Accreditation Standards For Hospitals in Kuwait: Surgical Care

Accreditation Standards
for Hospitals in Kuwait
SURGICAL CARE
Version 5
2015, Ministry of Health, Kuwait
SURGICAL CARE
ADMISSION
1.0 There is a defined process for admitting the patient to the Surgical Care
Service.
1.1 The patient is evaluated at the point of contact to match the patient to the
hospitals surgical service.
the hospital clearly identifies the scope of care and treatment which is
delivered by this service in the inpatient and ambulatory care setting
there is defined evaluation process used by this service to ensure the
Service is able to deliver the care and treatment required by each patient
Guidelines:
When admitting a patient, regardless of whether it is for in-patient or
ambulatory care, service must ensure that it is capable of meeting the
patients care needs. If this is not possible a process is in place for stabilizing
the patient and/or referring the patient where those care needs can be met.
1.2 Patients are categorized according to their need for the Surgical Care Service
and those with immediate need are given priority.
methods to determine priority rankings are established and used
waiting lists are established and maintained, where appropriate
a pre-registration system exists for ambulatory care patients
1.3 There are written policies and procedures in place and followed for admitting
patients, including:
obtaining patient-related information from
patient and family
referring practitioners, both internal and external
records of previous related visits
Ratings (PSRA) Ratings (Criteria)

No Compliance Fully Implemented No Compliance Partial Compliance (51-75%)
Developed Monitored Partial Compliance (1-25%) Substantial Compliance (76%)
Partially Implemented Not Applicable Partial Compliance (26-50%) Not Applicable
Version 5
1
SURGICAL CARE
obtaining informed consent from the patient, or when necessary, from

the family
routine pre-operative workups
when services may be denied to a patient
Guidelines:
The team follows clearly defined criteria when deciding whether to deny
services to a patient. Each organization defines the criteria, and documents
them. Services are not denied to patients in urgent or emergency situations.
1.4 The patient and the family are provided with information during admission,
including:
orientation to the Service
orientation to the physical environment of the Service
visitation protocols for inpatients
introduction to caregivers
routines and rules of the Service
information about patient and family rights and responsibilities
Guidelines:
The team has access to the services of a translator or interpreter when
required to ensure information provided to patients is easy to understand,
and in the language and format most acceptable to the patient and family.
These rights and responsibilities include: the right of the patient to participate
in decisions about care and treatment; the ways the patient can express
concern about care or treatment; and, the need for the patient to comply
with safety- related requirements.

Version 5
2
SURGICAL CARE
ASSESS AND PLAN FOR CARE
2.0 The patient is assessed and an interdisciplinary care plan is prepared based
on the results.
Standard Intent:
The patients care is provided by a team of caregivers from a variety of
disciplines and specialties (e.g. nursing, medicine, pharmacy, laboratory, etc.).
It is important for quality of patient care that all team members communicate
and cooperate with each other to develop a plan of care that will meet the
needs of the patient. An interdisciplinary team implies a collaborative style
of care that draws on the skills of multiple providers and disciplines, and may
also be termed multidisciplinary.
2.1 The patients needs are assessed in an integrated way (for preventive,
palliative, curative and rehabilitation services) and are prioritized based on the
patients condition at the time of entry to the hospital. The assessment may
include information on the following:
present illness or injury
patients understanding of illness, procedure to be done, or injury
symptoms, including level of pain
nutritional needs
functional status
mental status, including cognitive functioning
emotional and behavioral functioning
allergies
medication therapies
cultural and religious preferences
level of support available to the patient from family and/or community
following discharge
Guidelines:
The care plan for ambulatory care patients may or may not require the
participation of care givers from multiple disciplines. When interdisciplinary
care is required, this should be clearly described.

