‬
‫قائمة االجراءات و العمليات عالية‬

‫التردد و التكلفة‬
‫سياسة‪-‬مشروع تحسين االستخدام‬ ‫االدارة‬

‫محاضراالجتماعات‪-‬اجراءات التحسين‬
‫سياسة‬
‫قائمة االسعار‬
‫المرضى وذويهم‬
‫أكواد التشخيص والتداخالت‬
‫تقارير قياس والتحليل‬

‫برامج التدريب‬ ‫موظفى حسابات المرضى‬
‫قائمة التعاقدات‬
‫معايير االختيار‬ ‫االدارة‬
‫المحاضر‬ ‫رؤساء األقسام‬
‫مؤشرات االداء‬ ‫المسئول‬

‫تقييم التعاقدات‬
‫العاملين‪-‬قادة المنشأة‬
‫العاملين‪-‬قادة المنشأة‬
‫سياسة‪-‬تقارير األحداث‬
‫سبل التواصل ‪ /‬محاضر اجتماعات‬ ‫القيادات ‪ -‬العاملين‬
‫استبيان رضا الموظف‬
‫مدونة السلوك الوظيفى‬ ‫االدارة‬
‫برنامج صحة العاملين‬
‫تقييم المخاطر المهنية‬
‫وثائق التدريب‬ ‫العاملين‬
‫برنامج التطعيمات‬
‫ملفات الموظفين‬
‫االجراءات المتخذة‬ ‫مسئول مكافحة العدوى ‪ -‬العاملين‬

care Facilities
score percentage%
2 > = 80%
1
<80% >=50%
0 <50%
N/A N/A
de Ac

‫معلنة بمكان عام بالمنشأة‬
‫تطبيق المهام‬
‫تطبيق المهام‬
‫توافر الموارد‬
‫االستخدام الصحيح لألكواد‬

‫تطبيق السياسة‬
‫اماكن راحة العاملين نظيفة وذات تهوية‬
‫واضاءة جيدة‬
‫اماكن راحة العاملين غير مزدحمة‬
‫اماكن راحة العاملين ووسائل االتصال‬
‫المكان مؤمن‬
Action plan

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Date OGM.01 OGM.02 OGM.03
70% 50% 50%
120%
100%
100%
80%
70%
60% 50%
50%
40%
20%
0%
OGM.01 OGM.02 OGM.03 OGM.04
‫لذاتي لمعايير االعتماد للمستشفيات‬
Self assessment tool for GAHAR hospital Accredit
scoring system
OGM.04 OGM.05 OGM.06 OGM.07 OGM.08 OGM.09
100% 100% 60% 100% 100% 50%
OGM Scorre
100% 100% 100% 100%
60%
50% 50% 50% 50%
OGM.03 OGM.04 OGM.05 OGM.06 OGM.07 OGM.08 OGM.09 OGM.10 OGM

‫أداة التقييم الذاتي لمعايير االعت‬
hospital Accreditation standards Edition 2021
coring system
OGM.10 OGM.11 OGM.12 OGM.13 OGM.14 OGM.15
50% 50% 50% 33% 33% 50%
OGM Scorre
100% 100% 100%
50% 50% 50% 50%
33% 33%
OGM.10 OGM.11 OGM.12 OGM.13 OGM.14 OGM.15 OGM.16 OGM.17 OG

OGM.16 OGM.17 OGM.18 OGM.19 OGM.20 Total
100% 100% 100% 100% 80% 71%
00% 100% 100% 100%
80%
71%
OGM.16 OGM.17 OGM.18 OGM.19 OGM.20 Total

NO
CAI.1
1
CAI.2
4
CAI.3
CAI.4
3
CAI.5
6
CAI.6
4
Community Assessment
.Hospital services are planned in line with international, national,

The hospital has an approved plan for community involvement in
regional, and/or national community initiatives
Relevant staff are aware of hospital’s planned community initiati
Community initiatives are in compliance with laws and regulation
Community needs are assessed in collaboration with community r
The hospital has an approved program for community assessmen

from a) through f).
A designated person (s) to coordinate community involvement act
There is evidence that gap analysis is done in collaboration with c
Selected solutions are announced and/or posted to the community

Hospital community activities, whether educational, cultural, recr
community
The hospital identifies the community partner organizations that

hospital in defining the community’s health needs
Hospital staff are aware of their specific community health needs
There is evidence of performed community involvement activities
Outcomes of community assessment and involvement progr
The hospital performs an evaluation for the community needs at
The hospital performs an evaluation for the community risks at l
The hospital measures community satisfaction of the provided so

The hospital handles and manages community suggestions a
The hospital has an approved policy for managing the community
Community and business customers’ complaints and suggestions
Community and business customers’ complaints are resolved in a
Community and business customers receive feedback about their
Measures are in place to handle aggressive situations, including c
There is a process for dealing with media and social media

The accredited hospital shares experience with neighboring
The hospital identifies other hospitals seeking accreditations and t
The hospital identifies areas in the accreditation process that can b

journey
The hospital provides support in terms of education, expertise and
The hospital works with other hospitals to ensure compliance to st

General
‫ أداة التقييم الذاتي لمعايير االعتماد للمستشفيات‬Self assessment tool for GAHA
MET
PARTIAL MET
NOT MET
NOT Applicable

2
1
fied learning needs and educational level of the
2
0
N/A
and, achieve, or maintain accreditation
N/A
1
General Administration Of Technical Support Fo
ssessment tool for GAHAR hospital Accreditation standards Editi
scoring sys

Total
Total score
percentage%
67% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
100% MET
70% PARTIAL MET
50% PARTIAL MET
Total chapter Score
64%
tration Of Technical Support For Healthcare Facilities
al Accreditation standards Edition
scoring system

user guide
‫خطة المشاركة المجتمعيه‬
‫الموظفين ذات الصلة‬
‫برنامج تقييم مجتمع‬
‫تكليف منسق اللجنة‬
‫تحليل الفجوة‬
‫إعالنات الحلول المقترحه‬

‫تحديد الجهات المشاركة‬
‫موظفين المستشفى‬
‫تقارير ‪ -‬محاضر ‪ -‬انشطة‬ ‫المسئول‬
‫تقييم االحتياجات‬
‫تقييم المخاطر المجتمعية‬
‫قياس مستوي رضاء المجتمع‬ ‫المسئول‬

