JCI Hand Book Saqr Hospital

Saqr Hospital
JCI Hand Book For Nurses

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

During the hospital survey
 What must I do if a surveyor asks me a question?

Keep calm- d don't panic
 I f you don't understand the question,

Ask them to explain it

Never argue with them

Be Honest!
 If you don't know an answer

Tell them where you can find the answer.

If you don't know that, tell them I will refer and tell you
 Only tell them what they want to know!
 Don't explain, or give more information than is required
 Don't use opportunity to complain about the Hospital.

1. What is JCIA? How is it good for us?
JCIA stands for Joint Commission International Accreditation. It is a US based not-for-profit
accreditation body which sets and addresses standards for the healthcare provider's level of
performance in key functional areas, such as patient rights, patient treatment and infection control.

2. What is the Value of JCI Accreditation?
JCI is the world's largest health care accreditor. JCI's Gold Seal of Approval is a widely recognized
benchmark representing
the most comprehensive evaluation process in the health care industry.
JCI standards are designed to do the following:
o Ensure a safe environment that reduces risk for care recipients and caregivers
o Offer quantifiable benchmarks for quality and patient safety
o Stimulate and demonstrate continuous, sustained improvement through a reliable process
o Improve outcomes and patient experience
o Enhance efficiency

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

o Reduce costs through standardized care
3. What is JCI standards?

The accreditation standards are listed in the seven editions of Joint Commission International
Accreditation Standards for Hospital and are functionally divided into 7 Patient Centered Chapters, 6
Health Care Organization Management chapters and 2 Academic Medical Center Hospital chapters.
Each standard contains the standard, intent (description of the standard) and
measurable element JCI Standards: JCI Standards.
Patient-Centered Standards
1. International Patient Safety Goals (IPSG
2. Access to Care and Continuity of Care (ACC)
3. Patient-Centered Care (PCC)
4. Assessment of Patients (AOP)
5. Care of Patients (COP)
6. Anesthesia and Surgical Care (ASC)
7. Medication Management and Use (MMU)
Health Care Organization Management Standards
Quality Improvement and Patient Safety (QPS)
Prevention and Control of Infections (PCI)
Governance, Leadership, and Direction (GLD)
Facility Management and Safety (FMS)
Staff Qualifications and Education (SQE)
Management of Information (MOI)
Academic Medical Center Hospital Standards
Medical Professional Education (MPE)
Human Subjects Research Programs (HRP)
4. What is the International Patient Safety Goals. (IPSG)
Identify the patient correctly
Improve Effective Communication
Improve the safety of high alert medications
Ensure correct site, correct procedure, correct patient surgery
Reduce the Risk of Health Care Associated Infections.
Reduce the Risk of Patient Harm Resulting from Falls

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

5. Could you tell me when you will identify the patient during your shift. b. Can you explain how do
you identify a comatose patient when you want to give medication? (Identifying patient correctly
#2)
1. Performing a procedure or treatment.
2. Administering medications.
3. Transfusion of blood or blood products.
4. Taking blood and other specimens for clinical testing.
5. Before any diagnostic procedure.

How we can identify Unconscious, comatose, not alert,
dementia, psychiatric with lack of insight patients:
The patient can be identified in the following manner:
- By accompanying person and/or family members.
- By demographic data sent with the patient from sending facility.
- By police and/or investigating officer. (If valid information is available)
- If all the above not available, the patient will be identified by assigning:
Unknown Male or Unknown Female followed by alpha letter sequentially from A – Z.

• You Identified that patient identity is not matching with the ID band. What steps you will take
Do you have any policy related to it
If the patient is incorrectly identified, the identification band with incorrect patient’s details
should be removed and a new identification band with correct patient’s details should be
provided through the registration clerk. OVR should be completed and submitted as per OVR
policy code (RAKHN/Admin/022). This step is considered as a main method to monitor the
implementation this policy.

6. How you identify your unknown patient?
Unknown Male or Unknown Female followed by alpha letter sequentially from A – Z.

7. Can you explain how you would take a verbal or telephonic order from a physician? Please show
me your policy on Verbal/Telephonic orders? (Telephonic / Verbal Orders#1)

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

1. Communicate a complete telephone order or prescribed medication with a full consideration
to patients two identifiers (patient’s full name and medical record number).

2. Place the order in Wareed system as per the documentation requirements of the system
whenever possible.

3. Read the telephone or verbal order back as appropriate to this policy.
4. Counter sign the telephone and verbal order in the system after the emergency situation ends

or within 24hours from the time of initiating the order make sure the order is correct and
complete.
5. Report any variation from the policy by using the OVR form.
8. Can you tell me what all are the critical point you need to endorse when you do patient handover
to the technician that you sent to the radiology and show me where you have to documented it?
Hand-off communication policy #3
High fall risk status, with allergies, Critical results, took control medication that will lead to fall,

documenting in hand off comments

9. Can you show me an example where you would document the notification of a critical result in
the medical record?

In provider notification of wareed system.

