Академический Документы
Профессиональный Документы
Культура Документы
2009
© Copyright 2009, Saudi Aramco. All rights reserved. No part of this manual may be reproduced in any form or
by any means without the express written consent of Saudi Aramco.
Disclaimer of Liability: The information enclosed in this manual is intended as a reference guide only, and if
implemented it should enhance the Remote Area Medical Facilities standard of care. Medical standards of care
and practice are dynamic and it is therefore critical that facilities providing medical services keep up-to-date
with current clinical and Industry Standards and Practices. Information provided in this manual is accurate at
the time of publishing, but Saudi Aramco emphasizes that it does not assume any legal liability or responsibility
for the accuracy, completeness, or usefulness of any information disclosed in herewith and that no guarantees,
expressed or implied are made.
Healthcare Development Organization
Medical Designated Facilities Department
Medical Consulting & Quality Assurance Division
Remote Area Urgent Care Facilities Group
Bldg. 554, Room G10, Box 76
Dhahran Health Center
To ensure safe practice and deliverance of quality health care to all patients receiving medical care at the
work site, Medical Designated Facilities subject matter experts, have put together this Manual to be used as
a reference to assist organizations setup, evaluate and monitor the standards of patient care mandatory at
Remote Area Clinic health care system.
The requirements within this manual are based on the Ministry of Health (MOH) regulations, Saudi Labor Law
and Saudi Aramco Standards (Saudi Aramco Safety Manual, section 28-Medical) and are therefore manda-
tory for all SA Proponent Organization and/or Contractor Companies performing work at Saudi Aramco job
sites in Saudi Aramco remote areas and/or industrial settings.
Should you require help with the technical aspects of using this manual, one of our advisors will be happy to
meet with you. For further information please contact the Remote Area Urgent Care Facilities Group Leader.
He can be contacted at 03-877-3459 or 03-877-3338.
Improving the quality of health care to all patients is a very broad, comprehensive and ambitious undertak-
ing, which can only be achieved by working together.
This manual is for nonprofit, noncommercial use only, and may not be sold. It is being published by Saudi
Aramco as part of a services enhancement program to improve Remote Area Medical Facilities standards of care.
Section 1 – Introduction
1. Select the Most Appropriate Level of Medical Facility - The Initial Category Evaluation Sheet
specifies the criteria for each category/level and therefore allows the proponent organization to evaluate
and determine the most appropriate level of first aid services and category of medical facility it must
provide at the work site in remote areas and/or industrial settings.
2. Setup a Medical Facility - The Survey and Compliance Review Report specifies the required
mandatory minimum medical standards for first aid services and medical facilities at the work site in
remote areas and/or industrial settings.
3. Monitor Compliance at Medical Facility - The Survey and Compliance Review Report can be used
as a tool to monitor and evaluate the mandatory minimum medical standard requirements for first aid
services and medical facilities, including privately owned facilities, operating at Saudi Aramco work sites.
Definition
1. Minimum Medical Standard Requirements – Are the minimum acceptable standards for first aid
services and medical facilities at the work site in remote areas and/or industrial settings as specified in the
Saudi Labor and Workmen Law, Saudi Aramco Safety Manual, General Instructions and policies and in
the Ministry of Health (MOH) mandatory regulations.
2. Remote Area Urgent Care Facilities - Are medical facilities operating at industrial work sites in a
remote area, able to provide first aid, urgent care, pre-hospital care, stabilization and prompt transfer of
sick and injured employees to the nearest definitive care facility. Also, they are able to provide medical
assistance in the event of a disaster.
3. Remote Areas - Are areas of operation, which by distance or topography, are isolated from any medical
facility capable of providing an opportunity and prompt response to an emergency situation. These
include:
x Areas accessed by tracks or dirt roads, such as pipeline corridors and skid roads.
x Areas which are far from inhabited areas, developed roads or landing strips.
x Areas over open water.
x Areas accessed by off-road travel, even if it is near paved roads, towns or industrial facilities.
Examples include offshore locations and off-road locations (i.e., drilling rigs, deep desert exploration, and
refining and distribution areas).
We hope the information provided facilitates your efforts in ensuring that medical facilities at the work site in
remote areas and/or industrial settings meet the mandatory standards of practices so you are able to provide
a safe patient care environment and quality care to all patients and employees.
1
Section 2 – Initial Category/Level Evaluation
Instruction of Usage
2. Second: Use the criteria listed on the checklist below to evaluate and select the category/level of medical
facility your organization requires to provide safe and quality health care to all employees at the work
site. The determining factors must be looked at collectively before a final category is selected. Complete
the “Final Category/Level Selection (¥)” section at the end of page 3.
3. Third: Go to the appropriate section of the survey and compliance review report as indicated in the
Final Category /Level Selection (¥) to identify the minimum standard requirements for your selected
category.
Evaluation Form
Category of Criteria: The following factors are used to determine the category (level) Tick
Medical of medical facility required to meet the health needs of your employees Here
Facilities at the work site.
1. Employee population exceeds 50 workers in a single location
or within a radius of 15 kilometers.
2. Access to medical care: The company operates at a remote
CATEGORY/LEVEL A area/location where inpatient medical facilities are not available in the
Physician operated facility, area to refer patients for definitive care or/and timely transfer of
large size with laboratory patients for definitive care is not possible.
and radiology services 3. Risk factors: The work site is potentially high risk for accidents,
disasters or explosions. Possibility of mass casualties is high.
4. Specialized services: In view of the remoteness of company
operation, providing on-site specialized medical procedures,
diagnostic or otherwise, will be cost-effective and benefit company
operation.
1. Employee population exceeds 50 workers in a single location
or within a radius of 15 kilometers.
2. Access to medical care: The Company operates at a remote
CATEGORY/LEVEL B area/location where only a limited number of inpatient medical
Physician operated facility, facilities are available in the area to refer patients for definitive care
small size without and/or timely transfer of patients for definitive care may be
laboratory and radiology difficult.
services 3. Risk factors: The work site is potentially high risk for accidents,
disasters or explosions with possibility of mass casualties.
4. Specialized services: Providing on-site specialized medical
procedures, diagnostic or otherwise, will be cost-effective and benefit
company operation.
CATEGORY/LEVEL C 1. Employee population amounts 50 workers in a single location
Nurse operated or within a radius of 15 kilometers.
facility 2. Access to medical care: The Company operates at a remote
area/location where inpatient medical facilities are available in the
area to refer patients for definitive care and timely transfer of
patients for definitive care is possible. The company has an
established medical support and logistic network, e.g., a referral
system for the duty nurse to immediately consult a physician for
advice and treatment and the capability to arrange an immediate
transfer or medivac.
2
Category of Criteria: The following factors are used to determine the category (level) Tick
Medical of medical facility required to meet the health needs of your employees Here
Facilities at the work site.