‫سياسة‬
‫تحقيق الشكاوي والمقترحات‬ ‫المسئول‬
‫السجل‬
‫التغذية الراجعه‬
‫نظام التعامل مع وسئل التواصل‬

‫االجتماعي واالعالم‬
‫المحاضر و التقارير‬ ‫اإلدارة‬
‫مشاركة الخبرات المميزه ‪ -‬تقارير‬
‫برامج التدريب والتعلم‬
‫اتفاقيات ‪ -‬تقييم‬
e Facilities
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
de Action

‫تطبيق الخطة طبقا للوائح والقوانين‬
‫مشاركة اعضاء من المجتمع‬

‫االنشطة المجتمعية‬
Action plan

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫ت‬
Self assessment too
Date CAI.01
67%
120%
100%
80%
67%
60%
50%
40%
20%
0%
CAI.01
scoring system
CAI.02 CAI.03 CAI.04 CAI.05 CAI.06
50% 50% 100% 70% 50%
CAL Score
100%
67% 70%
64%
50% 50% 50%
CAI.01 CAI.02 CAI.03 CAI.04 CAI.05 CAI.06 Total

2021
Total
64%
64%
NO
WFM.1
1
WFM.2
4
5
WFM.3
5
WFM.4
WFM.5
2
3
WFM.6
5
WFM.7
WFM.8
1
2
WFM.9
4
5
WFM.10
WFM.11
2
3
WFM.12
WFM.13
1
6
WFM.14
WFM.15
1
2
WFM.16
2
3
WFM.17
4
5
WFM.18
WFM.19
1
4
Work
. Workforce recruitment, education, training, and appraisal proce

Hospital recruitment practices comply with laws and regulations.
Hospital workforce education and all training activities comply w
Hospital workforce performance appraisals comply with laws and
Hospital staffing plan identifies the number of staff and defi

members needed to meet the .hospita
Staffing plan matches the mission, strategic and operational plan
Staffing plan complies with laws, regulations, and recommendatio
Staffing plan identifies the estimated needed staff numbers includ

hospital needs.
In critical care and anesthesia services, Competent staff members

Staffing plan is monitored and reviewed at least annually.
.A uniform recruitment process is applied with the participation o
The hospital has an approved policy to recruit staff members incl

e) in the intent.
Staff who are involved in recruitment, are aware of the hospital p
The recruitment process is uniform across the hospital for similar
The hospital leaders participate in the recruitment process.
Selection criteria are recorded in the staff’s file.

Hospital job descriptions, address each position requirements and
There is a job description for every position.
Job descriptions include the requirements (license, certification o

of each position.
Job descriptions are discussed with staff including independent p
Performance evaluation is based on job descriptions.
New and current staff credentials are verified.
Required credentials for each position are kept in staff files inclu
There is a process for verifying credentials and evaluating the qu

The process is uniformly applied to assess staff members’ credent
Actions are taken when credentials cannot be verified
A staff file is developed for each workforce member
The hospital has an approved policy that addresses at least elemen
Staff members who are involved in creation, storage and use of sta
Staff files are confidential and protected
Staff files include all the required records
Staff files are disposed as per hospital policy

Appointed, contracted, and outsourced staff undergo a form
General orientation program is performed and it includes at least
.Department orientation program is performed and it includes at l
.Job specific orientation program is performed and it includes at l
.Any staff member attends orientation program regardless of emp
.Orientation completion is recorded in the staff file
A continuing education and training program is developed a
.There is a continuing education and training program for all staff

.Resources (human and non-human) are available to deliver the pr
.The program is based on needs assessment of all staff
.Results of a performance review are integrated into program desi
Staff performance and competency are regularly evaluated.
Performance and competency evaluation is performed at least ann
Performance and competency evaluation is performed also when i

education and training provided
There is evidence of employee feedback on performance and comp
Actions are taken based on a performance review

Performance and competency evaluation is recorded in staff memb
An organized medical staff structure is developed to provide
The hospital has a medical staff structure that is developed accord

professional practices to meet patient needs
Medical staff structure is approved by the governing body
Medical staff structure clearly defines lines of responsibilities duri
Medical staff bylaws are developed.
.The governing body approves medical staff bylaws
Medical staff bylaws are consistent with laws, regulations, and pro
The documents include elements in the intent from a) through j)
Appointment of medical staff members is performed accord
There is a uniform process for the initial appointment of medical s
Medical staff appointments are made according to the hospital me
Medical staff appointments are consistent with the hospital missio
Medical staff appointments are according to laws and regulations.
Medical staff members have current and specific delineated

The hospital has an approved policy that addresses at least all elem
Medical staff members are aware of the process of clinical privileg

clinical privileges
Clinical privileges are delineated to medical staff members based o
Clinical privileges are accessible to and used by staff involved in b
Physicians' and dentists' files contain personalized recorded clinic
Physicians and dentists comply with their clinical privileges.

Performance of each medical staff member is reviewed and
Performance evaluation records include at least all elements from
Medical staff members are aware of performance evaluation criter
Evidence of medical staff members’ performance is assessed based

medication use.
Performance evaluation results are used to improve individual me
An ongoing peer review process is developed.
.The hospital has an approved policy that addresses all elements fr

.Medical staff members are aware of the peer review processes
.Peer review processes are implemented
.Results/reports of peer review are used for reappointment and re-
Legal requirements governing the professional regulation of
The hospital has a standardized procedure to gather and documen

certifications, and experience of each nursing staff member.
Education, training, and certifications are verified.

Laws and regulations of nursing care are followed.
When a violation to nursing care laws or regulations is identified,
The hospital has a defined nursing structure that is led by a
.There is a current, approved job description for the nursing direc
. The nursing director file fulfills the licensure, qualification, and e
.The hospital defines trainee nurses and the duration of working u
.Trainee nurses' practice under supervision through their job desc

.Nursing standards of practice are adopted and educated
.Nursing standards of practice are implemented
The hospital has a uniform process to identify job responsib

practitioners’ credentials and any regulatory requirements
Licensure, education, training, and experience of other health care
.The process considers relevant laws and regulations
The process supports the staffing process for other health care pra
violation to nursing care laws or regulations is identified, correctiv
The hospital ensures safe and efficient working hours.