10. Is nurse competent for Point of care testing? Who train them? Where are u documenting the
critical results? Are you maintain log book for point of care critical results?
Pure health company in work shop done in our hospital, in provider notification, In Process.

11. Could you show me where you are keeping Dextrose 25% in Water in your department. Why you
are not keeping dextrose 25% in your department
Only we have in Crash cart, because it is HAM fluids

12. Could you tell me where you are keeping look like sound like medication as per the policy?
All LASA medications should be labeled with a yellow label of “LOOK ALIKE SOUND ALIKE”, stored
separately in a secure place.

13. What label you are using for Adenosine, Soluble insulin, VALsartan (tablet), Potassium chloride

Red label (HAM)

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Saqr Hospital

14. How do you reduce the risk for patients administering high alert medications? Policy #4

By adhering to Improving the Safety of High Alert Medication Policy
High Alert Medication: are those medications involved in a high percentage of
errors and/or sentinel events, medications that carry a higher level of risk for
adverse outcomes
Label HAM medication by using red label of “High Alert, Double Check”, highly
concentrated electrolytes shall be labeled with brown label as “highly concentrated

electrolyte

15. Do you have any Surgical/ Procedure Safety Practice in your hospital, are you
following any checklist, when they are doing pre-op checklist and what are the
content in pre-op checklist?

Surgical/ Procedure Safety Practice
A. all situations where the informed consent of a procedure is required unless if
this procedure is not mentioned in the attached list
B. Surgery name, Pt safety preparation, patient rights, site marking, skin condition,
isolation.
Surgical safety check list is the checklist we are following to make sure Surgical/
Procedure Safety Practice

16. When to conduct a preoperative verification check?
Before transferring the patient from ward to OT the preoperative verification to be
completed.

17. What is time out process & by whom is it called?
Time out is called out by the circulating nurse in the presence of entire team
(Inclusive of Surgeon and anesthetist (in OT)) prior to the incision. At the time of
time out the nurse verifies the patient Two Patient Identifier (Patient's full name,
CMRN)
Correct side/site, level including marking, if applicable
Correct procedure
Correct patient position
Procedure written in the consent form

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Saqr Hospital

Any Investigations results
Special equipment/implants/requirements, if applicable.
Access to the patient images and other documents.
18. Ask the nurse when to do the sign in/Time out /Sign out and B. where to
document?
a. When performing procedures that need Surgical/ Procedure Safety Checklist
All procedures under General/ Regional anesthesia
All procedures done under sedation
All minor surgeries done under injectable local anesthesia excluding closure of
superficial skin and subcutaneous cut wounds done in ED
All plastic surgeries done under local anesthesia
All radiological studies requiring contrast media
Bronchoscopy (diagnostic / therapeutic)
Central venous catheterization (permanent / temporary)
Endoscopy and related procedures (diagnostic / therapeutic)
Elective Cardioversion
Insertion of inter-costal drainage tube
Internal abscess including dental that require incision and drainage
Intermittent / continuous renal replacement therapy
Intra-articular injection
Intra-vertebral injection of medication
Lumbar puncture / related therapeutic / diagnostic procedures
Lithotripsy
Cystoscopy (therapeutic/Diagnostic)
Phototherapy
Skeletal traction
Thrombolytic therapy
Tooth extraction
Ventricular tapping
b. In surgical safety checklist form in wareed system

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

19. What is the requirement for site marking in your hospital? Please show me the
policy?

The marking shall be performed by the person performing the procedure and the
patient/next of kin shall be involved in the marking process by asking the patient/ next
of kin directly as appropriate
2.5. Appropriate ink shall be used, blue color (indwell) to mark a site of
operation/procedure.
In case the patient/ next of kin refuses the marking after well-explained process, the
mark should be placed on anatomical picture of the human body as per the EMR
(Wareed) (Attachment 1).
2.6. Privileged physician shall mark the site of operation/procedure for patients with
bandage or dressing covering the area of procedure on the same site of the
operation/procedure if the space is available on the same skin. If the limb was fully
covered with dressing, the mark should be placed on an anatomical picture of the
human body
20. How you are maintaining Equipment and machine are safe to use. If PPM expire,

what is your role?
By Checking PPM, not to use the machine and to label it as out of service and to notify
the biomedical then report it by using OVR

21. Where you can access the MSDS sheets and what is the purpose of MSDS sheets?
Share folder, Hazards material inventory
22. Tell me what is your role in maintaining Crash cart on your department?

1. Maintaining a fully stocked crash cart at all times.
2. Restocking crash cart to the unit within 60 minutes after code termination and

notifying concerned department.
3. Verifying contents of cart in as per the Inventory list.
4. Ensuring the Co‐signing of the crash cart log by pharmacist for drugs and

expiration date.
5. Verifying the presence and expiration date of all items on carts.

