‫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

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

The hospital has an approved policy that addresses all elements m

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

The hospital has an approved policy that addresses all elements m

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

The hospital has an approved policy that describes all elements me
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

The hospital has an approved policy that addresses all elements m

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

The hospital has an approved policy that describes all elements me

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

The hospital has an approved policy that describes all elements me

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.

The hospital has an approved policy that describes all elements me

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

status of preparedness

MET

PARTIAL MET

NOT MET

NOT Applicable

score comments / findings

lations, and clinical guideline /protocol.

 1

are assigned according to applicable laws and

1

1
1

1
0

0
0

0
1

0
 0

N/A

N/A

N/A
 N/A

N/A

N/A

licable guidelines.

1
1

0
1

1
‫‪1‬‬

‫‪1‬‬

‫‪1‬‬

‫ينقص بروتوكول التعاون لتحويل عينات الباثولوجي‬

‫‪1‬‬

‫‪1‬‬

‫ينقص تقييم مستشفي النصر‬

 1

0
1

1
1

1
2

0
0

1
‫‪1‬‬

‫‪1‬‬

‫‪1‬‬

‫‪2‬‬

‫‪1‬‬

‫‪1‬‬
‫‪ gym‬اليتم عمل معايره لجهاز‬
1

0
 ‫‪0‬‬

‫‪0‬‬

‫‪1‬‬
‫يوجد اتفتق تعاون للمعايره الخارجيه مع المجمع ولكنه غير مستكمل‬

‫‪and release of verified laboratory tests.‬‬

‫‪1‬‬

‫‪0‬‬

‫‪1‬‬

‫‪1‬‬
1

0
0

1
2

0
 0

lations and clinical guideline /protocol.

2
 1

N/A

N/A

N/A

N/A

N/A

y.
 1

quirements.

1
2

1
1

1
1

1
1

1
1

0
 General Administration Of Technical Support F

assessment tool for GAHAR hospital Accreditation standards Edi

scoring s

atus of preparedness ‫التقييم‬

MET ‫مطبق بشكل كامل‬

PARTIAL MET ‫مطبق بشكل جزئي‬

NOT MET ‫غير مطبق‬

NOT Applicable ‫غير قابل للتطبيق‬

Total
Total score
percentage%

33% Not Met

38% Not Met
30% Not Met
25% Not Met
25% Not Met
25% Not Met
8% Not Met

0% Not Met
N/A N/A
67% PARTIAL MET
17% Not Met
58% PARTIAL MET
50% PARTIAL MET
42% Not Met
58% PARTIAL MET
58% PARTIAL MET
10% Not Met
50% PARTIAL MET
58% PARTIAL MET
17% Not Met
40% Not Met
25% Not Met
50% PARTIAL MET
75% PARTIAL MET

38% Not Met

63% PARTIAL MET
N/A N/A

75% PARTIAL MET

83% MET
50% PARTIAL MET
50% PARTIAL MET
58% PARTIAL MET
50% PARTIAL MET
Total chapter Score