.The hospital has an approved policy to ensure safe and efficient w
.Staff are aware of the hospital’s policy
,The staff schedules ensure suitable working hours planned rest tim
and arrangements for breastfeeding according to laws and regulat
.When working hours exceed the approved limits, measures are ta

General Adm
‫أداة التقييم الذاتي لمعايير اال‬ Self assessment tool for GAHAR hospit
MET
PARTIAL MET
NOT MET
NOT Applicable

N/A
1
1
1
2
2
2
1
2
2
N/A
1
1
1
1
ylaws.
1
0
1
1
1
N/A
N/A
N/A
N/A
N/A
N/A
2
2
2
2
2
General Administration Of Technical Support For Healthcare
r GAHAR hospital Accreditation standards Edition 2021
scoring syst
us of preparedness ‫التقييم‬
Total percentage
Total score
%
50% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET

50% PARTIAL MET
42% Not Met

38% Not Met
50% PARTIAL MET

100% MET
100% MET
100% MET
100% MET
Total chapter Score
70%
ical Support For Healthcare Facilities
dards Edition 2021
scoring system
user guide
‫القوانين و اللوائح‬
‫انشطة التدريب و التعليم‬
‫تقييم األداء ‪ /‬ملفات العاملين‬
‫خطة التوظيف ‪ -‬الخطط التشغيلية ‪-‬‬

‫الخطة االستراتيجية‬
‫اللوائح والقوانين ‪-‬خطة التوظيف‬
‫خطة التوظيف‬ ‫مسئول الموارد البشرية‬
‫عدد العاملين‬
‫مسئول الموارد البشرية ‪-‬‬
‫تقارير التقييم السنوى للخطة‬ ‫االدارة‬
‫الشخص المسئول‬
‫ملفات العاملين‬
‫االدارة ‪ -‬القيادات‬
‫ملف الموظف ‪ -‬معايير االختيار‬

‫التوصيف الوظيفى‬
‫نموذج تهيئة ملف الموظف‬
‫التوصيف الوظيفى تقيييم االداء‬ ‫االدارة ‪-‬الموارد البشرية‬
‫التحقق من االعتمادات‬
‫االدارة ‪-‬مسئول الموارد‬
‫البشرية‬
‫مسئول الموارد البشرية ‪-‬‬

‫قائمة بالمسموح لهم االطالع على‬

‫الملفات‬
‫برنامج التهيئة العام‬
‫برنامج تهيئة األقسام‬
‫برنامج التهيئة الوظيفى المحدد‬
‫ملف العاملين‬ ‫العاملين ‪-‬مسؤل القسم‬
‫البرنامج التدريبي‬
‫مسئول التدريب ‪ -‬فريق العمل‬
‫ملف العاملين ‪-‬تقييم االحتياجات‬

‫التدريبية‬
‫تقييم االداء ‪ -‬التوصيات‬
‫تقييم األداء و الكفاءه ‪-‬ملف الموظف‬
‫االدارة‪-‬مسئول الموارد البشرية‬
‫التغذيه الراجعه من الموظفين ‪-‬‬ ‫العاملين‬

‫االجراءات التصحيحية‬
‫هيكل الطاقم الطبي‬ ‫االداره‬
‫اعتماد مجلس االدارة‬
‫المهام والمسئوليات‬
‫اعتماد االئحة الطبية من مجلس‬ ‫االدارة‬

‫الالئحه الطبيه‬
‫محتويات االئحة الطبية‬
‫عمليه التعين‬
‫مهام و خدمات المستشفى‬
‫القوانين و اللوائح‬
‫سياسة‬
‫الفريق الطبى‬
‫معايير االمتيازات االكلينيكية‬
‫ملفات العاملين (االطباء ‪ -‬االسنان)‬
‫تقييم االداء ‪ -‬الملف الطبي‬

‫تقييم االداء‬
‫الفريق الطبي‬
‫معاييرتقييم االداء ‪-‬مؤشرات االداء‬
‫مسئول الموارد البشرية‪-‬رؤساء‬

‫االجراءات التصحيحية‬ ‫االقسام‬
‫سياسة‬
‫الفريق الطبى‬
‫نتائج مراجعة النظراء‬
‫التقارير ‪-‬اعادة التعيين واالمتيازات‬ ‫االدارة‬
‫سياسة‬
‫رئيسة التمريض‪ -‬التمريض‬
‫االجراء التصحيحى‬ ‫االدارة‪-‬رئيسة التمريض‬
‫توصيف وظيفى‬
‫ملف الموظف رئيسة التمريض‬
‫سياسة‬
‫ادلة االجراء‪-‬نماذج التدريب ‪-‬ملف‬
‫المريض‬ ‫التمريض‬
‫ملف المريض‬ ‫التمريض‬
‫سياسة‬
‫االجراءات التصحيحية‬ ‫‪ -‬االدارة‬

‫سياسة‬
‫جداول العمل‬ ‫مسئول الموارد البشرية‪-‬‬

‫التقارير واالجراءات التصحيحية‬

score percentage%
2 > = 80%
1
<80% >=50%
0 <50%
N/A N/A
de Action

‫حمايه وسريه الملفات‬
‫طريقه التخلص من الملفات‬

‫توافر االمتيازات‬

‫التاكد من المستندات‬

‫تطبيق االجراء طبقا للوائح والقوانين‬
Action plan

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Data WFM.01 WFM..02 WFM.03 WFM.04
50% 50% 50% 100%

1/23/2021
PARTIAL MET PARTIAL METPARTIAL MET MET
120%
100% 100%
100%
80%
60%
50% 50% 50%
40%
20%
0%
WFM.01 WFM..02 WFM.03 WFM.04 WFM.05

Self assessment tool for GAHAR hospital Accreditation sta

scoring system
WFM.05 WFM.06 WFM.07 WFM.08 WFM.09 WFM.10
100% 50% 100% 100% 50% 50%
MET PARTIAL MET MET MET PARTIAL METPARTIAL MET
0% 100% 100% 100%
50% 50% 50% 50% 50%
WFM.04 WFM.05 WFM.06 WFM.07 WFM.08 WFM.09 WFM.10 WFM.11 WFM.12

‫أداة التقييم الذاتي لمعايير ا‬
ital Accreditation standards Edition 2021

ng system
WFM.11 WFM.12 WFM.13 WFM.14 WFM15 WFM.16
50% 50% 42% 38% 50% 100%
PARTIAL METPARTIAL MET Not Met Not Met PARTIAL MET MET
100% 100% 100% 100%
50% 50% 50%