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

23. Ask the staff about different types of code and how they will activate. Ask what
PASS stands for. Ask what RACE stand for. Do you have a competency on this?
How often you will do this competency and what Resource you will use to
complete this competency

Emergency Type ‫اﻟﺮﻣﺰ‬Code ‫ﻟﺔ اﻟﻄﻮارئ‬
Fire Code Red ‫ﺮﻣﺰ اﻷﺣﻤﺮ‬
Emergency (external emergencies,
mass casualty…) Code Orange �‫ﻣﺰ اﻟ ب�ﺗﻘﺎ ي‬
Absconded Patient
Chemical Spill Code Yellow ‫ﺮﻣﺰ اﻷﺻﻔﺮ‬
Evacuation Code Brown ‫اﻟﺮﻣﺰ اﻟﺒ ن يي‬
Bomb Threat Code Green �‫ﺮﻣﺰ اﻷﺧ ض‬
Physical Assault/ Aggressive person Code Black ‫ﺮﻣﺰ اﻷﺳﻮد‬
Child Abduction Code White ‫ﺮﻣﺰ اﻷﺑ�ﺾ‬
Utility Failure Code Pink ‫ﺮﻣﺰ اﻟﺰﻫﺮي‬
Code Grey ‫ﺮﻣﺰ اﻟﺮﻣﺎدي‬

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

24. Who all are the members of your code blue team?

-MRP/Designee (communicate with Family).
-Anesthetist/Intensivist on duty (Airway Management/Team Leader).
-ICU Nurse (crash cart management).
-ER nurse (medication and IV access)
-Assigned Nurse (initiate BLS).
-Nursing supervisor/designee (completing the code blue form)
25. Ask the staff member what is the procedure when there is an unplanned downtime of the

Wareed? Do you have a policy on it?
RAKHN shall ensure that the manual hard copies of patient’s medical record are available as a
standby to respond to health information system downtime time status.
Electronic Downtime Medical Record Management
When unplanned downtime occurs, staff need to be notified immediately upon discovery of the event.
The manner in which information is communicated to staff will depend on the system that is down. Such
as:

• If the hospital’s network goes down, communication to staff via telephone may be required.
• Multiple communication strategies should be developed in order to address the different

systems that may be affected.
• It may be necessary to develop strategies for external communication. Such as: if the hospital

has an interfacing application with outside/contracted laboratory or radiology services and it
becomes unavailable due to downtime, there needs to be a process for obtaining the results
during downtime and a plan to have results reported back via the interface when the downtime
is over.
26. You have doctors’ privilege to do the particular procedure?
Yes, in share folder

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

27. If shortage of staff in your department how you are managing. How you know that floating staff is
competent?

By following floating staff policy, that is stated
To ensure the availability of the number and qualifications of different healthcare providers
throughout the time of RAKHN operations
The float assignment shall be compatible with professional skills and experience of the float
nurse. This is safe effective nursing practice.
28. who is required to be restraint, and restraint order valid up to how many hours for adult or

pediatric pts? When u should release the restraint?

Use of restraint devices shall be limited to those situations where it is clearly necessary for the purpose
of preventing harm by a patient to him/herself or others

Time-limited physicians order, 24 hrs for adult and 12hrs for Pediatric under age 9 yrs
Release for 15 mins every 4hours
29. How many of your patient is on moderate to high-risk fall. Show me one of the fall risk

assessments. Show/tell me the plan of care for this patient. How long the nurse should stay away
from patient at high risk of fall to prevent fall?
1- staff should give number
2- from ongoing
3- the plan of care should include the intervention

25. When you enter the patient room for giving medication, you saw the patient lying on the floor.

When you asked, he told fall from the bed, what action you will take as per the policy.
If a fall occurs the following must be completed:

• Assess for level of consciousness, any injuries and changes in range of motion and provide
appropriate first aid.

• Notify Doctor.
• Note the date, time and location of the fall.
• Notify family as appropriate.
• Continue to monitor patient as condition warrants
• Document circumstances in nursing record or other health care provider record.
• Complete OVR and forward it to the Quality department
• Assess physiological and environmental factors that contribute to the fall.

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Saqr Hospital

• Assess interventions and modify plan of care as needed.
Important point:
The assigned nurse shall perform fall risk assessment for the patient using the following fall risk
assessment tools in an inpatients and ambulatory settings as defined in the health information
system:
1- Humpty Dumpty tool for pediatric patients below 13 years
2- Morse Fall Risk tool for adult patients 13 years and above
3- Obstetric Fall Risk Assessment tool (OFRA) (Pregnant up to 6 weeks postnatal women)
4- Wilson Sims Fall Risk Assessment Tool (WSFRAT)
All patients will be reassessed for risk of falls at the following times:
1- Every 24 hours
2- When there is a change in their clinical condition, e.g., following anesthesia, new order of
medication that may increase the level of risk like sedatives or alike.
3- Patients, particularly elderly, taking sedatives, analgesia or medications that may contribute to a
fall.
4- Transfer from one inpatient unit to another
5- Following a fall
26. Discharge planning process as per the policy:
Discharge planning will be initiated at the time of admission and will be reassessed continuously
throughout the patient’s hospital stay. The patient/family will be involved in this process as appropriate
1- Healthcare providers in Hospitals shall ensure that patients and family education and instructions are
related to the patients on going needs for care and service
1- The education and instruction shall include the followings:

• Review all medications to be taken at home
• Safe and effective use of all medications
• Pain management as needed
• RAKHN shall insure that patients transporting vehicles (owned by the hospital /

contracted vehicles) meets relevant laws and regulations related to their operations,
conditions and maintenance.
• Follow up appointment
• When they need to come to hospital if there is side effect
27. Did you discharge a patient yesterday or today? Show me the discharge education?