3. Risk factors: The work site is potentially high risk for accidents,
CATEGORY/LEVEL C disasters or explosions with low possibility of mass casualties.
Nurse operated 4. Specialized services: Specialized procedures can be provided at a
facility (Cont.) company designated hospital. It will not be cost-effective or benefit
company operation to have this service provided on-site.
1. Employer who employs less than fifty (50) workmen shall provide at
CATEGORY/LEVEL D the work site a first aid cabinet. And shall assign an appropriate
First Aid Kits/ number of his workmen to receive first aid training. (Saudi Arab
Cabinets Government Decision No. 404, Articles I-VI dated 17 Jamada 11,
1494 (July 7, 1974 and Saudi Aramco GI-150.002.)
Specialized Services include Radiology, Laboratory, physicals, and other tests/procedures preformed as part
of the company’s health conservation program, e.g., hearing test and pulmonary function test.
G
D Ź Complete Section 4 of the Survey and Compliance Review Report
Remarks:
3
Section 3 – Survey and Compliance Review Report for Category ABC Facilities
GENERAL REGULATIONS – References: Saudi Labor Law, Section 28 of Saudi Aramco Safety Manual and Ministry of Health (MOH) Regulations.
Every contracting company which operates within Saudi Aramco remote
areas work sites shall provide medical care to all employees in accordance
1.1 with Section 28 of the Saudi Aramco Safety Manual, which incorporates
the relevant elements of Chapter 7 of Saudi Labor Law. At a minimum:
For more information, see Attachment 1-2, pages 84-86.
An employer who employs less than fifty (50) workmen shall
1.1-1 provide at the work site a first aid cabinet.
For more information, see section 4, pages 76.
An employer who employs fifty (50) or more laborers at a
1.1-2
minimum shall provide its employees with the following:
A first aid room at the work site. Depending on
1.1-2-1 needs, the first aid room can range from a single
room portable facility to a multi-room facility.
A Saudi MOH licensed nurse shall be on duty 24
1.1-2-2
hours a day, seven days a week (24/7).
Every proponent organization shall have a copy of the MMSR manual at
1.2 the work site medical facility for implementation, compliance and
reference purposes.
Every proponent organization shall provide healthcare as per the
1.3 mandatory insurance laws in the Kingdom of Saudi Arabia implemented in
1999 and 2003:
There is evidence that all employees, including subcontractor
1.3-1 employees, are registered in a 24 hour a day, seven days a week
(24/7), inpatient hospital.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
4
4
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
1.0 HEALTH CARE PROVISIONS AT REMOTE LOCATIONS (Cont.)
GENERAL REGULATIONS
There is evidence that all employees and subcontractor
employees are provided with health insurance coverage for
1.3-2
emergency and inpatient care including appropriate
investigations.
There is evidence that the organization designated an inpatient
hospital where a physician (specialist or otherwise) can be
1.3-3
consulted by the work site medical facility staff for further
advice, referral and/or transfer of patients as needed.
There is evidence that the organization maintains adequate
funds at all times in the proposed inpatient hospital. Current
1.3-4
documentation of advanced payment of agreed funds is
available upon request.
Every proponent organization shall have a database system that at a
1.4
minimum includes, but is not limited to the following information:
1.4-1 Employee’s name.
1.4-2 Employee’s ID number.
1.4-3 Employee’s medical registration (MR) number.
1.4-4 Name of Medical Facility.
1.4-5 Medical insurance card number and level of medical coverage.
1.4-6 Proponent organization head office contact number.
Proponent organization 24 hour on-site representative contact
1.4-7
number.
Contact number of Saudi Aramco Supervisor overseeing the
1.4-8
contractor work.
1.4-9 All information above is kept current at all times.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
5
5
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
1.0 HEALTH CARE PROVISIONS AT REMOTE LOCATIONS (Cont.)
GENERAL REGULATIONS
Every proponent organization at a minimum shall define their
1.5
organizational values as follows:
A vision, a statement about what the organization wants to
1.5-1
become.
1.5-1-1 Vision statement is posted.
A mission, an organization's vision translated into written
1.5-2 form. It materializes the management's view of the direction and
purpose of the organization.
1.5-2-1 Mission statement is posted.
Every proponent organization shall ensure that there is at least one (1)
crew member per shift with basic level of medical care awarded by a
recognized training program (Saudi Red Crescent Society or Saudi Aramco
1.6 Health Promotion Unit as applicable). At a minimum training includes,
but is not limited to:
For more information see Saudi Aramco GI-150.002
1.6-1 Basic Life Support (BLS).
1.6-1-1 Current certificate available upon request.
1.6-2 First Aid (FA).
1.6-2-1 Current certificate available upon request.
Every proponent organization shall ensure that their medical facilities’
healthcare professionals have the required Government license to practice
1.7 their profession in the Kingdom. At a minimum all professional staff is
registered and licensed by the following government bodies:
For more information, see Attachment 3, page 91.
1.7-1 Saudi Council for Health Specialties (SCFHS).
1.7-2 Ministry of Health (MOH).
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
66
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
7
7
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
8
8
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
9
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
1010
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
11
11
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
12
12
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
13
13
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
General Standards
Every proponent organization has a backup plan in place to provide
3.1 coverage for unplanned emergencies, holidays, sickness, off-duty days,
absences and other unplanned events.
Every contractor company shall ensure that for all matters pertaining to
clinic operation, all registered nurses (RN) are under the direct supervision
3.2 of a senior RN or physician. Distant supervision is acceptable and contact
for advice/consultation shall be available 24 hours a day, seven days a
week (24/7).
A work schedule detailing staff’s duty hours to cover a 24/7 operation is
3.3
available and posted.
3.4 An on-call schedule for off-duty hours must be available and posted with
respective contact numbers.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
14
14
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
4.0 STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS
A. General standards
Each proponent organization shall ensure that there is an appropriate
4.A.1
recruitment system to select medical staff.
There is evidence that the recruitment system has a process for reviewing
4.A.2 and approving resumes/CVs and carrying out pre-hire interviews as
required.
There is evidence that resumes/CVs of healthcare candidates are reviewed
by relevant experienced healthcare professionals (physician, registered
4.A.3
nurse, pharmacist) noting experience, qualifications and clinical
competency.
B. Staff Education and Competency
4.B.1 There is an employee New Hire Orientation (NHO) program in place.
There is a mechanism in place to provide all staff with continuing
4.B.2
education.
There is a mechanism in place to provide all staff with periodic mandatory
4.B.3
education. At a minimum this includes, but is not limited to:
4.B.3-1 Basic Life Support (BLS), every two (2) years.
4.B.3-2 Fire safety, yearly.
4.B.3-3 Infection control, yearly.
All mandatory education shall remain current and completion of all
4.B.4
courses shall be documented and made available upon request.
Where special clinical tests and procedures are approved as part of the
4.B.5
scope of service, a list of these tests and procedures is available.