43%
nistration Of Technical Support For Healthcare Facilities

ital Accreditation standards Edition

scoring system

‫التقييم‬

‫مطبق بشكل كامل‬

‫مطبق بشكل جزئي‬

‫غير مطبق‬

‫غير قابل للتطبيق‬

user guide

Documents intertview
 ‫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

‫ملف العاملين‬

‫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

‫ملف المريض‬

‫مقدمي الخدمه‬
 ‫سياسه‬

‫ملف العاملين‬ ‫مقدمي الخدمه‬

‫ملف المريض ‪ -‬سجل النتائج‬

‫تقاريرجمع وتحليل البيانات‬ ‫االداره ‪ -‬مسئول القسم‬

‫مشاريع التحسين‬

‫تقارير‪ -‬االخطار‬
 ‫السياسة‬

‫مقدمي الخدمه‬

‫تقارير ‪ -‬ملف المريض‬

‫‪-‬تقارير ‪ -‬ملف المريض‬ ‫مقدمي الخدمه‬

‫البرنامج‬

‫تقييم المخاطر‬

‫العاملين بالقسم‬
‫جرعات االشعة المستخدمة‬
‫للمرضى‬

‫ملف المريض‬

‫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
 ‫التقارير‬

‫سياسه‬

‫وثائق التدريب‬ ‫مقدمي الخدمه‬

‫قائمه بالمسموح لهم‬

 ‫الطاقم الطبي‬

‫تقارير ادارة االستخدام‬ ‫مدير المعمل‬

‫سياسه‬

‫دليل خدمات المعمل‬

‫مقدمي الخدمه‬
‫اإلجراءات‬

‫مقدمي الخدمه‬
‫سجالت المعمل‬

‫التقارير‬

‫سياسه‬

‫تقارير التحقق‬
 ‫مقدمي الخدمة‬

‫سجل ‪ -‬التقارير‬

‫سجل ‪ -‬التقارير‬

‫االجراءات المكتوبة لطرق التحليل‬

‫مدير المعمل‬

‫االجراءات‬
 ‫وثائق التدريب‬ ‫مقدمي الخدمه‬

‫تقارير المراجعه‬ ‫مدير المعمل ‪ -‬المسئول‬

‫البرنامج‬

‫ملف العاملين ‪ -‬التدريب‬ ‫مقدمي الخدمة‬

‫تقارير‪ -‬سجل التوثيق‬

‫تقارير الجودة واالداء‬ ‫المسئول‬

‫الخطه التصحيحه‬

‫البرنامج‬

‫تقارير‬ ‫مقدمي الخدمه‬

‫تقارير‪ -‬السجالت‬
 ‫تقارير‬

‫تقارير‪ -‬السجالت‬

‫تقارير‬ ‫مدير المعمل‬

‫سياسه‬

‫قائمة المصرح لهم مراجعة واعتماد‬

‫النتائج‬
 ‫مقدمي الخدمه‬

‫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 ‪-‬‬

‫ملف الموظف‬

‫السياسة‪-‬تقارير‬

‫التوثيق والتقارير‬ ‫الشخص المكلف‬

‫ادليل جودة‬

‫مقدمي الخدمه‬
‫المؤهالت العلميه ‪ -‬الخبرات ‪-‬‬ ‫مسئول بنك الدم‬
‫ملف الموظف‬

‫سياسه‬

‫مقدمي الخدمه‬

‫المتبرعين ‪ -‬مقدم الخدمة‬

‫تقارير والتسجيل‬
‫سياسه‬

‫مقدمي الخدمه‬

‫السياسة‬

‫مقدمي الخدمه‬
 ‫فني الصيانه‪-‬مقدمي الخدمة‬

‫سياسه‬

‫االتفاقات‬

‫‪-‬محددات وضوابط‬ ‫االداره‬

‫معايير التقييم‬

‫مقدمي الخدمه‬

‫تقارير‬

‫سياسه‬

‫مقدمي الخدمه‬
 ‫ملف المريض‬

‫العاملون‬

‫طلب نقل الدم ‪ -‬ملف المريض‪-‬‬

‫قائمه التحقق‬

‫سياسه‬

‫مقدمي الخدمه‬
‫تقارير التطابق ‪ -‬ملف المريض‬

‫مقدمي الخدمه‬

‫ملف المريض ‪ -‬التقارير‬ ‫مقدمي الخدمه‬

‫سياسه‬
 ‫مقدمي الخدمه‬

‫مقدمي الخدمه‬

‫ملف المريض‬

‫مقدمي الخدمه‬
are Facilities

score percentage%

2 > = 80%