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Saqr Hospital

(Must include follow up appointment, when and how to obtain urgent care)
1- staff should show from EMR

28. What do you do if a patient wants to leave against medical advice? Where i can find the policy?
NORMAL LEAVE AGAINST MEDICAL ADVICE:

1. Inform Treating / Attending Physician about the patient requests for LAMA.
2. The patient should be assessed to identify the reasons for requesting the leave against medical

advice.
3. As RAKHN recommendation, Explain in an understandable language:

.1. The medical risks of inadequate treatment (LAMA).
.2. Discuss the reasons of LAMA and other alternatives.
.3. Involve the patient’s family, friend to help in convincing the patient to stay and complete the
treatment / diagnostic procedures.
.4. Patients are encouraged to return at any time to the hospital.
.5. Inform patient’s physician if the number is available to ensure continuity of care.
4- Document in LAMA form, components include the following as appropriate:
.1. Two Patient Identifier (Patient’s name, MRN)
.2. Patient (or Legal guardian) Signature.
.3. Physician Signature.
.4. LAMA form should be attached in the patient’s Medical record.
5- A Discharge Summary must be developed for the patient, and the patient must receive a copy of the
discharge summary.
6- A complete documentation in patient’s EMR that clarify the reasons of patient’s refusal to stay in the
RAKHN
7- In case the patient refuses to sign LAMA, Form or leaves without informing the healthcare providers,
an O.V.R should be reported in 24 hours
policy will find in share folder, quality, policy and procedure 2022 (leave against medical advice)
29. General measures when an inpatient leave without informing Healthcare Providers or failed to
return to the ward at the agreed time or miss his planned treatment
1-Locate the patient by initially searching the immediate area, then by calling the patient’s contact
numbers, or other point of contact
2-Inform Security Staff, Nurse Supervisor.

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Saqr Hospital

3-Organize a search Team in the facility with the assistance of the security, and contact relevant
personal which may include On-Call Doctor.
4-If the Patient leaves without informing HealthCare Provider is confused, police case, or airborne
infectious case:
.1 Alert other staff and security
.2 Start the search immediately
.3 Inform concern staff, On-Call doctor, MRP, Nursing supervisor and infection control
supervisor for cases of airborne infectious cases.
5-If the patient was not found within 2 hours inform hospital administration, patient’s family, and the
police (if the patient is a police case),
6-If Patients from outpatient department did not respond after 3 calls before being seen by physician,
document in the patient’s EMR (NOT FOUND)
7-Complete an O.V.R within 24 hours
IMPORTANT POINT:

• All patients leaving against medical advice without informing healthcare providers or refuse to
sign LAMA Form within RAKHN should be reported on the approved Occurrence Variance Report
(OVR).

• A complete discharge procedure shall follow patient’s signing LAMA Form, and patient should
receive a full discharge summary.

• Patients who leave the hospital during their waiting time - after triaging them and before
examination - are not considered as patients who leave against medical advice and an O.V.R.
form shall be completed.

29. How you are informing the patient and family about their rights?
staff needs to locate and show the handout that is provided for patient and displayed on unit.
(Patient right should be given in emergency and should be present in-patient room)

30. How do you facilitate consent if the patient does not speak the language of the physician or
yourself? For how long is informed consent valid in your organization
1- policy name patient involving policy contain translator staff can explain to patient
2- informed consent valid for 90 days
3- and if doctor mention in the consent specific time like during hospitalization (like blood
transfusion)

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Saqr Hospital

31. Do you allow patient to go out, out on pass consent. What is the duration and how you are
document in Cerner?
Out on Pass For inpatients who requests out on pass, healthcare provider shall follow the below:

1- INFORMED PHYSION AND APPROVAL SHALL BE TAKEN AND DOCUMENT IN THE SYSTEM
2- INFORMED THE PATIENT THE TIME NEED TO COME AND NOT EXCEED 8 HR
3- If the patient does not come back at the specific time, he will be called two times by the

concerned staff within the next 24 hours. If the patient does not respond, then the hospital staff
will treat the case as Leaving Against Medical Advice (LAMA)
Inform the MRP
32. What all nursing assessment and reassessment are doing for your patients and how often you will
do it. show me your policy?
Page 8, 9, 10 in policy
33. Can you show me when you have assessed one of your patients’ pains during your shift? How
often you are re-assessing the patient:
• Staff will open the EMR and show the pain assessment
• The patient with or without pain will be re-assessed every 12 hrs. for pain and whenever the

patient complains of pain or patient’s condition changes.
All staff shall assess pain by using appropriate pain scale in EMR:
.1. Numerical rating scale (Adult & Pediatrics)
2. The Wong-baker FACES pain scale (WBF): for children between 7-13 years, and all patients in recovery
room (to be documented in EMR under numeric).