Version 5
3
SURGICAL CARE
In pediatric cases with prolonged admission, the team has a responsibility to

identify the capacity of the child to pursue ongoing education, and to discuss
their recommendation with the family and education providers.
2.2 Appropriate diagnostic tests (laboratory, diagnostic imagining) are performed

and results are documented in the patients record.
appropriate clinical information accompanies the request for a diagnostic
procedure
clear protocols exist for preparing the patient for various diagnostic tests
diagnostic testing is done in a timely manner
the results of diagnostic testing are available in a timely manner and are
provided to the patient by the appropriate caregiver
results are documented in the patients record according to defined
hospital practice
Guidelines:
The timeliness of diagnostic testing and the availability of results will
depend on the patients illness and the specific tests which are ordered,
however, clinical practice guidelines should dictate the advisable speed at
which testing should be done for specific conditions in order to preclude
serious repercussions for treatment.
2.3 The care plan is developed, and includes:

patient condition, age, patient medical history, drug allergies, and gender
assessment of potential complicating conditions
admitting, or preliminary, diagnosis and expected goals (outcomes) for the
patient
description of care and treatment to be provided and specific
interventions to be made (including the surgical intervention)
anesthetic assessment and requirements
pain management requirement
medication plan
nutrition plan
post-operative rehabilitation plan

Version 5
4
SURGICAL CARE
notation of discussion by the responsible caregiver with the patient/family

of any care, treatment and/or intervention and its risks for the patient
Guidelines:
The detail of the ambulatory plan should consider the above items; however,
the patient may not require intervention in all areas.
2.4 The care plan is clearly documented in the patients record.
Guidelines:
The care plan from all interdisciplinary providers is integrated into a single
plan and documented.
2.5 The care plan is clearly communicated and known to all caregivers who will be
involved in the care of the patient.
Guidelines:
The care of the patient involves a team of caregivers. Primarily, these include
the physician and the nurse but may include others depending on the needs
of the patient, such as a: physiotherapist, pharmacist, or dietician. It is very
important that the patients care plan is communicated to all members of the
care team and that all understand their role in carrying out the plan.
2.6 The care plan is discussed with the patient and/or family who participate in
decisions about the care plan.
the plan for surgery and the anesthetic plan are discussed
the risks, benefits, potential complications, and options related to the care
plan and interventions therein are discussed with the patient and family.
Content of this discussion is noted in the patient record
Guidelines:
Each individual hospital will define how the care plan is prepared for both
inpatient and ambulatory care patients, where it can be found and its precise
content.
The Service must ensure that there is adherence to the law which requires
discussion of the care plan with the patient (except when the patient is
mentally incapacitated).

Version 5
5
SURGICAL CARE
DELIVER CARE
3.0 Care is delivered to the inpatient or ambulatory care patient according to

the care plan.
3.1 Qualified individuals are identified as responsible for the patients care.
Guidelines:
Certain members of the care team must be identified as having final and
ultimate responsibility for the patients care. A senior physician member of
the team must have responsibility for the total medical care which is delivered
to the patient. A senior nurse will be responsible for the nursing care. The
designation of responsibility must be clearly noted in the patients record.
3.2 The Surgical Care Service has qualified staff.

the surgical service is directed by a qualified physician
qualified physicians perform surgical procedures
the anesthetic service is directed by a qualified anesthesiologist
qualified anesthetists deliver anesthetic for surgical procedures
a registered nurse, qualified by education and experience, manages the
operating rooms
there are at least 2.5 qualified nursing staff to assist in each operating room
the surgical team is appropriately constituted for the surgical procedure
being done
there is a list of available personnel to call upon for contingencies
qualified nurses deliver care in the surgical service
those responsible for patient care are identified in the patients record
when the patient moves from one phase of care to another the
responsible individual may change and this is documented in the patients
record
all staff caring for the patient know the individual responsible for the
patients care
specific staff qualifications required for this service are met

Version 5
6
SURGICAL CARE
Guidelines:
Those who are responsible for the care of patient sign and stamp the record.
Contingencies when additional staff might be needed include community
emergencies or disasters. In this event, all available personnel may be asked
to work.
3.3 Care is delivered according to pre-established guidelines, policies and

protocols that are revised and updated regularly (for example: clinical practice
guidelines, care paths). There is evidence and documentation of guidelines,
policies, and protocols that are used. Guidelines may include:
consent for the surgical intervention
requirement to complete an operating room checklist for each patient
case scheduling for the operating rooms (day surgery and inpatient
surgery)
handling of anatomical/pathological waste
aseptic techniques
universal precautions
pain management and sedation
staff safety
anesthetic use
Guidelines:
The operating room checklist ensures readiness of the operating room
prior to each surgery, and requires checking that the appropriate supplies,
equipment and instruments are available.
Anesthetic use refers to the entire episode of care, including pre-operative
assessment, monitoring during the procedure, and the post-operative
recovery (POR) phase.
3.4 Information about the care that is provided to the patient (in-patient and
ambulatory) is documented in the patients record.
every member of the surgical team is responsible for the recording
and accuracy of information related to the surgical procedures and the
signatures (and codes, if appropriate) of all members are recorded in the
patient record