42%
38%
M.10 WFM.11 WFM.12 WFM.13 WFM.14 WFM15 WFM.16 WFM.17 WFM.18 W

WFM.17 WFM.18 WFM19 Total
100% 100% 100% 70%
MET MET MET PARTIAL MET
00% 100% 100%
70%
WFM.17 WFM.18 WFM19 Total

NO
IMT.01
1
2
IMT.02
IMT.03
1
NSR.12 IMT.04
2
3
IIMT.05
5
6
IMT.06
IMT.07
1
2
IMT.08
3
4
IMT.09
IMT.10
1
IMT.11
2
3
IMT.12
3
4
5
Information Man
.Information management processes are implemented according to
The hospital leadership and responsible staff members of informa

aware of the requirements of law and regulations
The hospital stores all its records and information according to la
The hospital responds timely to any required reports from inspec
When gaps are identified, needed steps and interventions are take
regulations.
Information management plan meets information needs
The hospital leadership has performed information needs assessm
The hospital leadership has approved effective information plan th

through c) in the intent
The hospital leadership ensures that actions are taken to meet iden
needs.
Developing, approving, tracking, and revising quality

The hospital has an approved document t
intent at least
The hospital leadership, heads of services, and the relevant proces

of this policy.
Staff can access those policies relevant to their responsibilities.
Only the last updated versions of Policies are accessible and distr
Policies are revised at least every three years.
The hospital defines standardized diagnosis codes, procedur
The hospital has an approved policy that includes all the element
All staff who records in the patient’s medical record are aware of
Approved codes are matching those provided by health authoritie
Symbols and abbreviations (even the approved list) are not used in
record that patients and families receive from the hospital about th
Data and information are confidential.
The hospital has an approved policy that includes all the points in
d).
All staff are aware of the policy requirements.
There is a list of authorized individuals to have access to the patie
Only authorized individuals have access to patient’s medical reco
There is a signed confidentiality agreement in each staff member'

Procedures are followed if confidentiality or security of informati
Patient’s medical record and information are protected from
.Medical records and information are secured and protected at all
Medical records and information are secured in all places, includin

and the medical records department.
The medical records department storage area implements measur

information integrity.
.When an integrity issue is identified, Actions are taken to maintai
Retention time of records, data, and information are perform
.The hospital has an approved policy that includes all the points in
.All staff are aware of the policy requirements
.The information confidentiality is maintained during the retention
.Data are archived as per policy
.Destruction and/ or removal of records, data, and information are
Patient’s medical record is managed effectively.
.All staff who are using patient’s medical record are aware of the p
.A patient’s medical record is initiated with a unique identifier for

.The patient’s medical record contents, format, and location of ent
The patient’s medical record is available when needed by a health
Patient’s medical record is reviewed effectively.
.All staff who are using patient’s medical record are aware of the p
.Review results are reported to the hospital leaders
. Corrective interventions are taken when needed
Health information technology systems are assessed, tested p

Health information technology stakeholders participate in the sele
.Health information technology systems are assessed and tested pr
.Health information technology systems are evaluated following im
. When patient safety issues are identified, actions are taken to ma
Response to planned and unplanned downtime of data syste
.There is a program for response to planned and unplanned down
.The program includes downtime recovery process

.The staff is trained in response to the downtime program
.The hospital tests the program at least annually to ensure its effec
Data backup process is defined.
.There is a process for data backup include the type of data, frequ
.Backups is performed on a scheduled basis to meet user requirem
.Backup schedules are developed for all new systems and the resto
.Backup data is secured during extraction, transfer, storage, and r
.Backup log is reviewed frequently to identify exceptions / failures

General Adm
‫ أداة التقييم الذاتي لمعايير االعتماد للمستش‬Self assessment tool for GAHAR h
MET
PARTIAL MET
NOT MET
NOT Applicable
2
1
1
1
2
2
2
2
e.
2
2
N/A
2
2
N/A
safety.
1
1
1
1
1
1
General Administration Of Technical Support For Hea
ment tool for GAHAR hospital Accreditation standards Edition
scoring s

Total percentage
Total score
%
63% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET

100% MET
100% MET
50% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
50% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
Total chapter Score
68%
Of Technical Support For Healthcare Facilities
creditation standards Edition
scoring system

user guide
- ‫العاملين بادارة المعلومات‬

‫القيادات‬
‫تقييم االحتياجات المعلوماتية‬
‫خطة معلومات معتمدة‬
‫المسئول ‪ -‬االدارة‬
‫وثيقة معتمدة‬
‫االدارة ‪ -‬القيادات ‪ -‬العاملين‬
‫قائمه باستالم السياسات‬
‫مراجعة السياسات‬
‫جميع مقدمى الخدمة‬

‫األكواد‬
‫‪ - informed cosent -‬التقارير الطبية‬

‫ملخص الخروج‬
‫قائمة باالشخاص المصرح لهم‬
‫اقرار السرية ‪ -‬ملف الموظف‬

‫االجراءات والتقارير‬
‫الشخص المسئول‬
‫السياسة ‪ -‬قائمة محدد بها وقت‬

‫حفظ الملفات طبقا لنوع المعلومات‬
‫تقارير او سجل تدمير او حذف‬

‫الملفات او المعلومات او البيانات‬
‫الملف الطبى‬
‫الملف الطبى (نماذج و محتويات‬
‫الملف)‬
‫مسئول السجالت الطبية‪-‬‬

‫مقدمى الخدمة‬
‫تقارير مراجعة الملفات‬
‫المشاركين في اختيار و تطبيق و‬
‫تقييم النظام‬
‫التقييم و االختبار‬
‫عمليه اصالح النظام‬

‫وثائق التدريب‬ ‫العاملين‬
‫االختبار السنوى‬
‫عمليه النسخ االحتياطى للبيانات‬
‫المسئول عن نسخ البيانات‬
‫جداول النسخ االحتياطي للبيانات‬

‫الجديده و تقارير اختبار المخزن‬
‫سجل نسخ الببانات‬
ties
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
de Act

‫تخزين طبقا للقوانين و اللوائح‬
‫توافر أحدث اصدارات السياسات‬
‫تطبيق االكواد‬
‫السماح لألشخاص المصرح لهم‬