3. FLACC scale for children between 2 months to < 7 years.

.4. NIPS for Pre- and full-term neonates. (Applicable to Abdullah Bin Omran hospital)
.5. FLACC scale for children between 7-13 years old with intellectual disabilities (mentally retarded) or
with cerebral palsy.
6. Behavioral pain scale – ventilated, unconscious Patient.

Patients identified with pain will be reassessed for pain after intervention as following:
.1. Oral analgesia: Maximum 1 hour after administration
2. Parenteral analgesia: Maximum 30 minutes after administration.
3. Cardiac pain should be re-assessed every five minutes whenever the treatment prescribed
warrants the use of nitrates or intravenous medication to manage pain.

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Saqr Hospital

4. Suppository analgesics: after 30 minutes Future Reassessments will depend on results from the
intervention and will follow the above timeframe.
Post-operative patients- ABO hospital/ IBHOH in Post-Anesthesia Care (PACU) - assessment and
reassessment of pain will be documented in the respective section in the patient’s EMR.

34. Do you have any high-risk patients/vulnerable patients in your unit? Can you show me the policy
guiding care of these patients (staff need to refer to high risk policy)?
Patients in the following groups are considered to beat greatest risk:
.1. Pediatric patients (Less than 13years of age)
.2. Mentally challenged patients.
.3. Physically challenged patients.
.4. Comatose patients.
.5. Disabled including patients at risk of abuse and neglect.
.6. Elderly patients (More than 65 yrs. old)
.7. Immunosuppressed
Policy in share folder, quality, policies 2022, Saqr policy and Procedure
Title: Care of Vulnerable patients
35. What do you do if a patient deteriorates, Is there a system in your hospital? Do you have any
policy based on that:
It must be emphasized that the Early Warning Score system may not trigger a score in some patients
who are or becoming acutely unwell. Therefore, healthcare practitioners must remember that this
tool alone will not always highlight when a patient is deteriorating and should be used to guide best
practice. Healthcare practitioners must use their clinical judgment in conjunction with the Early
Warning score tool at all times.
Early Warning score must be calculated in the following situations:
.1. Upon admission. And every 12 hours in general wards.
2. Upon transfer from other units.
3. Prior to transferring to another ward within the hospital, or to an external healthcare facility.
4.Patients with acute changes in condition. e.g. post-operative patients.
5. Patients with a score of 3 and above or an increase of the score by 2 or more in any of the
assessment criteria.

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Saqr Hospital

Rapid Response Team (RRT):
1.Most senior Medical or Pediatric or Ob/Gyne doctor on call.
2. Anesthesia and/or Intensivist on call.
3. MRP about the patient or his designate.
4. Nursing in charge or Nursing supervisor on call.
5. Assigned Nursing Staff.
36.Select one patient's EMR and ask the staff to show where she documented about
patient and family received education.
1- Patient education documented on ongoing assessment, discharge mohap when patient
discharge, after blood transfusion ….
37. What type of patient you receive in your unit? Ask the staff to show Scope of Service of the
unit.
According to department
38. Do you have departmental KPIs and what is the compliance rate. Where you are keeping the
data
Staff should List down department KPI(Nursing)
If they are any role for nurses for Hospital or doctors KPI. They should be aware about it also.

Each department keeping on KPI board
39. What steps you will take if there is blood or blood product adverse reaction, do you have a policy
and where you will document it. Do you have a competency related to blood transfusion? How often
you will do this competency and who will evaluate your skill on this competency?

Perform the following if a transfusion reaction occurs:
.1. The transfusion should be discontinued immediately and appropriate therapy initiated. The
transfusion shall not be restarted without clinical and/or laboratory review. Do not discard the
blood unit.
.2. Document the Transfusion reaction in blood administration transfusion form (Attachment 5).
.3. All significant adverse reactions to transfusion, including possible bacterial contamination of a
blood component or suspected disease transmission, should be immediately reported to as required
in the Occurrence Variance, Sentinel Event Policy
Policy in share folder
Yes, we have competency, in core competency, done once, and preceptor or CRN will evaluate
40. Could you tell me the frequency of vital signs to be taken during blood product administration:

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Saqr Hospital

Blood administration:
Perform and document the patient’s routine checking of temperature; pulse; respiratory rate; and
blood pressure is as the following:
.1. Within the hour prior to staring the transfusion
.2. At the beginning of the transfusion,
.3. Every 15 minutes for the first 30 minutes of the start of the transfusion;
.4. Every 30 minutes for the next one hour;
.5. Every hour until the end of the transfusion; and
.6. At the end of the unit.
7.Check vital sign 30 minutes & one hour following completion of the transfusion
Platelet administration:
Ensure platelet concentrates are transfused as soon as possible and no longer than 6 hours after
pooling
Observe during a platelet concentrates transfusion pulse, blood pressure and temperature.
1. Before transfusion
2. After 30 minutes
3. .. After one hour
4. And later if indicated
41. How do you Identify a patient with a nutrition risk? To whom you will inform about it?
Check the nutrition risk on admission and every 12 hrly
If patient need should refer to nutrition specialist
42. Do your hospital have any hospital wide/Nursing Quality Improvement Projects? Please tell me
about it.
2 QIP
Blood and Blood products administration
Post operative
43. Staff are wearing identification.
How you are improving your professional qualification
By actively participating in Professional development model which leaded by Professional development
department in EHS

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

PCI related JCI question:

In what all moments you will do hand hygiene. Do you have any competencies based on
hand hygiene and what resource are using for doing the competencies. How often you
are doing the competencies and who is validating your skills for this competency.

Yes we have competency, as mandatory competency

44. How many Negative pressure room you have.?. How you are checking it?
See the Monitor should be -2.5 pascal, check manually by tissue paper

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Saqr Hospital

45. If the negative pressure room is not working while patient admitted, what is your role.
We will follow the policy,
In form and attachment hoe to check the negative pressure

46. How you are receiving the patient with sign of infection.
Page 3 to 10 in transmission-based precaution

47. How are you reducing the risk for Health Care Associated Infections in your unit?
By hand hygiene, standard precaution

48. Do you have a policy that guides you on prevention of infections? Please show me the policy?
Yes, in share folder, quality, policy 2022

49. Do you have any isolation patient in your assignment, what precaution you are taking while you
do procedure to that patient or What you meant by standard precaution and what all are the Isolation
precaution as per your policy?

Stander precaution: apply to non-intact skin, mucous membranes, blood, all body fluids,
secretions, and excretions except sweat, regardless of whether or not they contain visible blood.
These general methods of infection prevention are indicated for all patients and are
designed to reduce the risk of transmission of microorganisms from both recognized and
unrecognized sources of infection in healthcare organizations.

The three types of Transmission-based Precautions shall be used alone or in combination
for diseases that have multiple routes of transmission:
a) Contact Isolation Precautions
b) Droplet Isolation Precautions
c) Airborne Isolation Precautions
50. How do you decide the type of isolation?
According to doctor decision and type of disease
51. Do you have doctor order for isolation?
Yes, doctor will order

Saqr Hospital JCI Hand book for Nurses

Saqr Hospital

52. What is the procedure you will do if you had a needle stick injury as per the hospital policy ?
Policy exposure to blood pathogen page 6 ,7

53. To whom you are reporting the infectious cases?
To infection control coordinator

54. For how long you can keep the sterile instrument?
We follow Event related sterility not time related

55. How do you know the sterile pack is being sterilized?
I will check the indicator color

56. Have you received any infection control education and when?
Yes, we have infection control program

57. How do you prevent SSI, CAUTI, CLABSI, VAP?
We follow bundle of care

58. How often do you send curtains for wash, show document?
Curtains / drapes should be washed periodically as follow:
.1 after each discharge of patient who has been on contact or droplet precautions
.2 Or when visibly solid
.3 And every 1 month (Show the Curtain washing checklist)

59. What do you use for equipment disinfection?
Clinil wipes

60. What is the contact time and shelf life of clinil wipes?
Shelf life for 6 month and contact time: 2 mints

61. What is your hepatitis B titer results?

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Saqr Hospital

Its reactive, regularly hospital is doing

62. Do you know your department compliance rate to: hand hygiene, bundle of care?

yes, on quality board

63. Do you support any staff member involved in unanticipated events. Do you have any policies
related to it. Who all are the coordinators for it as per the policy?

Yes, we have a policy as per RAKHN, Second Victim Support Program policy. The recommended
second victim coordinator would hold positions such as HR Director, Medical Director, Nursing Director,
Nursing Supervisor, Nursing Manager, Head of Department or Head of Quality or similar positions in the
Hospital.

The way that surveyor ask questions

The purpose of this document is to share some common questions, however, you are still responsible for reading all

policies and procedures.

Common Qs

Welcoming the surveyor • Unit manager shall escort the surveyor.