Version 5
7
SURGICAL CARE
there is a description of the surgical procedure, findings, and any

anatomical piece or biopsy taken and the following
time in/out of the operating room
persons present in the operating room
instruments used
instrument and sponge count post-surgery
there is a description of the post anesthetic recovery period
3.5 The Surgical Care Service records, reports and assesses adverse events and
incidents.
processes are defined and used for recording, reporting and assessing
adverse events and incidents.
Guidelines:
Definitions:
Adverse event:
1) Injury related to health-care management rather than to the underlying
disease process;
2) An unplanned and undesired harmful occurrence, directly associated
with care or service provided to a patient.
Incident:
An occurrence in which there is problem with the process of care; an incident
may lead to a serious consequence, or adverse event, for the patient.
4.0 The Surgical Care Service (inpatient and ambulatory) has appropriate
physical facilities and medical equipment that meet patient care needs.
4.1 The Surgical Care Service has appropriate physical facilities, including:
operating rooms have two-way traffic
there are separate units for day surgery and inpatient surgery
there is anti-static flooring and appropriately grounded electrical circuits
there is an uninterrupted power supply

Version 5
8
SURGICAL CARE
hand washing (scrub) facilities are well located

operating rooms have appropriate air flow systems
entry to the operating rooms is restricted
there is appropriate storage of equipment and supplies
there are separate change rooms for male and female staff
facilities are safe and protect against infection (all surfaces in the
operating rooms are smooth and non-porous)
post anesthetic recovery area is appropriately located next to operating
rooms
4.2 The hospital and the Surgical Care Service assess its physical facilities on a
regular basis and modifications are made when necessary.
4.3 The Surgical Care Service has appropriate medical equipment, including:
surgical instruments appropriate to each type of surgical procedure
performed
monitoring equipment
anesthetic equipment
intercom facilities
crash cart
4.4 The Surgical Care Service has an up-to-date list of all medical equipment, and
a maintenance and/or replacement schedule for each piece of equipment.
Guidelines:
All medical equipment requiring calibration is noted and the schedule for
calibration is specified. It is expected that the physical facilities and medical
equipment that are available to the Service will enable the patients to be
cared for safely.

Version 5
9
SURGICAL CARE
The Service will likely share responsibility for the list of equipment and the
maintenance schedule with other services in the hospital (e.g. engineering,
biomedical engineering).
REVIEW CARE AND ADJUST GOALS
5.0 The care plan is reviewed and modified as required.
5.1 The plan for post-surgical care is reviewed regularly, especially during post
anesthetic recovery.
5.2 Changes to the goal(s) of care are documented.
5.3 Changes to the care plan are documented.
5.4 Changes to the care plan are made known to the care team members.
5.5 Changes to the care plan are discussed with the patient and family.

Version 5
10
SURGICAL CARE
Guidelines:
Review and modification of the care plan may be necessary only for those
ambulatory care patients who require repeated ambulatory care visits.
PREPARATION FOR DISCHARGE, TRANSFER OR FOLLOW-UP
6.0 There is a process to discharge/transfer/follow-up the patient.
6.1 Starting at admission, or during the patient care process, there is planning for
discharge/transfer/follow-up. Processes include:
discharge from the operating room, including post anesthetic recovery, to
the inpatient surgical unit
discharge from the operating room, including post anesthetic recovery, to
home
Guidelines:
The team applies defined criteria when determining when to discharge or
transfer a patient. The team develops and uses a checklist detailing each step
in the process, and a checklist is completed for each patient prior to discharge
or transfer to ensure consistency between patients.
6.2 The process considers and makes provision for support services and
continuing medical services that may be needed after discharge/transfer.
6.3 The patients readiness for discharge/transfer/follow-up is assessed and

documented and follow-up requirements are determined.