‫حمايه و تأمين الملفات‬
‫مناطق تقديم الرعايه للمريض و األقسام‬
‫قسم تخزين الملفات الطبيه‬
‫تطبيق اإلجراءات‬
‫السريه اثناء حفظ الملفات‬
‫تخزين الملفات‬
‫توافر الملف الطبي عند االحتياج‬
‫توافر النماذج الالزم استخدمها عند‬

‫فشل نظم المعلومات‬
‫التأمين‬
Action plan
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
Self assessment tool for
Date ITM.01 ITM.02 ITM.03
63% 50% 50%
120%
100%
100%
80%
63%
60%
50% 50%
40%
20%
0%
ITM.01 ITM.02 ITM.03 ITM.04 I
sment tool for GAHAR hospital Accreditation standards Edition 2021
scoring system
ITM.04 ITM.05 ITM.06 ITM.07 ITMS.08 ITM.09
100% 100% 50% 100% 100% 50%
IMT SCore
100% 100% 100% 100%
0% 50% 50% 50% 50% 50%
3 ITM.04 ITM.05 ITM.06 ITM.07 ITMS.08 ITM.09 ITM.10 ITM.11 I

tion 2021
ITM.10 ITM.11 ITM.12 Total
50% 50% 50% 68%
68%
50% 50%
10 ITM.11 ITM.12 Total

NO
QPI.01
1
QPI.02
3
4
QPI.03
QPI.04
1
2
QPI.05
4
5
QPI.06
QPI.07
1
QPI.08
3
4
QPI.09
QPI.10
1
2
QPI.11
3
4
QPI.12
3
4
QPI.13
4
QPI.14
4
Quality and Performan
Quality management program is governed by an interdisciplinary

There is a multidisciplinary performance improvement, patient s
committee in comply with relevant law and regulations including
intent
There is official assignment document for designated committee c

committee meetings
The committee meets at predefined intervals and record the agen
The committee evaluates its performance on an annual basis
There is a hospital-wide performance improvement, and patient s
There is a current and approved performance improvement, pati

items from a) through k) in the intent
Hospital director and leaders actively participate in the planning

improvement, patient safety and risk management.
The plan was implemented hospital wide, according to the timeta

The plan is evaluated and updated annually.
The plan is communicated to the relevant stakeholders
A qualified staff member is assigned as performance improvement
An individual with knowledge, skills and experienced in performa

related activities.
There is a clear job description that support the work of perform

the program activities.
Quality management team receives required support in terms of

and staffing.
The hospital staff including medical staff members, nurses a

activities.
The hospital encourages staff members to perform performance i

The hospital provides training to educate staff of quality managem
participants in performance improvement program’ activities
The participating staff member(s) from physicians, nurses and ot

knowledge and skills for data review, aggregation, and analysis
The hospital includes performance improvement activities in indi
Performance measures are identified, defined, and monitore
There is an approved documented work sheet (Data analysis repo

performance measure, standardized template is preferred, that in
in the intent from a) through g)
The work sheets (Data analysis report) clarify the definition, defin
used formulae and methodology of data collection and analysis fo
Those responsible for the collection, interpretation and/or use of p

are aware of its definition and specified frequency, sampling tech
methodology of data collection, and analysis
The hospital makes its performance results/data publicly availabl

The results are used in benchmark internally, externally and with
Results of measures analysis are reported to those accountable fo
Clinical Care Performance Measures are used to identify op
For each relevant standard care areas, the hospital selected appro
services, requirements in the intent, governing laws and regulation
The relevant clinical care areas for each standard is monitored fre
Performance measures are calculated and displayed in a table, cu
Performance measures are used by hospital leaders to take decisio
Managerial Performance Measures are used to identify opp

For each relevant standard care areas, the hospital selected appro
services, intent requirements, governing laws and regulations, and
The relevant managerial areas for each standard are monitored fr
Performance measures will be calculated and displayed in a table,
Performance measures are used by hospital leaders to take decisio
A staff member(s) with appropriate experience, knowledge,
There is a written process of data management includes the aggreg
Responsible staff members for data aggregation and analysis are a
Data is aggregated and trended over-time

Descriptive analysis is done
Data validation is performed according to defined criteria
There is a written process for data review and validation
Responsible staff for data review is aware of their roles.
Data review techniques are implemented to ensure all the element

are considered.
Data validation is done when data is going to be published, sent to

used for measurement
A risk management plan/program is developed
The hospital has a risk management plan/ program that includes a

A plan, policies, procedures, a risk register and processes support
High risk processes are re- designed based on the result of the ana
The hospital has an approved proactive risk reduction tool for at l
An incident-reporting system is developed.
The hospital has an approved policy defines an incident-type and r
All staff are aware of the incident-reporting system, including con
Sentinel events are investigated and gaps in services are identified

Hospital communicates with patient’s/services users about adverse
Corrective actions are taken to close gaps in services in a timely m
Significant events and/or near misses are analyzed and corre
There is a document that defines criteria and process for intensive

time required to complete the investigation and the time required
In case of significant/near misses incident, a committee is formed w

relevant staff are trained on intensive analysis.
All significant unexpected /near misses events are timely investigat

Corrective actions are taken with clear time frame and responsibl
The hospital defines investigates, analyzes and reports sentin
The hospital has a sentinel events management policy covering the

policy requirements
All sentinel events are analyzed and communicated by a root cause

does not exceed 45 days from the date of the event or when made a
All sentinel events are communicated to GAHAR within seven day
The root cause analysis identifies the main reason(s) behind the ev
recurrence in the future.
Appropriate and sustained improvement activities are perfo
.There is a written process or methodology for improvement
.Actions to correct problems were taken timely and appropriately
. Improvement activities were tested and the results were recorded
There is evidence that patient safety processes were improved and

Genera
‫أداة التقييم الذاتي لمعايير االعتماد للمستشفيات‬Self assessment tool for GAH
MET
PARTIAL MET
NOT MET
NOT Applicable
management committee(s)
N/A
1
N/A
2
2
2
2
toward hospital ‘objectives.
toward hospital ‘objectives