Where special clinical tests and procedures are carried out, staff shall
receive appropriate training and certified competent to perform these
4.B.6
and/or competent to use associated equipment including performing
manufacturer’s required calibration.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
15
15
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
4.0 STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS (Cont.)
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
1616
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
4.0 STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS (Cont.)
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
17 17
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
4.0 STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS (Cont.)
Nurses Requirements:
Each proponent organization shall ensure that their staff completed an
emergency skills competency assessment prior to being assigned to work
independently. Competency assessment determines the employee’s
4.D.6 readiness to practice independently. Program details and performance
appraisal (assessment) is available upon request. At a minimum
assessment includes, but is not limited to following skills:
For more information, see Attachment 20, page 132.
4.D.6-1 Airway Management.
4.D.6-2 Ability to administer BLS.
4.D.6-3 Ability to use at least six (6) types of emergency equipment.
4.D.6-4 Ability to manage at least 10 kinds of first aid.
4.D.6-5 Ability to manage at least six (6) kinds of emergencies.
4.D.6-6 Ability to activate a disaster response.
Ability to complete a pharmaceutical, drug familiarization
4.D.6-7
program.
4.D.7 Good written and verbal English language skills.
Physicians Requirements:
General practitioner with five (5) years experience in a hospital setting and
4.D.8
a minimum of one (1) year emergency room experience.
4.D.8-1 Evidence of recent practice, less than 2 years.
To practice his profession in the Kingdom, physician is registered and
4.D.9 licensed by the following government bodies:
For more information, see Attachment 3, page 91.
Registered with Saudi Council for Health Specialties
4.D.9-1
(SCFHS), prior to work site assignment.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
18
18
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
4.0 STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS (Cont.)
Physicians Requirements:
When registration is under process, the nurse shall have a
4.D.9-2 valid SCFHS registration card or a follow-up card with K
number only until registration card is issued.
4.D.9-3 Has a valid Saudi MOH license within 6 months of hire.
Physicians have the basic level of medical care from a recognized training
4.D.10 program/institution (SRCS or SA - HPU) prior to work assignment. At a
minimum this includes, but is not limited to:
4.D.10-1 Basic Life Support (BLS), current certificate.
4.D.10-2 First Aid (FA), current certificate.
4.D.11 Good written and verbal English language skills.
Ambulance Drivers Requirements:
4.D.12 Ambulance driver at a minimum meets the following work requirements:
Saudi driving license with minimum of one (1) year driving
4.D.12-1
experience.
4.D.12-2 A good driving record.
4.D.13 Secondary school certificate (L7-9), diploma or equivalent.
Ambulance driver has the basic level of medical care from a recognized
4.D.14 training program/institution (SRCS or SA - HPU) prior to work assignment.
At a minimum this includes, but is not limited to:
Basic Life Support (BLS), current certificate. Course in Arabic
4.D.14-1
is acceptable.
First Aid (FA), current certificate. Course in Arabic is
4.D.14-2
acceptable.
4.D.15 Good command of English language skills preferred.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
19
19
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
4.0 STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS (Cont.)
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
20
20
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
4.0 STAFF QUALIFICATIONS, EXPERIENCE, COMPETENCY, CONTINUING EDUCATION AND EDUCATION/TRAINING RECORDS (Cont.)
Every proponent organization shall ensure that their medical facilities have
5.1 fire safety equipment available. At a minimum this includes, but is not
limited to:
5.1-1 Fire Extinguishers as follows:
5.1-1-1 Appropriate fire extinguishers (A, B, C).
5.1-1-2 Clearly identified.
5.1-1-3 Placed in strategic locations.
Labeled with proof of periodic inspection, usually
5.1-1-4
quarterly.
5.1-2 Smoke detectors.
5.1-3 Scott Air Pak (At location where exposure to H2S is a risk).
Every proponent organization shall ensure that their medical facilities have
5.2
eyewash station available as follows:
5.2-1 Unit is outside the facility building and in proper working order.
There is evidence that unit is regularly tested/inspected to ensure
5.2-2
it is in proper working order.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
21
21
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
Every proponent organization shall ensure that their medical facilities have
5.3
decontamination shower available as follows:
5.3-1 Unit is in proper working order.
There is evidence that unit is regularly tested/inspected to
5.3-2
ensure it is in proper working order.
Every proponent organization shall ensure that their medical facilities
properly manage their compressed gas cylinders. At a minimum, the
5.4 following precautions and safety regulations shall be observed when
storing, handling, and using compressed gas cylinders in order to keep the
hazards to a minimum:
Pressure is checked and logged daily, log sheet available upon
5.4-1
request.
Cylinders are replaced when content reaches 500 pressure per
5.4-2
square inch (psi).
5.4-3 Cylinders are securely stored as follows:
Either on oxygen delivery carts, walls, or in a secure
5.4-3-1
storage cage.
5.4-3-2 In an upright position (valve end up), on a level floor.
5.4-3-3 Well ventilated and dry storage area.
In a storage room free from flammable substances
5.4-3-4
(i.e., oil and/or volatile liquids).
Away from direct sunlight and from other sources of
5.4-3-5 heat as cylinder temperatures must not exceed 50 °C
(122 °F).
All sources of ignition (i.e., motors, generators,
5.4-3-6 communication systems, etc.) are removed from the
storage room.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
22
22
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
23 23
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
2424
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
5.0 SAFETY REQUIREMENTS (Cont.)
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
25
25
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
2626
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
6.0 ENVIRONMENTAL HEALTH AND INFECTION CONTROL REQUIREMENTS
VACCINATION PROGRAM - Every proponent organization shall ensure
6.1
that their medical facilities have a vaccination program in place as follows:
There is a vaccination program for all open wound injuries and
6.1-1
is implemented.
Administered vaccines are appropriately logged in a book or
6.1-2 database.
For more information, see Attachment 6, page 94.
As per MOH regulations, all staff before site assignment, shall
6.1-3
be screened and immunized as follows:
6.1-3-1 Chest X-ray.
6.1-3-2 Tuberculosis skin test (tuberculin or PPD test).
6.1-3-3 Hepatitis B (HBV) and Hepatitis C (HCV).
6.1-3-4 Human Immunodeficiency Virus (HIV).
There is evidence that screening and immunization
6.1-3-5
were completed.
Every proponent organization shall ensure that staff knows and complies
6.2
with the following standard precautions:
6.2-1 Hand washing.
6.2-2 Gloves.
6.2-3 Mask.
6.2-4 Handling sharps.
6.2-5 Cleaning of spills.
6.2-6 Patient placement (isolation).
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
27
27
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
6.0 ENVIRONMENTAL HEALTH AND INFECTION CONTROL REQUIREMENTS (Cont.)
Every proponent organization shall ensure that personal protective
6.3 equipment (PPE) is always available. At a minimum this includes, but is
not limited to:
6.3-1 Disposable masks.