Version 5
11
SURGICAL CARE
Guidelines:
An inpatient may require follow-up in ambulatory care following discharge
from the hospital or may require community based services. An ambulatory
care patient may require assistance from other services, internal or external
to the hospital during the recovery phase or on an ongoing basis.
6.4 The patient and family are informed well in advance of discharge/transfer and
are told what provisions have been made for the patients continuing needs
following discharge.
6.5 Education for discharge/transfer/follow-up is provided to the patient.

education may be done on an individual or group basis or may be
provided in written form
6.6 A summary of the patients care is placed in the patients record at discharge/
transfer.
6.7 There is mandatory reporting of specified diseases and events.

Version 5
12
SURGICAL CARE
QUALITY AND SAFETY
7.0 Quality improvement is monitored in the Surgical Care Service.
7.1 The Surgical Care Service has a quality improvement plan.
7.2 The quality improvement plan identifies areas for improvement, actions to be
taken, results of actions, and follow-ups that must be completed.
a method exists for determining the priority for selection of various
quality improvement activities and may be based on the level of risk or
volume of problems associated with the activity
7.3 Staff members of the Surgical Care Service are aware of quality improvement
activities.
information about quality improvement activities and their results are
communicated to staff
7.4 Staff members receive appropriate and ongoing training on methods to assess
and measure quality improvement.
7.5 Staff members participate in quality improvement activities as appropriate.

the nature of quality improvement activities and staff workload are
considered when selecting staff to participate in these activities

Version 5
13
SURGICAL CARE
7.6 Indicators of performance for quality are identified for the Surgical Care
Service and are monitored as part of the quality improvement activities.
indicators of performance are selected and monitored for both inpatient
and ambulatory care
the data to be collected for indicators and methods to be used to collect
these data are established
Guidelines:
Quality indicators may be directed toward the effectiveness and efficiency of
the Service since these have a direct impact on quality of service.
8.0 The Surgical Care Service has a safety plan.
8.1 The Surgical Care Service has a safety plan.
8.2 The safety plan identifies areas for improvement, actions to be taken, results
of actions, and follow-ups that must be completed.
a method exists for determining the priority for selection of various
patient safety activities and may be based on the level of risk or volume of
problems associated with the activity
8.3 Staff members of the Surgical Care Service are aware of safety activities.
information about safety activities and their results are communicated to
staff
8.4 Staff members receive appropriate and ongoing training on methods to assess
and measure safety.

Version 5
14
SURGICAL CARE
8.5 Staff members participate in safety activities as appropriate.

the nature of safety activities and staff workload are considered when
selecting staff to participate in these activities
8.6 Indicators of performance for safety are identified for the Surgical Care
Service and are monitored as part of the safety plan.
indicators of performance are selected and monitored for both inpatient
and ambulatory care
the data to be collected for indicators and methods to be used to collect
these data are established
9.0 The team complies with patient safety required areas.

Guidelines:
These areas are internationally researched and accepted as essential practices
to enhance patient safety and minimize risk to the patient.
9.1 PSRA: Transfer of Patient Information at Transition Points: The Service

transfers information effectively among providers at transition points
(including: patients status, medications, treatment plans, and significant
status changes).
Guidelines:
Patients may be treated by a number of service providers in multiple settings
and can encounter up to three shifts of staff each day. Transfer of information
about the patient during these transitions (handovers) from service provider
to service provider or shift staff to shift staff is critical for patient safety and
prevention of adverse events and incidents.
Test(s) for compliance:
9.1.1 The hospital has a documented protocol to transfer patient
information. The Service uses mechanisms (for example, transfer
forms, checklists, SBAR (Situation-Background- Assessment-
Recommendation) technique) for timely and accurate transfer of
patient information at transfer points.