2
n, and analysis within approved time frame.
N/A
2
N/A
N/A
2
1
1
1
1
1
nt harm and recurrence.
N/A
1
2
N/A
2
General Administration Of Technical Support For
sessment tool for GAHAR hospital Accreditation standards Editio
scoring sys
Total
Total score
percentage%
50% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
100% MET
100% MET
50% PARTIAL MET
100% MET
100% MET
100% MET
63% PARTIAL MET

50% PARTIAL MET
50% PARTIAL MET
50% PARTIAL MET
83% MET
Total chapter Score
71%
ration Of Technical Support For Healthcare Facilities
al Accreditation standards Edition
scoring system
user guide
‫مهام انعقاد اللجنة‬
‫وثيقة تكليف رئيس اللجنة‬
‫محاضر و اجندة االجتماعات‬
‫تقارير التقييم‬ ‫مسئول الجودة‪-‬رئيس اللجنة‬
‫الخطة‬
‫ـتماعات‬
‫‪-‬‬ ‫محـاضر اـالج‬ ‫مدير المستشفي ‪ -‬القيادات‬
‫تقييم الخطة‬
‫محضر االجتماع‬ ‫القيادات ‪ -‬االدارة‬
‫تكليف مسئول الجودة‬
‫التوصيف الوظيفى‬
‫مسئول الجودة ‪-‬االدارة‬
‫البرنامج التدريبى‬ ‫العاملين‬
‫تقييم االداء ‪ -‬ملفات العاملين‬
‫تقرير تحليل البيانات‬
‫تقريرتحليل البيانات‬
‫المسئولين (فريق الجودة)‬

‫النتائج‬
‫نتائج تحليل القياسات‬
‫مؤشرات األداء‬
‫مؤشرات األداء‪-‬التقارير الدورية‬
‫مؤشرات االداء ‪ -‬التقارير‬
‫محاضر االجتماعات الخطة‬ ‫مسئول الجودة ‪-‬االدارة‬

‫مؤشرات األداء‬
‫مؤشرات األداء‪-‬التقارير الدورية‬
‫مؤشرات االداء ‪ -‬التقارير‬
‫محاضر االجتماعات الخطة‬

‫التصحيحية‬ ‫مسئول الجودة ‪-‬االدارة‬
‫آللية تجميع وتحليل البيانات‬
‫أمر تكليف‬ ‫المسئول‬
‫التحليل الوصفى‬
‫آلية التحقق من البيانات و مراجعتها‬
‫خطة‪ /‬برنامج ادارة المخاطر‬

‫الخطط‪-‬السياسات ‪ -‬االجراءات‬
‫مسئول الجودة ‪-‬االدارة‬
‫التحليل‬
‫محاضر اجتماع‬
‫االجراءات التصحيحة‬ ‫مسئول الجودة ‪-‬االدارة‬
‫وثيقة تحدد ضوابط التعامل مع‬

‫األحداث المهمه‬
‫تشكيل و تدريب االعضاء ‪-‬محاضر‬

‫اجتماع اللجنة ‪ -‬التقارير‬
‫تحليل الحدث‬
‫الخطة التصحيحة‬ ‫مسئول الجودة ‪-‬االدارة‬
‫التقارير ‪-‬محاضر االجتماع‬
‫التحليل ‪ -‬الخطة التصحيحية‬ ‫مسئول الجودة ‪-‬االدارة‬

‫وثيقة التحسين‬
‫التقارير‪-‬االجراءات التصحيحية‬
‫التقارير ‪-‬االجراءات التصحيحية‬ ‫مسئول الجودة ‪-‬االدارة‬

Facilities
score percentage%
2 > = 80%
1 <80% >=50%
0 <50%
N/A N/A
de Action

‫تطبيق الخطة‬
‫توفير التجهيزات‬
‫المشاركة فى انشطة الجودة‬

‫المشاركة فى مراجعة وتجميع وتحليل‬
‫البيانات‬
‫نشر تقارير ربع سنوية عن االداء‬

‫بالمستشفي‬
‫تطبيق األجراء‬
‫مراجعة البيانات‬
‫التاكد من البيانات‬
‫تطبيق االجراء طبقا للخطة‬
‫‪ proactive risk‬تطبيق مشروع‬

‫‪reduction‬‬
‫تقارير االبالغ عن الحوادث‬
‫تطبيق االجراءات التحسينية‬
‫تطبيق االنشطة‬
Action plan

‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫اداة التقييم الذاتي لمعايير اعتماد المستشفيات‬
scoring system
Date QPI.01 QPI.02 QPI.03 QPI.04 QPI.05 QPI.06 QPI.07 QPI.08 QPI.09 QPI.10 QPI.11 QPI.12 QPI.13 QPI.14 Total
50% 50% 50% 100% 100% 50% 100% 100% 100% 63% 50% 50% 50% 83% 71%
QPI Score
120%
100% 100% 100% 100% 100%
100%
83%
80% 71%
63%
60%
50% 50% 50% 50% 50% 50% 50%
40%
20%
0%
QPI.01 QPI.02 QPI.03 QPI.04 QPI.05 QPI.06 QPI.07 QPI.08 QPI.09 QPI.10 QPI.11 QPI.12 QPI.13 QPI.14 Total
NO
ADD.01
1
ADD.02
1
2
ADD.03
4
5
ADD.04
ADD.05
1
2
ADD.06
4
5
ADD.07
ADD.08
1
2
ADD.09
2
3
4
Section 4: Additional Requ
An educational governance structure is established to impro

The hospital clearly assigns the responsibility of medical educatio
Staff members’ qualification and number matches hospital needs

and workload including planning of services of clinical care
The hospital has an appropriate level of clinical supervision at all

supervisor, who can advise or attend as needed
Students and other learners are not expected to work beyond thei
Hospital ensures that students and other learners have an inducti

clearly sets out their duties, supervision requirements, scientific r
Medical students, house officers, residents and trainees are allowe

training
The educational and clinical governance systems are integrated, a

address concerns about patient safety, the standard of care, and t
The hospital has the capacity, resources, and facilities to deliver s
opportunities, clinical supervision and practical experiences for s
The hospital investigates and takes action to address concerns an
The hospital seeks and responds to feedback from students, house

compliance with standards of patient safety and care, and on edu
Placement, planning, education, training, and appraisal of m
Learning outcomes are defined for each level of training/educatio
Medical school curricula and assessments are developed and imp

outcomes
Medical school curriculum includes patient safety related topics
Educators are selected, inducted, trained, and appraised to reflec