6.3-2 Gloves.
6.3-3 Goggles.
6.3-4 Gowns.
6.3-5 Plastic aprons.
6.3-6 Safety shoes.
Facility ensures that sterilization is not performed by soaking in liquids,
6.4
boiling and/or steaming. This is NOT an acceptable practice.
Every proponent organization shall ensure that all CSS supplies
6.5 (instruments and packs) in their medical facilities are disposable. At a
minimum these include, but are not limited to:
6.5-1 Dressing packs.
6.5-2 Forceps.
6.5-3 Tongue depressors.
6.5-4 Dressing scissors (individual pack).
6.5-5 Suture pack.
6.6 All clinical areas have sinks (wash basins) available with the following:
6.6-1 Hot and cold water.
6.6-2 Antiseptic liquid soap.
6.6-3 Wall mounted paper towel dispensers.
6.6-4 Trash bins.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
28
28
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
7.0 ENVIRONMENTAL HEALTH AND INFECTION CONTROL REQUIREMENTS (Cont.)
Every proponent organization shall ensure that their medical facilities have
6.7
approved alcohol-based hand-rub, if sink(s) are not available.
Staff knows and is able to demonstrate appropriate hand sanitizing/ hand
6.8
washing technique as per established hand washing policy.
Examination tables are protected with disposable cover sheets or paper
6.9
rolls.
Every proponent organization shall ensure that their medical facilities have
6.10 appropriate bactericidal available and that it is used to disinfect hard
surfaces.
6.11 Clean linen is stored in a protected clean area.
Soiled linen is placed (deposited) into covered, leak proof bags, as per
6.12
established criteria.
There are adequate puncture resistant, leak-proof sharp containers in all
6.13
clinical areas, as follows:
6.13-1 All clinical areas have sharp containers.
6.13-2 Sharp containers are wall-mounted.
6.13-3 Replaced when they are three quarters (¾) full.
There is no recapping of needles. If used needles are recapped, the scoop
6.14
method is used.
Healthcare providers are able to verbalize what to do in the event of a
6.15
needle stick/sharps injury.
Housekeepers are able to verbalize what to do in the event of a needle
6.16
stick/sharps injury.
Every proponent organization shall ensure that their medical facilities have
a system in place for the safe management (identification, segregation,
6.17
collection, storage, transportation, treatment and disposal) of infectious
wastes/biomedical waste, as follows:
System is in compliance with Infection Control (IC) guidelines
6.17-1
and is in accordance with MOH regulations.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
29 29
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
6.0 ENVIRONMENTAL HEALTH AND INFECTION CONTROL REQUIREMENTS (Cont.)
Staff is familiar with and is able to verbalize the disposal
6.17-2 protocol (i.e., all sharps boxes are securely taped shut, double
boxed and transported to an approved agent for disposal).
Every proponent organization shall ensure that their medical facilities have
6.18
two (2) dedicated refrigerators available, as follows:
6.18-1 Medication refrigerator is used for medications only.
6.18-2 Refrigerator is used for staff’s food only.
Temperature is maintained between 2-8 degrees Celsius (36-
6.18-3
46 degrees Fahrenheit).
6.18-4 There is a thermometer available in each refrigerator.
Refrigerator’s temperature is recorded twice a day in a log
6.18-5
sheet. Log is available upon request.
Refrigerators are cleaned inside and out on a regular basis,
6.18-6
and when applicable, defrosted as needed.
Every proponent organization shall ensure that their medical facilities have
6.19
adequate color-coded foot-operated waste bins, as follows:
6.19-1 For regular waste.
6.19-2 For infectious waste.
6.19-3 Bins are labeled.
Every proponent organization shall ensure that their medical facilities have
6.20 blood spill kits available.
For more information, see Attachment 7, page 95.
There is evidence that personnel responsible for cleaning and disinfecting
6.21
blood and body fluids spills are adequate trained.
Laboratory Services
Laboratory specimens are handled, stored and transported in accordance
6.22
with established policy/protocol.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
30
30
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
31 31
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
Observation bed.
7.1-9
Not applicable to single room portables.
7.1-10 Entonox/nitronox unit, portable.
7.1-11 Examination light, wall mounted.
7.1-12 Refrigerators dedicated as follows:
7.1-12-1 For staff, small, medium or large.
7.1-12-2 For chilled items/drugs, small, medium or large.
7.1-13 Hare traction unit.
7.1-14 Infusion pump.
Intravenous (IV) pole/stand, mobile.
7.1-15 Due to space limitation in single room portables, any device
which facilitates the hook up of IV bag/bottle is acceptable.
7.1-16 Ophthalmoscope/otoscope, wall mounted and/or desk top.
7.1-17 Oxygen cylinder D size, wall secured or cart.
7.1-18 Oxygen cylinder E size, wall secured or cart.
Oxygen Resuscitation unit (e.g., Robert Shaw or Oxy-Viva
7.1-19
Resuscitator).
7.1-20 Portable emergency eye irrigation unit.
Stretcher emergency, disposable (e.g., Life lite emergency),
7.1-21
five (5) per box.
Stretcher, basket.
7.1-22 In single room facility, to be part of operation emergency
response supplies.
7.1-23 Weight/height scale.
7.1-24 Ring cutter.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
3232
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
33
33
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
34
34
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
35 35
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
7.0 MEDICAL EQUIPMENT AND MEDICAL SUPPLIES REQUIREMENTS (Cont.)
7.2-26 Suction catheters, sizes include, but are not limited to:
7.2-26-1 14 french.
7.2-26-2 16 french.
7.2-27 Catheterizations set urethral, size 14 french, disposable.
Cervical collars, hard, stiff neck brand only, sizes include, but
7.2-28
are not limited to:
7.2-28-1 No neck adult.
7.2-28-2 Small adult.
7.2-28-3 Regular adult.
7.2-29 Cold packs.
7.2-30 Cotton balls, sterile, 10 packs.
7.2-31 Cardio Pulmonary Resuscitation (CPR) board.
Glue, derma bond.
7.2-32
Not for Category C facilities.
7.2-33 Drain Penrose, sizes include, but are not limited to:
7.2-33-1 ½ inch.
7.2-33-2 1 inch.
7.2-34 Dressings include but are not limited to:
7.2-34-1 Non-adhering.
7.2-34-2 Disposable dressing pack.
7.2-34-3 Tegaderm, 6 centimeter x 7 centimeter (cm).
7.2-34-4 Multi-trauma dressing, sterile.
7.2-35 Ear speculum dispenser.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
3636
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
37 37
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
3838
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
39 39
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
7.2-73 Optivisor.
7.2-74 Oxygen connecting tubes.
7.2-75 Oxygen flow meter, to fit various size cylinders.
7.2-76 Oxygen masks adult, simple.
7.2-77 Oxygen masks, non-breathing, adult.
7.2-78 Oxygen nasal cannulas, adult.