• Great him/her and introduce yourself

• Ensure you are fully aware of the scope of service document

content

• Ensure you know how many patient admitted at the day of

the visit

• Ensure your unit is clean

• Quality whiteboard is ready (No printing without the

approval of the quality department review on the final drafts

)

• The Surveyor will ask about the implementation of all the

policies. However, we will try to cover some of the common

Qs

• Train the staff to answer as per the policy

• It is totally fine to ask the surveyor to repeqrepeatt the Qs

• You should have access to the following: Shared folder,

Policies, Translator list, Drs Privileges

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Saqr Hospital

• Keep updated staff educational materials and reminders

• Prepare the quality whiteboard

• Ensure the privacy and confidentiality of patients during the

visit

•

IPSGs

Topic Common Qs Notes
Patient Identification
-How do you identify your -Surveyor will be observing staff
Hand-off communication
patients? during the moments where they are
Critical results
-What are the moments that expected to identify the patient, or

you need to identify the they may give a scenario to test the

patient? staff knowledge

-Do you collect any data to

check your compliance?

-What are the moments you -Surveyor will check staff

conduct hand-off documentation

communication?

-What is the main information

exchanged?

-Do you conduct hand-off to

Drs ? or to Radiology?

-Do you collect any data to

check your compliance?

- Do you have a list that -Prepare :

defines critical results in your Your data on reporting PCOT

hospital? can you access i? Keep the list of PCOT test displayed

- Do you receive critical on your board

notifications from the lab ? -Staff should know the PCOT tests +

-What is the approved process normal ranges

for reporting critical results in -Staff should keep the Logsheet

your hospital? available

-Do you have a list of point-of-

care tests? Can you access it?

Who supervises the POCT

program in your hospital? Did

you get training/Competency?

-Do you conduct QC tests?

Where do you document it?

-do you collect data on

reporting PCOT to Drs?

- How do nurses report the

critical results to Drs? Do you

document that?

-What is the approved time to

notify of a critical result?

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-Do the Dr document the
action taken? Do you have
data on that?

High alert Medications (HAM) -Do you keep HAM in your -The surveyor will check HAM in the
FALL unit? Where?do you have a medication room+Crash carts
list?
Hand Hygiene -What are the precautions
Surgical safety checklist taken when you deal with
Verbal order HAM?
-What is special about HAM
administration

- Do you conduct fall -The surveyor will check the
assessments? documentation
-Ensure Nursing bell working+placed
- Do you conduct Fall proberly in the toilets

re-assessment? how The surveyor will observe the staff

frquent ? what about -The surveyor will review medical
records
chronic patients? -Ensure the Informed consent
needned
- What tool do you use? -Be ready in advance with some
- What preventive cases

measures do you
take?
- If a fall happened,
what will you do?
- Do you educate
patient and families?
- -Do you collect any
data on fall incidents?
-What are the moments you
need to wash your hands?
- Do you collect any data on
staff compliance?
-Do you have a list of
procedures that require
surgical safety checklist ?
- Process (Sign in /Time
out/Sign out)
-Site marking
-Informed consent (Who will
do it ?)
-Do you accept verbal orders
in your hospital?
- What is the process of
accepting and documenting
verbal order?

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Saqr Hospital

Topic - Do you collect any data on Notes
Involvement in the quality program/activity? staff compliance?  Show the surveyor from the
Qip
The Quality program quality whiteboard
KPI Common Qs

Topic - Are you involved in
the quality 
Training program/activity?
Security Notes
- What are your Quality 
Safety improvement project  Pediatric and neonates read

-What is your project in the the security plan on code
unit? pink
-Why you selected the
project?  Have a look on the risk
assessment
-What was your role in the
project?
- What is your objective?
-What are your results?

-You need to know how to
read the KPI card
-What do you want to
improve?
-what is your target?
-How do you collect
information/Data?
-What are your unit results
compared to the hospital?
-What is your action plan ?

Facility management
Qs

Did you receive training on
FMS ?
How do you maintain the
security in the unit?
How do you activate the white
code/Pink Code? who
responds to the code?
Is any code white announced
recently? Drill ?
How you manage visitors?
Did you conduct a safety risk
assessment in the unit?
What are examples of
findings?

Saqr Hospital JCI Hand book for Nurses

Fire Saqr Hospital  Nearest Fire
extinguisher/Types/Different
Spills management How you act if a fire happened uses
Utility management in the unit?
Emergency plan Who is your Fire response  Nearest Fire alarm
Biomedical management team?  Assemblyle point
Did you conduct a drill? what  Have a look on the drill
temperature and humidity were the findings?
Stores management How do you evacuate report
patients?
Who and how do you 
deactivate gas valves in the
unit?  How to act if Elan electricity
shutdown occurred in
What is the code for spills? critical areas+Medication
How do you activate it ? who
will respond to the code?Drill? 
What is the code for utility
problems (Water /Electricity 
supply ?)
How you act if you have utility  Temp and humidity
failure?Drill ?  Expiry
What will be your  No brown cartoons+Plastic
dedepartment’spartment role
in case of orange code boxes labeled
announced?Drill?  No storage near to the
Do you have a list of your
department equipment? ceiling
Are your equipment checked  Clean +Easy to access
frequency?
How do you know?PPM
How do you clean it between
patient ?
Do you have a spill kit?