Educators receive the support, resources, and time to meet their e
Activities of house officers and residents are arranged
The hospital has an approved program that includes all the point
House officers and residents are oriented about their scope of pra
House officers and residents are oriented to and comply with med
policies and procedures.
House officers and residents are given protected time for learning
The hospital participating in professional graduate educatio
The hospital has an approved program that includes all the point
Medical specialty trainees are oriented to and comply with medic
policies, and procedures.
Medical specialty trainees comply with policies and procedures of
Educators are trained and calibrated in the assessments they are
The hospital establishes an ethical framework for research a
The hospital ensures that the research ethics committee has a mult
.includes individuals with backgrounds relevant to the areas of res
The hospital supports the committee with resources, including staf
The committee members are trained and competent to perform th
The committee sets minimum requirements for approval of resear

The committee approves all research protocols that involve human
Patient rights are protected during research activities.
The hospital has an approved program that includes all the points
Researchers are aware of the policy requirements.
Signed patient consent for participation in research is placed in th

.record
When patient safety issues are identified during research, patients

ensure patient safety
Organ and tissue procurement process is defined.
The hospital approved a document for organ donor recruitment th

.)from a) through f
Promotion of donation of human cells, tissues, or organs by means
.undertaken according to laws and regulation
Physicians and other health professionals do not engage in transpl

organs concerned have been obtained through exploitation or coer
Specific measures are in place to protect donating minors.
Consent is taken from tissue/organ donor and is recorded in patien
Organ and tissue transplant services are performed accordi

clinical guideline/protocol.
The hospital approves a document that covers all points mentioned
All staff involved in tissue/organ transplantation processes are awa

Pre-transplantation evaluation criteria are assessed for all patient
record
Post-transplantation care plans and health instructions are record

‫اإل‬
021 ‫ أداة التقييم الذاتي لمعايير االعتماد للمستشفيات‬Self assessment tool f
MET
PARTIAL MET
NOT MET
NOT Applicable
n
N/A
and the standard of care or of education and
2
2
ording to laws and regulations
2
2
2
2
2
0
2
2
ns and approved organization policy and
N/A
2
2
General Administration Of Technical Su
‫ أداة ا‬Self assessment tool for GAHAR hospital Accreditation stand
scoring
tus of preparedness ‫التقييم‬
Total
Total score
percentage%
38% Not Met

100% MET
80% MET
100% MET
100% MET
80% MET
100% MET
100% MET
67% PARTIAL MET
Total chapter Score
85%
al Administration Of Technical Support For Healthcare Facilities
HAR hospital Accreditation standards Edition
scoring system
user guide
‫تكليف باالشراف علي التعليم‬
‫الطبي‬
‫ملفات العاملين ‪ -‬خطة التوظيف‬ ‫االدارة ‪ -‬المسئول‬
‫‪ Roster‬قائمة المهام واالشراف‬ ‫االدارة ‪ -‬العاملين‬
‫برنامج التعريف للدارسين‬ ‫المشرفين ‪ -‬الدارسين‬
‫التالميذ و المتدربين‬
‫تقارير واالجراءات التصحيحية‬ ‫االدارة ‪ -‬المشرفين‬
‫تقارير التغذية الرجعية‬
‫تحديد االهداف والنتائج المرجوة‬

‫لكل برنامج‬
‫المنهج الطبي ‪ -‬طرق التقييم‬ ‫المتدربين‪ -‬المدربين‬
‫المنهج الطبي‬
‫ملف العاملين ‪ -‬تقييم االداء‬ ‫االدارة ‪ -‬المدربين‬

‫المدربين‬
House officers and

residents
House officers and

residents
‫‪Medical specialty trainees‬‬
‫وثائق التدريب ‪ -‬التقييم‬
‫تشكيل اللجنة‬
‫أعضاء اللجنة‬
‫وثائق التدريب ‪ -‬الخبرات ‪-‬‬

‫اشتراطات الموافقة علي‬

‫البروتكوالت‬
‫بروتكوالت االبحاث علي‬
‫المرضي‬
‫الباحثين‬
‫االقرار‪ -‬ملف المريض ‪ -‬ملف‬

‫البحث‬
‫المريض ‪ -‬الباحثين‬
‫االقرار‪ -‬الملف الطبي‬
‫العاملين بالبرنامج‬
‫تقييم قبل االجراء‪ -‬الملف الطبي‬
‫خطة الرعاية بعد االجراء ‪-‬‬

Healthcare Facilities
score percentage%
2 > = 80%
1
<80% >=50%
0 <50%
N/A N/A
de A

‫تطبيق السياسة‬
‫أماكن وقاعات التعلم‬
‫االلتزام بتطبيق اللوائح والسياسات‬
‫المستشفي‬
‫االلتزام بتطبيق اللوائح والسياسات‬
‫المستشفي‬
‫التجهيزات المتوفرة‬
‫الدعاية واالعالن عن البرنامج‬
‫االجراءات لحماية القاصرين‬

‫المتبرعين‬
Action plan
responsible person Target Date

Status
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫مكتمل‬
‫عتماد المستشفيات‬
Self assessment tool for GAHAR hos
scor
Date ADD.01 ADD.02 ADD.03
38% 100% 80%
120%
100% 100% 100%

100%
80%
80%
60%
40% 38%
20%
0%
ADD.01 ADD.02 ADD.03 ADD.04 ADD
‫اداة التقييم الذاتي لمعايير اعتماد المستشفيات‬
nt tool for GAHAR hospital Accreditation standards Edition 2021
scoring system
ADD.04 ADD.05 ADD.06 ADD.07 ADD.08
100% 100% 80% 100% 100%
100% 100% 100% 100%
85%
80%
67%
ADD.04 ADD.05 ADD.06 ADD.07 ADD.08 ADD.09 Total

ADD.09 Total
67% 85%
85%
Total
CODE
Care Delivery Related Safety

1 NSR.01
2 NSR.02
3 NSR.03
4 NSR.04
5 NSR.05
6 NSR.06
7 NSR.07
8 NSR.08
9 NSR.09
10 NSR.10
11 NSR.11
Medication Management and Safety
12 NSR.12
13 NSR.13
14 NSR.14
15 NSR.15
16 NSR.16
Surgery and Invasive Procedure Safety
9 NSR.17
10 NSR.18
11 NSR.19
12 NSR.20
Environment and Facility Safety
14 NSR.21
15 NSR.22
16 NSR.23
17 NSR.24
18 NSR.25
19 NSR.26
20 NSR.27
21 NSR.28
NSR
120%
100% 100% 100% 100% 100% 100% 1