7.2-79 Paper roll for examination table (e.g., Vanco).
7.2-80 Paper cups.
7.2-81 Paramedic scissor/sheer.
7.2-82 Penlight torch/flashlight.
7.2-83 Percussion hammer.
Pleur evac drainage.
7.2-84
Not for Category C facilities.
7.2-85 Red dot monitoring electrodes.
7.2-86 Safety pins, large.
7.2-87 Safety hard hat, size to fit.
7.2-88 Scalpel handle, disposable with the following:
7.2-88-1 Blades number 11.
7.2-88-2 Blades number 20.
7.2-89 Shroud Kit.
Sharps boxes (SB) at a minimum include, but are not limited
7.2-90
to:
7.2-90-1 SB with wall brackets, large.
7.2-90-2 SB with wall brackets, small.
7.2-90-3 SB small, ambulance.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
4040
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
41
41
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
4242
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
7.2-106 Urinals.
7.2-107 Urinary drainage bag.
7.2-108 Paper rolls for stretcher, disposable (e.g., Vanco).
7.2-109 Vaseline gauze, sizes include, but are not limited to:
7.2-109-1 ½ inch x 72 inch.
7.2-109-2 3 inch x 18 inch.
7.2-110 Water for irrigation, 2,000 cc, sterile.
7.2-111 Wrench adjustable metal type to open all cylinder sizes.
7.2-112 Adhesive remover (e.g., Whisk).
Every proponent organization shall ensure that their medical facilities
depending on their category and operational needs have adequate
7.3 quantity of linen supplies (disposables are preferable where available). At a
minimum supply includes, but is not limited to:
For more information, see Attachment 10, page 108.
7.3-1 Bed sheets.
7.3-2 Blankets.
7.3-3 Pillows.
7.3-4 Pillow cases.
7.3-5 Plastic cover for pillows.
7.3-6 Face cloths.
7.3-7 Bath towels.
7.3-8 Patient gowns.
7.3-9 Linen hamper/container.
7.3-10 Linen hamper/container bags.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
43 43
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
Every proponent organization shall ensure that their medical facilities have
adequate storage facilities available (steel cabinet, cupboards and shelves)
7.4
to properly/safely store materials and supplies and free the floor from
clutter.
Where shelves are used, they are off floor level and 18 inches clear of the
7.5
ceiling.
7.6 There is evidence that an inventory system is in place.
7.7 There are no expiry items on the shelves.
Every proponent organization shall ensure that their medical facilities have
a drug formulary. This formulary shall contain a wide spectrum of drugs
enabling patients to be treated for minor ailments, emergencies, and
stabilization prior to transfer to definitive medical care facility. The
8.1 selection of drugs and quantity for each drug category depends on the
facility’s operational needs and it is determined by the responsible
physician. At a minimum drugs include, but are not limited to:
For more information, see Attachment 11, page 109.
8.1-1 Analgesic (non-narcotic) agents at a minimum include, but
are not limited to:
8.1-1-1 Oral analgesic/antipyretic tablets (e.g.,
acetaminophen).
Oral analgesic/anti-inflammatory, non-steroidal
8.1-1-2
anti-inflammatory drug (NSAID), tablets/capsules.
8.1-1-3 Injectable analgesic/anti-inflammatory, NSAID.
8.1-1-4 Analgesic topical cream and/or ointment.
8.1-2 Muscle relaxant, tablets.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
4444
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
45 45
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
46
46
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
47
47
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
48
48
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
49
49
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
50
50
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
51
51
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
5252
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Ambulance Service
Every proponent organization shall ensure that their medical facilities
provide, or make arrangements to provide, a dedicated emergency vehicle
9.1
(ambulance) to transport the sick and injured to a hospital facility for
further management.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
53
53
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Ambulance Service
Every proponent organization shall ensure that their ambulance is a two-
9.2 wheel or four-wheel (2WD/4WD) drive vehicle depending on location and
terrain condition (e.g., tracks, dirt roads, etc.).
Every proponent organization shall ensure that every ambulance is fully
equipped with adequate supplies and other necessities. At a minimum
9.3 these include, but are not limited to:
For more information, see Attachment 12, page 116.
9.3-1 Proper warning flashlights.
9.3-2 Purpose markings as follows:
9.3-2-1 Red Crescent Insignia.
9.3-2-2 Ambulance signs painted on the outside.
9.3-3 Air conditioning unit in the patient compartment.
9.3-4 Fire extinguisher ABC, small type.
9.3-5 Appropriate communication device (radio, cellular and/or satellite
phone) with available network and appropriate frequency.
9.3-6 Ambulance essential medical emergency and resuscitation
supplies at a minimum include, but are not limited to:
Some items have been included as additional in order to backup
the emergency response bag supplies. The items marked with an
*asterisk, are loaded-up at the time of dispatch.
For more information, see Attachment 12, page 116.
9.3-6-1 *Emergency Response Bag.
9.3-6-2 *Automated External Defibrillator (AED).
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
54
54
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Ambulance Service
*Suction machine (portable) with the following
9.3-6-3
accessories:
9.3-6-3-1 Suction catheters.
9.3-6-3-2 Tubing.
9.3-6-4 Stretcher collapsible (Ferno or other).
9.3-6-5 Backboard short with straps.
9.3-6-6 Long board short with straps (van type only).
9.3-6-7 Kendrick Extrication Device (KED).
9.3-6-8 Hare traction.
Oxygen cylinder, large size (modular and van type
9.3-6-9
only).
Portable oxygen resuscitation unit (e.g., Robert Shaw
9.3-6-10
unit or other).
At a minimum, the following oxygen supplies
9.3-6-11
accessories are available:
9.3-6-11-1 Rebreathing mask.
9.3-6-11-2 Nasal cannulas.
9.3-6-11-3 Tubing.
9.3-6-12 Oxygen cylinder key.
9.3-6-13 Rigid cervical collar, sizes as follow:
9.3-6-13-1 Small.
9.3-6-13-2 Medium.
9.3-6-13-3 Large.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
55
55
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Ambulance Service
9.3-6-14 First aid supplies as follows:
First aid kit - unit size 36.
9.3-6-14-1 For more information, see
Attachment 23, page 140.
9.3-6-14-2 Ace bandages.
9.3-6-14-3 Kerlix.
9.3-6-14-4 Cold packs.
9.3-6-14-5 Scissors.
Infection/Environmental control items and Personal
9.3-6-15 Protective Equipment (PPE) include, but are not
limited to:
9.3-6-15-1 Goggles.
9.3-6-15-2 Surgical mask.
9.3-6-15-3 Plastic apron.
9.3-6-15-4 Examination gloves (sterile).
9.3-6-15-5 Examination gloves (unsterile).
9.3-6-15-6 Small sharps container.
9.3-6-15-7 Infectious waste plastic bag.
9.3-6-15-8 Plastic trash bag.