Where are the areas you need
to check Temp and
humidity?Why you check ?
What is the normal range?
How do you act if the
Temp/Humidity is out of
range?
How do you ensure the safety
of stores?

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Saqr Hospital

Hazmat management -Where do you keep the 
hazmat?
- do you have  Review the policy
inventory?MSDS file? Notes
- What is the first aid for
material X? 
-Do you have eyewash?how it 
is used?

Smoking Policy 

Medication management 

Topic Common Qs  Review the policy

Medication room Secured Notes
Review the crash cart
Temp and humidity checked management policy

Medication list Do you keep medication
 Review the Early signs policy
stock?

Who approves the list of

medications?

Do you have a high alert

Medication order and verification Who verifies

medications?Process?

Medication references If you need to know further

information about a

medication,Side effects ,

whare are the approved

references ?

Medication administration Patient identification

Adverse Drug reaction How do you manage and

report adverse drug reactions?

Patient own medication

Emergency management and crash cart

Topic Common Qs

How do you manage staff with proper resuscitation

training availab during shift

Crash cart management -Inventories

-Checkings

- Medication

Code Blue -Did you conduct drills? What

were the findings?

-How do you activate the

code? Who responds to the

code?

RRT (MEW/PEWs/MEAWs) -Scoring ,intervention and
escalation
-Documentation

Saqr Hospital JCI Hand book for Nurses

Topic Saqr Hospital Notes
Notes
Training Infection control 
Common Qs 
Cleaning and disinfecting
Did you receive training on 
Sterilization Infection control ? 
Clean/Dirty utilities Do you have cleaning and 
Linen management disinfectant guidelines for the 
available equipment? 
Waste How do you clean/Disinfect
Isolation rooms the equipment 
What is the contact time?
Topic Do you have some equipment 
Patient rights and involvement sent for sterilization? What is
the process?
Leave against medical advice
-Where do you keep
Clean/Dirt linen
-Do you send curtains for
washing? how frequent?

-Where do you keep waste?
-How frequent is it
transported from the clinic?
-Who is kept in the isolation
room?
-How do you check the
pressure ?how frequent?
-What are the used PPEs?
-How housekeep ers will clean
the room after patients ?

 Patient Rights
Common Qs

-How will patients know about
their rights? Patient rights Bill
-How do you involve the
patient? (Check IRMIS
Initiative)
-How do you manage the
language barrier ? Translator
list

- How do you manage
patients seeking leave
against medical
advice?

- Do you collect data?
-

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Saqr Hospital

Second opinion -How do you manage patient 

requests for a second opinion 

Complaints -How can a patient submit a 

complaint? 

Patient Education -Do you educate patients? 

How you ensure effective 

education? Proper topic+Clear 

language+Demonstration ……
Notes
 Other important policies 
 Staff need to be aware of
Blood transfusion
the list content (What are
Restrain the tests and the critical
values )
Downtime  how to access the list
 The list should be
Ambulance presented near to the area
where they conduct the
Transfer patients test
 Ensure you have the form
Clinical alarm management (V important ) of Reporting critical results
used by Physicians and
Disclosure of bad news to patient /Family Nurses in the policy
 It is mandatory for the staff
Pain management receiving the
verbal/telephonic Results
Common Qs to WRITE DOWN the
results on this form and
Critical Results for Dr+ Nurses then READ IT BACK to the
Ordering/Informing Staff
Common Qs Answer and CONFIRM to ensure
that it is correct and will
Do you have a list defining the critical values? yes enter in the provider
notification of cerner
Do you have a list defining the point of care critical Yes (wareed system)

values which

shall be reported to Drs when performed by

nurses?

How does the nurse/Dr receive reported critical 2.12.1 Listen;
results from Lab? 2.12.2 Write it down;
2.12.3 Read back;
How you are receiving and documenting when you 2.12.4 Confirm.
receive a critical result

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Saqr Hospital

Who oversite/supervises the point of care testing laboratory (Their role ): - Two patient identifiers
program? 1-Training which are the Full name of
2- ensure that the quality the patient and the MRN
Did the staff perform point-of-care testing, have control performance (Medical Record Number),
the required qualifications and training and are 3-Mantaince of machines will be verified..
competent to perform the test.? Yes
Who trained them? 
Are you monitoring and evaluating the point of **Lab should keep evidence of
care testing program? training  This shall be demonstrated
Yes as part of their
individualized competency
How do you report POCT to Drs? - Telephonic/ verbal list.
contact with physician
If In troubleshooting discrepancies between POCT using the following  KPI: Compliance of Nursing
results and the laboratory results, which result do process: to reporting POCT critical
you take? results to Drs within the
2.12.1 Listen; timeframe
2.12.2 Write it down;
2.12.3 Read back;  Ensure to register the
2.12.4 Confirm. POCT with critical results in
the logsheet
- Record in the patient’s
file 

In troubleshooting
discrepancies between POCT
results and the laboratory
results, favour laboratory-
produced results.

Saqr Hospital JCI Hand book for Nurses