Version 5
15
SURGICAL CARE
9.2 PSRA: Medication Reconciliation: Reconcile the patients medications upon

admission to the hospital (including the emergency department or inpatient
units) with the involvement of the patient.
Guidelines:
Medication errors are a leading cause of injury and death in hospitals.
Medication reconciliation is a process designed to prevent medication errors
at patient transition points by creating an accurate list of all medications
a client is currently taking and comparing that list against the physicians
medication orders (given at admission, transfer, and discharge). Medication
reconciliation should include prescription and non- prescription (over-the-
counter) medications, vitamins, nutritional supplements,
potentially interactive food items, herbal preparations, and recreational
drugs. Medication reconciliation should include (as appropriate) the purpose/
indication, dose, frequency, route, and timing of last dose. Guidance on
implementing medication reconciliation and medication reconciliation forms
is at the websites of the IHI.
9.2.1 The hospital has a documented protocol to reconcile patient
medications upon admission (either through the emergency
department or to an inpatient unit)
9.2.2 The protocol includes single documented, comprehensive list of the
most accurate and current medications that the patient has been
taking prior to admission to the organization (best possible medication
history)
9.2.3 The protocol includes a review of this prior-to-admission medication
list with the new medications ordered by the hospital
9.2.4 The protocol requires documentation that the two lists have been
compared; differences have been identified and resolved; and that
appropriate modifications to the new medications have been made
where necessary
9.2.5 The protocol makes it clear that medication reconciliation is a shared
responsibility between patient and the health care provider
9.2.6 The hospital has a documented plan to implement the medication
reconciliation protocol throughout the organization

Version 5
16
SURGICAL CARE
9.3 PSRA: Training on Patient Safety: Deliver training and education on patient
safety at least annually to senior leaders, staff, and service providers.
Guidelines:
Staff education and awareness of patient safety are acknowledged as a key
step in addressing safety in the hospital. The WHOs World Alliance for Patient
Safety has identified competencies, training and skills as one of its top ten
research priorities in patient safety.
9.3.1 The organization delivers annual training and education on patient
safety
9.3.2 The training and education is tailored to staff needs and the
organizations focus areas. The curriculum addresses, at a minimum,
the following four patient safety competencies:
Applying core patient safety knowledge, skills and values to
everyday work
Working together as a team to deliver patient care
Communicating effectively
Recognizing, responding to, reporting, and disclosing adverse
events
9.3.3 The training and education curriculum is revised to meet current and
future needs
9.4 PSRA: Avoiding Catheter and Tubing Misconnections: Develop systems and
procedures to prevent catheter and tubing misconnections.
Guidelines:
Tubing, catheters, and syringes are used to deliver medications and fluids
to patients. The design of these devices makes it possible to inadvertently
connect the wrong syringes and tubing and then deliver medication or fluids
through an unintended and therefore wrong route. Tubing and catheter
misconnections can lead to wrong route medication errors and result in
serious injury or death to the patient.

Version 5
17
SURGICAL CARE

9.4.1 High risk catheters are labelled (for example, arterial, epidural,
intrathecal)
Note: the use of catheters with injection port for these applications should be
avoided
9.4.2 Use of Luer-connection syringes are prohibited for the administration of
oral medications or enteric feedings
9.4.3 There is a standardized line reconciliation process as part of handover
communications (including: rechecking tubing connections and tracing
all patient tubes and catheters to their sources)
Note: handovers occur at staff shift changes and when patients arrive in a
new setting or service
9.4.4 Training on the hazards of misconnecting tubing and devices is
incorporated into the orientation and continuing professional
development of practitioners and health care workers
9.5 PSRA: Patient Verification: Implement a patient identification protocol for the
Service. The protocol may be standardized across all services in the hospital
(for example, wrist bands, photo identification).
Guidelines:
Failure to correctly identify patients results in medication errors, transfusion
errors, testing errors, and wrong person procedures.
9.5.1 The Service uses at least two methods (for example, name and date of
birth) to identify a patient before providing any service or procedure.
The patients room number cannot be used to identify the patient.