9.3-6-15-9 Heavy duty gloves.
9.3-6-15-10 Safety hard hat.
9.3-6-15-11 Safety shoes.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
5656
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Ambulance Service
9.3-6-16 Miscellaneous items include, but are not limited to:
9.3-6-16-1 Notepad.
9.3-6-16-2 Pen.
9.3-6-16-3 Flash light, 9 volt.
9.3-6-16-4 Tire gauge.
9.3-6-16-5 Kleenex tissue.
9.3-6-16-6 Safety triangle.
Every proponent organization shall ensure that their ambulance’s
9.4 equipment and supplies are checked daily, weekly or after each patient
trip. Inspections are recorded and available upon request.
Every proponent organization shall ensure that their ambulance(s) is taken
for a test run on a daily basis. The vehicle condition is checked and
9.5
recorded and available upon request.
For more information, see Attachment 13, page 118.
Every proponent organization shall ensure that their ambulance(s) is
9.6 thoroughly cleaned inside and washed outside on a weekly basis or after a
patient run, if necessary.
Every proponent organization shall ensure that their ambulance(s) have
9.7 periodic maintenance (quarterly) and required Government road test.
Documentation evidence is available upon request.
Communications
Every proponent organization shall ensure that their medical facilities have
9.8 a communication book/file available to staff to maintain effective internal
and external communication.
Every proponent organization shall ensure that their medical facilities have
9.9 a notice board(s) available and that it contain current relevant information,
e.g., safety, infection control, etc.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
57 57
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Communications
Every contractor company shall ensure that their medical facilities have the
9.10
following communication devices available:
A landline phone with internal and external access, including
9.10-1
direct access to emergency services.
Global system for mobile communications (GSM) and/or other
9.10-2 communication devices with available network and appropriate
frequency for field communication.
Every proponent organization shall ensure that their medical facilities have
a dedicated telephone available for internal communication and with
9.11 appropriate dial access to communicate directly with Medical Designated
Facilities (MDFs) or other agencies to request external medical assistance
and advice.
Every proponent organization shall ensure that their medical facilities have
9.12 a fax machine available either in the medical facility or in a nearby
administrative office.
Every proponent organization shall ensure that their medical facilities have
a dedicated emergency communication device (110 or similar), for
9.13
receiving expedient information/instructions regarding fire and/or other
disaster in the camp and/or surrounding construction area.
Every proponent organization shall ensure that their medical facilities
9.14 where applicable, have all their communication equipment checked per
shift. Findings must be documented and available upon request.
Janitorial Services
Every proponent organization shall ensure that their medical facilities have
9.15
a dedicated part-time or full-time janitor on the day shift.
Every proponent organization shall ensure that their medical facilities are
9.16
cleaned inside and outside to acceptable healthcare standards.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
5858
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Janitorial Services
Every proponent organization shall ensure that their medical facilities’
janitor receives training/orientation in medical housekeeping. On-site
9.17 orientation performed by a nurse and/or a senior janitor is acceptable.
Evidence of completion, which lists all the items covered during the
orientation, is available upon request.
Every proponent organization shall ensure that their medical facilities’
janitor attended an infection control class. On-site orientation performed
9.18
by a nurse, is acceptable. Evidence of completion, which lists all the items
covered during the orientation, is available upon request.
Every proponent organization shall ensure that their medical facilities’
9.19 janitor is appropriately immunized prior to medical facility assignment.
Evidence of immunization is available upon request.
Every proponent organization shall ensure that their medical facilities
according to their size and needs have sufficient housekeeping equipment
9.20 and supplies. At a minimum these include, but are not limited to:
For more information, see Attachment 14, page 119.
9.20-1 Mops of two (2) different color.
9.20-2 J Cloth.
Trolley with dual mop bucket and wringer or portable, bucket
9.20-3
with wringer for small clinic.
9.20-4 Sodium Hypochlorite (Clorox bleach).
9.20-5 Liquid soap.
9.20-6 Trigger spray bottle.
9.20-7 Detergent upgrade or similar, e.g., Beaucoup for patient area.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
59
59
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Janitorial Services
9.20-8 Plastic bags for rubbish (color coded for infectious waste).
9.20-9 Paper towels for sinks and spills.
9.20-10 Paper towel dispenser.
9.20-11 Wet floor sign.
9.20-12 Blood Spill Kit.
9.20-13 Floor polish.
9.20-14 Window cleaner.
9.20-15 Furniture polish.
9.20-16 General multi-cleaner with bleach for sinks, etc.
9.20-17 Toilet bowl and urinal cleaner.
9.20-18 Waste bin, pedal type with lid for clinical waste.
9.20-19 Waste basket, general purpose.
9.20-20 Hand brush and dust pan.
9.20-21 Heavy duty rubber gloves.
9.20-22 Hand sanitizer, ethyl alcohol 70% base (Santi-gel or Septogel).
Every proponent organization shall ensure that their medical facilities’
9.21 janitor closet is clean and tidy.
Not applicable for single portable facility.
Every proponent organization shall ensure that their medical facilities’
9.22
cleaning agents and disinfectants are appropriately labeled and stored.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
60
60
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Janitorial Services
Every proponent organization shall ensure that their medical facilities’
9.23 color coded mops are cleaned and disinfected on a daily basis. Evidence is
available upon request.
Every proponent organization shall ensure that their medical facilities’ are
9.24 cleaned on a daily basis, cleaning is in evidence. At a minimum cleaning
includes, but is not limited to:
9.24-1 Damp dusting.
9.24-2 Polishing floors and/or furniture as applicable.
9.24-3 Vacuuming.
9.24-4 Mopping of floor.
9.24-5 Cleaning toilet areas.
Every proponent organization shall ensure that their medical facilities’
9.25 janitors use separate cleaning equipment for toilet areas. This shall be in
evidence.
Medical facilities shall ensure that there is a regular (twice daily and as
9.26
necessary) removal of trash from all clinical areas.
Every proponent organization shall ensure that their medical facilities have
9.27 a procedure for cleaning blood spills and that it is posted. This shall be in
evidence.
Janitor and other staff know/verbalize the blood spill cleaning procedures
9.28
and cleaning fluid dilution ratios, as per guidelines.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
61
61
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
General Requirements
Every proponent organization shall ensure that their medical facilities have
10.1 a quick reference Medical Emergency and Disaster Response plan
available. At a minimum, plan outlines the following information:
Communication chain list of key personnel and various
services (i.e., security, firefighting and support services) and
10.1-1 show how chain is activated (e.g., ring-down-system flow
chart). This is strategically posted (e.g., nursing station/ safety
notice board).
Role of each medical personnel in the event of medical
10.1-2
emergency and disaster response.
Every proponent organization shall ensure that their medical facilities have
a 24 hour emergency and key personnel telephone numbers available and
10.2 that it is properly displayed in the clinic to facilitate proper/timely response
in the event of medical emergencies, disasters, transfers and Medivacs. At
a minimum list includes the following telephone numbers:
10.2-1 Company Security Operations.