1 <80% >=50%

0 <50%

N/A N/A

de Ac

observation corrective action

 ‫الخدمات المقدمة داخليا او بالتعاقد‬
‫مطابقة‬

‫الخدمات تقدم في جميع االوقات واالماكن‬

‫بنفس الجودة‬

‫تطبيق االجراء‬
‫متوفر ومتاح‬
 ‫تطبيق االجراء‬

‫تطبيق االجراء وتوفير المعلومات‬

‫لجميع المستخدمين‬

‫تطبيق االجراء‬
 ‫االجراءات‬

‫تطبيق االجراء‬
 ‫تطبيق االجراء‬

‫تطبيق االجراء‬

‫تطبيق االجراء‬

‫تطبيق االجراءات‬

‫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
 ‫تطبيق االجراء طبقا للسياسة‬

‫نقل العينات والتعامل معها طبقا‬

‫للسياسة‬

‫التخلص من العينات طبقا للسياسة‬

‫تطبيق االجراء‬

‫شروط التخزين‬

‫تطبيق االجراء‬
‫تطبيق االجراءات طبقا للسياسة‬

‫تطبيق االجراء‬
‫تطبيق االجراءات طبقا للسياسة‬

‫تطبيق االجراءات طبقا للبرنامج‬

‫تطبيق الخطه التصحيحه‬
 ‫أماكن تخزين السجالت‬

‫تطبيق االجراء طبقا للسياسة‬

‫تطبيق االجراء طبقا للسياسة‬

‫تطبيق االجراء طبقا للسياسة‬
‫توافر كفاءة حقائب االنسكابات و غاسله‬
‫االعين و الدش‬

‫تطبيق احتياطات السالمه‬

‫تطبيق االجراءات‬
 ‫تطبيق االجراء‬

‫تطبيق االجراءات‬

‫توافر مكان مناسب ‪ -‬توافر‬

‫المستلزمات و االدوات‬
‫تطبيق االجراء طبقا للسياسة‬
‫تطبيق االجراء طبقا للسياسة‬

‫تطبيق االجراء طبقا للسياسة‬

‫تميز اكياس الدم و مشتقاتة‬

‫النظام المتبع‬
 ‫تخزين الدم و مشتقاتة‬

‫االنذارات الحرجة ‪ -‬مصدر كهرباء‬

‫ثانوي‬

‫تطبيق االجراء طبقا للسياسة‬

‫تطبيق االجراء طبقا للسياسة‬

‫تطبيق االجراء‬
 ‫تطبيق االجراء‬

‫تطبيق االجراء طبقا للسياسة‬

‫تطبيق االجراء طبقا للسياسة‬

‫تطبيق االجراء طبقا للسياسة‬

‫تطبيق السياسه‬
 Action plan

responsible person Target Date Status

 ‫مكتمل‬

‫غير مكتمل‬

‫مكتمل‬

‫مكتمل‬

‫مكتمل‬

‫غير مكتمل‬
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‫غير مكتمل‬

‫غير مكتمل‬

‫غير مكتمل‬

‫مكتمل‬

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‫غير مكتمل‬

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Data DAS.01 DAS.02 DAS.03

33% 38% 30%

DAS.04 DAS.05 DAS.06 DAS.07 DAS.08 DAS.09

25% 25% 25% 8% 0% N/A

 ‫لذاتي لمعايير االعتماد للمستشفيات‬
Self assessment tool for GAHAR hospital Accredi
scoring system
DAS.10 DAS.11 DAS.12 DAS.13 DAS.14 DAS.15

67% 17% 58% #REF! 50% 58%

‫اأداة التقييم الذاتي لمعايير االعتماد للم‬
HAR hospital Accreditation standards Edition 2021
scoring system
DAS.16 DAS.17 DAS.18 DAS.19 DAS.20 DAS.21

58% 10% 50% 58% 17% 40%

DAS.22 DAS.23 DAS.24 DAS.25 DAS.26 DAS.27 DAS.28

25% 50% 75% 38% 63% N/A 75%

DAS.29 DAS.30 DAS.31 DAS.32 DAS.33 Total

83% 50% 50% 58% 50% #REF!