Version 5
18
SURGICAL CARE
9.6 PSRA: Control of Concentrated Electrolytes: Concentrated electrolyte

solutions are only available in the pharmacy and in specific critical care areas
where there might be an urgent need for these solutions. In cases where
concentrated electrolyte solutions are stored in critical care areas, the
hospital must ensure safeguards are put in place (e.g. limited access, visible
warning labels and independent double-check) as specified in the policy on
control of concentrated electrolytes from the Ministry of Health.
Guidelines:
While all drugs have a defined risk profile, concentrated electrolyte solutions
for injection are particularly dangerous. Potassium chloride (KCl) is the
most common concentrated electrolyte implicated in adverse events,
but concentrated potassium phosphate and hypertonic (>0.9%) sodium
chloride can also be deadly when administered improperly. These drugs
can be especially deadly because the effects of inappropriate preparation
or administration are usually irreversible. Research has shown that removal
of concentrated electrolyte solutions from patient care units has markedly
reduced death and disability associated with these drugs.
9.6.1 There are no concentrated electrolyte solutions stored in patient
service areas (with the exception of specific critical care areas).
9.7 PSRA: Safe Surgical Practices: Develop a process and written protocol for safe
surgery that complies with the WHO Surgical Safety Checklist.
Guidelines:
Nearly half the harmful events affecting patients are related to surgical
care and services. Wrong site surgery, wrong procedure and wrong patient
surgery usually result from poor communication or unavailable/inaccurate
information. The WHO World Alliance for Patient Safety has published and
recommends use of a Surgical Safety Checklist which encompasses three
elements of safe surgery: preoperative verification, site marking and timeout
prior to starting the procedure to verify critical information (correct patient
name, correct procedure, correct site, correct patient position, and presence
of all necessary equipment.

Version 5
19
SURGICAL CARE

9.7.1 The organization has a documented protocol for safe surgery that
complies with the WHO Surgical Safety Checklist
9.7.2 The protocol requires preoperative verification to gather information
prior to starting the procedure
9.7.3 The protocol requires a preoperative marking of the precise site where
the surgery will be performed, using an unambiguous mark
9.7.4 The protocol requires a time out immediately prior to the procedure
9.8 PSRA: Timely Administration of Prophylactic Antibiotics: Administer

prophylactic antibiotics to prevent surgical site infections.
Guidelines:
Timeliness of administering antibiotic prophylaxis is widely recognized for
reducing post surgical infections, but administration must be appropriately
done to be effective and not pose risks to patients.
9.8.1 The organization has a documented protocol (e.g. time-out
procedure, standing orders) to administer antimicrobial agents for
prophylaxis within 60 minutes prior to skin incision. Vancomycin and
fluoroquinolone may be administered up to two hours prior to skin
incision
9.8.2 The organization has a documented protocol to (e.g. standing order) to
discontinue the administration of prophylactic antimicrobial agents 24
hours after the surgical procedure. Vancomycin and flouroquinolone
may be discontinued 48 hours after the surgical procedure

Version 5
20
SURGICAL CARE
9.9 PSRA: Safe Injection Practices: Develop safe injection protocols and practices
in order to prevent harm to patients and hospital workers.
Guidelines:
Unnecessary injections and use of injection devices without appropriate
sterilization present serious risks for infection to patients. As well, unsafe
injection practices place hospital workers at risk. The WHO recommends a
three-part strategy to achieve safe injection practices: changing patient and
health worker behaviour, ensuring the availability of safe injection equipment,
and managing waste safely and appropriately.
9.9.1 The hospital regularly assesses local attitudes towards non-injectable
medications and, when necessary, addresses misconceptions about the
effectiveness of non-injectable medications by:
Providing training to health care workers on the effectiveness of
non- injectable medications
Providing information resources for clients and their families about
the alternatives to injectable medications
9.9.2 The hospital has a documented protocol stipulating that medication
is only given by injection when medically necessary and when an
equivalent oral formulation is not available
9.9.3 The hospital has a documented protocol stipulating the use of single
use injection devices for preventative and therapeutic injections
(including administration by injection or via an intravenous line)
9.9.4 The hospital has a documented protocol for the management of
injection devices waste disposal
9.9.5 Sterile, single use injection devices (for injection and reconstitution)
and safety boxes (for disposal) are available in sufficient quantities for
the number of injections administered