10.2-2 Saudi Aramco Security Operation.
10.2-3 Police.
10.2-4 Red Crescent.
10.2-5 Nearest healthcare facilities including MOH hospitals.
10.2-6 Company designated hospitals.
On-call company representative or alternate (construction
10.2-7
Manager/Admin Manager/Health or Safety Advisor).
Trained first aiders in charge of first aid kits, available and
10.2-8
displayed.
10.2-9 Evacuation group leader, where applicable.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
62
62
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
General Requirements
Every proponent organization shall ensure that their medical facilities at a
10.3
minimum have the following emergency response bag(s) available:
10.3-1 At least two (2) bags in Category “A and B” facilities.
10.3-2 At least one (1) bag in Category “C” facilities.
Every proponent organization shall ensure that their medical facilities
emergency response bag(s) have the required medical supplies. The
10.4
contents of each bag include, but are not limited to:
For more information, see Attachment 15, page 120.
10.4-1 NURSE SUPPLIES at a minimum include, following items:
10.4-1-1 Sphygmomanometer.
10.4-1-2 Stethoscope.
10.4-1-3 Paramedic shears (scissors).
10.4-1-4 Penlight.
Disposable gloves at a minimum include, the
10.4-1-5
following sizes:
10.4-1-5-1 Medium, unsterile.
10.4-1-5-2 Large, unsterile.
10.4-1-6 Masks.
10.4-1-7 Paper bag, waxed.
10.4-1-8 Sharps container, small.
INTRAVENOUS (IV) SUPPLIES at a minimum include, the
10.4-2
following items:
10.4-2-1 Lactated ringers (LR), 1,000 cc, bag.
10.4-2-2 Normal saline (9NS), 1,000 cc, bag.
10.4-2-3 Dextrose 5%, 500 cc, bag.
10.4-2-4 Adhesive tape, 1 inch.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
63 63
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
10.0 MEDICAL EMERGENCY, DISASTER RESPONSE AND MEDIVAC PROCEDURES (Cont.)
General Requirements
IV administration (giving) sets at a minimum
10.4-2-5
includes, the following:
10.4-2-5-1 5 drop set.
10.4-2-5-2 6 drop set.
10.4-2-6 Alcohol swabs.
IV cannulas (catheters) at a minimum include
10.4-2-7
but are not limited to, the following sizes:
10.4-2-7-1 14 gauge.
10.4-2-7-2 16 gauge.
10.4-2-7-3 18 gauge.
10.4-2-7-4 20 gauge.
10.4-2-7-5 22 gauge.
10.4-2-8 Band aids.
10.4-2-9 Tourniquets, 1 inch and/or ½ inch.
10.4-2-10 Tegaderm, 6 cm x 7cm.
10.4-2-11 Gauze sponges 2 x 2, sterile.
AIRWAY SUPPLIES (PATIENT SUPPLIES) at a minimum
10.4-3
include, the following items:
10.4-3-1 Ambu bag (BVM), adult.
Oral airway adult, at a minimum includes, the
10.4-3-2
following sizes:
10.4-3-2-1 Small (3).
10.4-3-2-2 Medium (4).
10.4-3-2-3 Large (5).
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
6464
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
General Requirements
Laryngeal masks at a minimum include, the
10.4-3-3
following sizes:
10.4-3-3-1 Small.
10.4-3-3-2 Medium.
10.4-3-3-3 Large.
10.4-3-4 Bandage, 1 inch.
10.4-3-5 Syringe, 10 cc.
10.4-3-6 Pocket mask, adult.
Oxygen masks with reservoir (non-rebreather),
10.4-3-7
adult.
10.4-3-8 Nasal cannula.
10.4-3-9 Suction connecting tubing.
10.4-3-10 Suction catheter, size 14 french/Yankauer.
DRESSINGS/BANDAGES SUPPLIES (PATIENT SUPPLIES) at
10.4-4
a minimum include, the following items:
10.4-4-1 Multi-trauma dressing, sterile.
10.4-4-2 Abdominal pad, sterile.
Gauze sponges at a minimum include, the
10.4-4-3
following sizes:
10.4-4-3-1 2 x 2, sterile.
10.4-4-3-2 4 x 4, sterile.
10.4-4-4 Vaseline gauze, 3 inch x 18 inch.
10.4-4-5 Triangular bandage.
10.4-4-6 Kerlix roll.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
65 65
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
General Requirements
Ace wraps at a minimum include, the following
10.4-4-7
sizes:
10.4-4-7-1 4 inch.
10.4-4-7-2 6 inch.
10.4-4-8 Non-adhesive dressing.
10.4-4-9 Micropore roll, 1 inch.
10.4-4-10 Povidine iodine swabs.
10.4-4-11 Ice pack.
10.4-4-12 Bacitracin ointment, tube.
10.4-4-13 Band aids.
SPLINTS, DISPOSABLE (PATIENT SUPPLIES) at a minimum
10.4-5
include, the following sizes:
10.4-5-1 Short.
10.4-5-2 Long.
BURN SUPPLIES(PATIENT SUPPLIES) at a minimum include,
10.4-6
the following items:
10.4-6-1 Sterile burn sheets, disposable.
10.4-6-2 Burn pads sterile.
10.4-6-3 Surgical face masks, disposable.
Sterile gloves at a minimum include, the
10.4-6-4
following sizes:
10.4-6-4-1 6.5.
10.4-6-4-2 7.0.
10.4-6-4-3 8.0.
10.4-6-5 Disposable gowns.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
66
66
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
General Requirements
EMERGENCY DRUGS FOR EMERGENCY RESPONSE BAG at
a minimum include, the following drugs:
10.4-7
Staff must be certified competent to administer these drugs.
For more information, see Attachment 16, page 122.
Adenosine 6 mg/2 ml ampule.
10.4-7-1
Not applicable for category “C” facility.
Amiodarone injection, 150 mg/3 ml ampule.
10.4-7-2
Not applicable for category “C” facility.
Atropine sulphate 1 mg/0 ml pre-filled syringe.
10.4-7-3
Not applicable for category “C” facility.
10.4-7-4 Albuterol inhaler, 200 inhalations inhaler.
Calcium chloride 10%, 1 gm/10 ml pre-filled
10.4-7-5 syringe.
Not applicable for category “C” facility.
10.4-7-6 Diphenhydramine 50 mg/1 ml vial.
Dopamine infusion 200 mg/5 ml vial.
10.4-7-7
Not applicable for category “C” facility.
Dextrose 50% injection, 50 ml pre-filled syringe.
10.4-7-8
Not applicable for category “C” facility.
10.4-7-9 Epinephrine 1: 1,000, 1 mg/1 ml.
Epinephrine 1: 10,000, 1 mg/10 ml pre-filled
10.4-7-10 syringe.
