ƋǐƗƧǁĎƋƉƇƻƝǁĎĪĖƇDžƎƲǘǁƋDŽƇƳǁĎƋƆǐNjǁĎ GAHAR GAHAR Handbook for Hospital Standards Edition 201 General Authority for Healthcare Accreditation and Regulation Table of Contents FOREWORD ....................................................................................................................................... 5 INTRODUCTION ................................................................................................................................. 6 SCOPE OF THIS HANDBOOK .......................................................................................................... 7 PURPOSE ........................................................................................................................................... 8 USE ..................................................................................................................................................... 9 READING AND INTERPRETATION OF THE BOOK..................................................................................... 9 USED LANGUAGE AND THEMES ........................................................................................................ 11 APPLYING FOR A GAHAR SURVEY ................................................................................................... 12 LOOK BACK PERIOD ......................................................................................................................... 13 SCORING GUIDE.............................................................................................................................. 14 ACCREDITATION DECISION RULES .................................................................................................... 15 ACKNOWLEDGMENTS ................................................................................................................... 16 ACRONYMS ..................................................................................................................................... 19 SECTION 1: ACCREDITATION PREREQUISITES AND CONDITIONS ........................................ 20 Compliance with GAHAR accreditation prerequisites .............................................................. 20 Transparent and ethical relationships ...................................................................................... 21 SECTION 2: PATIENT-CENTERED STANDARDS ......................................................................... 24 NATIONAL SAFETY REQUIREMENTS .................................................................................................. 27 PATIENT-CENTEREDNESS CULTURE ................................................................................................. 29 Planning and protecting the patient-centeredness culture ....................................................... 31 Empowerment and involvement of patients and their families ................................................. 35 Ensuring patient’s physical comfort .......................................................................................... 41 Protecting patient’s belongings, privacy, and confidentiality .................................................... 42 Responsiveness to patients’ and families’ voices .................................................................... 44 ACCESS, CONTINUITY, AND TRANSITION OF CARE ............................................................................. 46 Effective and safe patient flow-in the hospital .......................................................................... 48 PCC.15 Waiting spaces; ACT.07 Patient flow risks; ACT.12 Patient transportation; ICD.22 Patient functional needs; DAS.02 Medical imaging service evaluation ................................... 52 Effective and safe patients flow within the hospital. ................................................................. 52 Effective and safe patients flow-out of the hospital .................................................................. 59 INTEGRATED CARE DELIVERY .......................................................................................................... 63 Sustaining uniform care ............................................................................................................ 65 Effective Screening, assessment, and care processes............................................................ 66 Effective basic screening, assessment, and care for hospitalized patients ............................. 70 Patient-tailored screening, assessment, and care processes .................................................. 79 Safe critical and special diagnostic and care procedures ........................................................ 88 Life threatening conditions management ................................................................................. 94 DIAGNOSTIC AND ANCILLARY SERVICES ........................................................................................... 98 Efficient planning and management of radiological services ................................................. 100 Effective operational processes of medical imaging .............................................................. 103 Safe medical imaging studies ................................................................................................. 107 Appropriate planning and management ................................................................................. 108 Effective operational processes in the laboratory .................................................................. 113 Safe laboratory services ......................................................................................................... 121 Effective Point of care testing ................................................................................................. 122 Efficient planning and management of blood bank ................................................................ 123 Effective operational processes of blood transfusion service ................................................ 124 Safe transfusion services ....................................................................................................... 128 SURGERY, ANESTHESIA, AND SEDATION ......................................................................................... 132 Safe and effective surgical and invasive procedures care ..................................................... 134 Safe and effective anesthesia care ........................................................................................ 143 Safe and patient-centered sedation services ......................................................................... 149 MEDICATION MANAGEMENT AND SAFETY ........................................................................................ 154 Effective planning and management of medication ............................................................... 156 GAHAR Handbook for Hospitals Standards 2 | P a g e General Authority for Healthcare Accreditation and Regulation Efficient medication selection and procurement ..................................................................... 158 Safe medication storage ......................................................................................................... 159 Safe medication preparation and dispensing ......................................................................... 168 Safe medication administration .............................................................................................. 170 Effective medication monitoring ............................................................................................. 171 SECTION 3: ORGANIZATION-CENTERED STANDARDS .......................................................... 174 ENVIRONMENTAL AND FACILITY SAFETY ......................................................................................... 176 Effective leadership and planning of environment and facility safety ..................................... 178 Safe fire planning.................................................................................................................... 180 Safe hazardous materials and waste management plan ....................................................... 183 Safety and security planning .................................................................................................. 185 Safe medical equipment ......................................................................................................... 187 Safe utility plan ....................................................................................................................... 188 Safe emergency preparedness plan ...................................................................................... 190 INFECTION PREVENTION AND CONTROL .......................................................................................... 192 Efficient structure of the infection prevention and control program ........................................ 193 Safe standard precautions ..................................................................................................... 196 Safe transmission-based precautions and precautions for immunocompromised hosts ....... 201 Safe laundry and healthcare textile management .................................................................. 205 Safe construction and renovation ........................................................................................... 206 Effective epidemiological surveillance and monitoring ..........................................................