100%
80%
80% 75%
60%
58%
50% 50% 50% 50% 50%
40%
20%
0% NSR.01 NSR.02 NSR.03 NSR.04 NSR.05 NSR.06 NSR.07 NSR.08 NSR.09 NSR.10 NSR.11 NSR.12 NSR.
NSR.27 NSR.28
CODE IN THIS
NSR KEYWORDS BOOK SCORING
ery Related Safety

Patient identification ACT.03 50%
Verbal and telephone orders ICD.18 100%
Hand hygiene IPC.05 80%
Catheter and tube misconnections ICD.35 100%
Fall screening and prevention ICD.11 58%
Pressure Ulcer Prevention ICD.12 50%
Handover Communication ACT.09 50%
Critical Alarms ICD.34 75%
Recognition of and response to clinical deterioration ICD.37 100%
Venous Thromboembolism Reduction ICD.13 50%
Critical Results ICD.30 50%
Management and Safety
Abbreviations IMT 04 100%
Medication Reconciliation MMS.10 100%
Medication storage and labelling MMS.04 100%
High alert medications and concentrated electrolytes MMS.06 100%
Look-Alike and Sound-Alike Medication MMS.07 100%
Invasive Procedure Safety
Surgical Site Marking SAS.05 50%
Preoperative Checklist SAS.06 50%
Time-out SAS.07 100%
Instrument Retention Prevention SAS.09 50%
nt and Facility Safety
Fire Safety EFS.03 100%
Fire Drill EFS.05 100%
Hazardous Material Safety EFS.06 100%
Safety Management Plan EFS.07 100%
Radiation Safety Program DAS.09 42%
Laboratory Safety Program DAS.24 83%
Medical Equipment Safety EFS.10 92%
Utilities Safety EFS.11 100%
NSR
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
75%
% 50% 50% 50% 50% 50% 50%

42%
5 NSR.06 NSR.07 NSR.08 NSR.09 NSR.10 NSR.11 NSR.12 NSR.13 NSR.14 NSR.15 NSR.16 NSR.17 NSR.18 NSR.19 NSR.20 NSR.21 NSR.22
100% 100% 100% 100%
92%
83%
42%
19 NSR.20 NSR.21 NSR.22 NSR.23 NSR.24 NSR.25 NSR.26

APC PCC ACT ICD DAS
77% 67% 66% 73% 62%

120%
100%
80%
60% 77% 67% 73%

66% 62%
40%
20%
0%
APC PCC ACT ICD DAS
Overall Dash Board
SAS MMS EFS IPC OGM
64% 97% 93% 69% 71%
97%
93%
73% 69% 71%

64% 64
62%
ICD DAS SAS MMS EFS IPC OGM

CAI WFM IMT QPI ADD
64% 70% 68% 71% 85%
85%
% 71% 71%
64% 70% 68%
PC OGM CAI WFM IMT QPI ADD

TOTAL
73%
85%
ADD

Final of Hospital Accreditation SAT

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Final of Hospital Accreditation SAT

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‫االدارة العامة للدعم الفني للمنشآت الصحية‬

‫أداة التقييم الذاتي لمعايير اعتماد المستشفيات‬

‫الجهة التابعة لها‬

‫تاريخ عمل التقييم‬

‫اسم مدير المنشأة‬

‫الجهة التابعة لها‬

‫تاريخ عمل التقييم‬

‫اسم مدير المنشأة‬

The hospital sustains, ensures and monitors compliance wi

The hospital establishes a process of frequent assessment of complianc

The hospital demonstrates using approved monitoring tools to measur

When a gap is identified, the hospital takes all necessary measures to i

The hospital reports to GAHAR any challenges that affect compliance

The hospital ensures safe medical provision through complying w

The hospital has an approved process for registering all members of th

The hospital assigns a taskforce to ensure complete registration and Id

The process covers all full-time, part-time, visiting, or other types of co

The hospital provides GAHAR with accurate and complete infor

The hospital reports accurate and complete information to GAHAR du

The hospital reports accurate and complete information to GAHAR du

The hospital provides GAHAR access to evaluation results and reports

The hospital uses the accreditation process to improve safety an

The hospital permits GAHAR to perform on-site evaluations of standa

The hospital informs staff and patients on mechanisms to report safety

The hospital maintains professional standards during the surve

During surveys, the hospital reports any conflict of interest to GAHAR

During surveys, the hospital maintains professional standards on deali

score comments / findings

and accreditation process.

ment tool for GAHAR hospital Accreditation standards Edition

atus of preparedness ‫التقييم‬

MET ‫مطبق بشكل كامل‬

PARTIAL MET ‫مطبق بشكل جزئي‬

NOT MET ‫غير مطبق‬

40% Not Met

‫مستند للتقيييم ومستند لنظام‬

‫ الخطة‬- ‫التقارير المستلمة‬

‫اداة التقييم المستخدمة‬

‫التقارير المرسلة من المستشفي‬

‫أمر التكليف ‪ -‬االطار الزمني‬

‫طريقة التسجيل لجميع العاملين‬

‫‪63%‬‬ ‫‪PARTIAL MET‬‬

‫التقارير بمعلومات صحيحة‬

‫التقارير عن الفترة بين التسجيل و‬

‫التقارير عن التعديالت االنشائية‬

‫التقارير التقييم الخارجية‬

Total chapter Score

‫تطبيق المالحظات الواردة‬

‫التقييم الفعلي للمنشأة عن‬

‫وجود تضارب في المصالح‬

‫وجود تعامل غير مهني‬

‫وجود مخاطر فيما يخص‬

‫نشر اخبار او صور بدون‬

corrective action responsible person

Target Date Status

APC.03 APC.04 APC.05 total

. The hospital advertisements are clear and comply with applicabl

The hospital has an approved policy guiding the process of providin

Patients and their families are informed of expected costs in a mann

.Patient-centeredculture is developed by interdisciplinary collaboration

The interdisciplinary committee has approved terms of reference.

The committee meets at predefined intervals multiple times a year.

The committee meetings are recorded.