Version 5
21
SURGICAL CARE
9.10 P
SRA: Performance of Correct Procedure at Correct Body Site: Develop a
process and written protocol for ensuring correct procedure at correct body
site prior to any invasive intervention.
Guidelines:
Incorrect procedure or incorrect body site for the procedure is considered
a medical error. In order to prevent this occurrence, a protocol should be
developed to ensure that pre-intervention verification, site marking, and
time-out process occurs.
9.10.1 The organization has a documented protocol for correct procedure at
correct body site
9.10.2 The protocol requires pre-intervention verification to gather
information prior to starting the procedure
9.10.3 The protocol requires a pre-intervention marking of the precise site
where the intervention will be performed, using an unambiguous
mark
9.10.4 The protocol requires a time-out immediately prior to the procedure

Version 5
22

Accreditation Standards For Hospitals in Kuwait: Surgical Care

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Accreditation Standards For Hospitals in Kuwait: Surgical Care

Uploaded by

Copyright:

Available Formats

Accreditation Standards

for Hospitals in Kuwait

Ratings (PSRA) Ratings (Criteria)

obtaining informed consent from the patient, or when necessary, from

Ratings (PSRA) Ratings (Criteria)

ASSESS AND PLAN FOR CARE

Ratings (PSRA) Ratings (Criteria)

In pediatric cases with prolonged admission, the team has a responsibility to

2.2 Appropriate diagnostic tests (laboratory, diagnostic imagining) are performed

2.3 The care plan is developed, and includes:

Ratings (PSRA) Ratings (Criteria)

notation of discussion by the responsible caregiver with the patient/family

2.4 The care plan is clearly documented in the patients record.

Ratings (PSRA) Ratings (Criteria)

3.0 Care is delivered to the inpatient or ambulatory care patient according to

3.2 The Surgical Care Service has qualified staff.

Ratings (PSRA) Ratings (Criteria)

3.3 Care is delivered according to pre-established guidelines, policies and

Ratings (PSRA) Ratings (Criteria)

there is a description of the surgical procedure, findings, and any

Ratings (PSRA) Ratings (Criteria)

hand washing (scrub) facilities are well located

Ratings (PSRA) Ratings (Criteria)

REVIEW CARE AND ADJUST GOALS

5.0 The care plan is reviewed and modified as required.

5.2 Changes to the goal(s) of care are documented.

5.3 Changes to the care plan are documented.

Ratings (PSRA) Ratings (Criteria)

PREPARATION FOR DISCHARGE, TRANSFER OR FOLLOW-UP

6.0 There is a process to discharge/transfer/follow-up the patient.

6.3 The patients readiness for discharge/transfer/follow-up is assessed and

Ratings (PSRA) Ratings (Criteria)

6.5 Education for discharge/transfer/follow-up is provided to the patient.

6.7 There is mandatory reporting of specified diseases and events.

Ratings (PSRA) Ratings (Criteria)

QUALITY AND SAFETY

7.0 Quality improvement is monitored in the Surgical Care Service.

7.1 The Surgical Care Service has a quality improvement plan.

7.5 Staff members participate in quality improvement activities as appropriate.

Ratings (PSRA) Ratings (Criteria)

8.0 The Surgical Care Service has a safety plan.

8.1 The Surgical Care Service has a safety plan.

Ratings (PSRA) Ratings (Criteria)

8.5 Staff members participate in safety activities as appropriate.

9.0 The team complies with patient safety required areas.

9.1 PSRA: Transfer of Patient Information at Transition Points: The Service

Ratings (PSRA) Ratings (Criteria)

9.2 PSRA: Medication Reconciliation: Reconcile the patients medications upon

Ratings (PSRA) Ratings (Criteria)

Ratings (PSRA) Ratings (Criteria)

Test(s) for compliance:

Ratings (PSRA) Ratings (Criteria)

9.6 PSRA: Control of Concentrated Electrolytes: Concentrated electrolyte

Ratings (PSRA) Ratings (Criteria)

Test(s) for compliance:

9.8 PSRA: Timely Administration of Prophylactic Antibiotics: Administer

Ratings (PSRA) Ratings (Criteria)

Ratings (PSRA) Ratings (Criteria)

Ratings (PSRA) Ratings (Criteria)

You might also like