Not applicable for category “C” facility.
10.4-7-11 Glucose powder, oral, bottle.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
67 67
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
General Requirements
10.4-7-12 Glucagon injection.
Hydrocortisone injection, 100 mg/2 ml vial.
10.4-7-13
Not applicable for category “C” facility.
Inderal (propanolol) ampule.
10.4-7-14
Not applicable for category “C” facility.
Magnesium sulphate injection, 1 gm/2 ml
10.4-7-15 ampule.
Not applicable for category “C” facility.
10.4-7-16 Nitroglycerin tablets, 0.4 mg, bottle.
Nitroglycerin 50 mg vial.
10.4-7-17
Not applicable for category “C” facility.
10.4-7-18 Normal saline, 10 ml, ampule.
Sodium bicarbonate 50 mEq/50 ml, pre-filled
10.4-7-19 syringe.
Not applicable for category “C” facility.
Vasopressin injection, 20 units/ml vial.
10.4-7-20
Not applicable for category “C” facility.
10.4-7-21 Xylocard 2%, 20 mg/ml, abboject.
Xylocard 20%, 200 mg/ml, abboject (for
10.4-7-22 dilution).
Not applicable for category “C” facility.
Xylocaine spray 10%.
10.4-7-23
Not applicable for category “C” facility.
Xylocaine injection (10 mg per 2 ml), 20 ml
10.4-7-24
multidose vial.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
6868
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
General Requirements
Every proponent organization shall ensure that their medical facilities
10.5 emergency response bag(s) are appropriately checked as follows: Evidence
of completion is available upon request.
10.5-1 On monthly basis and/or after use.
10.5-2 Quantity is checked and recorded.
10.5-3 Validity is checked and recorded.
Every proponent organization must ensure that staff has periodic disaster
10.6
training as follows:
Training includes the application of a commonly used triage
system (e.g., Simple Triage and Rapid Transport (S.T.A.R.T.);
10.6-1
Move, Assess, Sort and Send (M.A.S.S.) in disaster
management.
Training is conducted yearly. Evidence of completion is
10.6-2
available upon request.
10.6-3 Staff takes part in at least two (2) disaster drills a year.
Completion of training both theoretical and practical is
10.6-4 documented on the staff’s training record. Evidence is
available upon request.
Every proponent organization shall ensure that their medical facilities have
11.1 a quality improvement study in progress. Evidence is available upon
request.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
69
69
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
12.0 PATIENT PROCESSING AND MEDICAL RECORDS
Every proponent organization shall ensure that their medical facilities have
12.1
dedicated medical record/file available for the following individuals:
For every employee as stipulated in article 136 of the Saudi
12.1-1 Labor and Workmen Law.
For more information, see Attachment 1, page 84.
12.1-2 For every patient.
Every proponent organization shall ensure that their medical facilities
12.2 document each and every encounter into the medical record. At a
minimum, the following information is included:
12.2-1 Patient’s name and ID number.
12.2-2 Date of visit.
12.2-3 Time in and time out.
12.2-4 History.
12.2-5 Examination and assessment results.
12.2-6 Diagnosis or impression.
12.2-7 Treatment given, medications, etc.
12.2-8 Discharge status/sick leave/work restriction/referral.
12.2-9 Discharge instructions.
Significant Medical Data Sheet (SMDS), i.e.,
12.2-10
ordinary/occupational/work injuries.
Every proponent organization shall ensure that their medical facilities have
a tetanus immunization record available in the patient’s medical
12.3 record/file.
For more information, see Attachment 6, page 94.
Every proponent organization shall ensure that their medical facilities
12.4 record all injuries in a log book. Evidence is available upon request.
For more information, see Attachment 5, page 93.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
7070
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
12.0 PATIENT PROCESSING AND MEDICAL RECORDS (Cont.)
Every proponent organization shall ensure that their medical facilities have
a process available (e.g., log book) for documenting patient’s attendance.
12.5 Information listed is generally nonclinical and is kept for statistics purposes
and for periodic report to management.
For more information, see Attachment 17, page 123.
Every proponent organization shall ensure that their medical facilities have
12.6 a process available for requesting medical aid and for reporting patient
off-duty status.
13.0 HEALTH CARE POLICIES, PROCEDURES AND GUIDELINES - For more information, see Attachment 25, page 145.
General Guidelines
Every proponent organization shall ensure that their policies and
13.1
procedures are accessible to all staff.
Staff knows/verbalize the location of their medical facility’s policies and
13.2
procedures.
Scope of Service Policies and Procedures
Every proponent organization shall ensure that each of their medical
13.3 facilities has a policy that defines their scope of service offered as follows:
For more information, see Attachment 4, page 92.
13.3-1 Type of care and treatment offered at the facility.
13.3-2 Eligibility of service.
Investigations, specialized tests and clinical procedures
13.3-3
(diagnostic or otherwise) performed in the facility.
13.3-4 Hours of operation.
Administrative - Manpower Requirements Policies and Procedures
MANPOWER REQUIREMENTS GUIDELINES - Every proponent
organization shall have a policy stating the criteria (influencing factors)
13.4
used by the organization to determine its manpower requirements to
ensure that their medical facilities have adequate coverage at all times.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
71 71
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
13.0 HEALTH CARE POLICIES, PROCEDURES AND GUIDELINES (Cont.)
Infection Control Policies and Procedures
INFECTION CONTROL GUIDELINES at a minimum include, the
13.5
following policies and procedures:
13.5-1 Infection Control in Medical Facility Personnel.
13.5-2 Blood and Infectious Fluid Exposure.
13.5-3 Employee Screening and Immunization Program.
13.5-4 Hand Hygiene.
13.5-5 Handling of Soiled and Clean Linen.
13.5-6 Specimen Collection and Transport, where applicable.
13.5-7 Cleaning of Spills.
13.5-8 Sharp Injuries, what to do in the event and reporting.
Reporting Occupational Illness/ Communicable diseases (i.e.,
13.5-9
Hepatitis B/C, Tuberculosis, Chicken pox, etc.).
GENERAL POLICIES AND PROCEDURES at a minimum include, the
13.6
following policies and procedures:
13.6-1 Waste Management.
Every proponent organization has a patient consultation,
referral and transfer policy to Saudi Aramco remote urgent
13.6-2 care facilities.
Contractor shall comply with RAC OM-10.
Every proponent organization shall ensure that their medical
13.6-3 facilities have a policy that describes a reliable alternative
system of transfer in place in the absence of an ambulance.
Every proponent organization shall ensure that a policy on
Occupational Health Services (physicals and conservation
13.6-4
program, i.e., hearing, pulmonary, etc.) is available for their
employees.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
72
72
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
13.0 HEALTH CARE POLICIES, PROCEDURES AND GUIDELINES (Cont.)
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
73
73
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “A, B and C” Facilities (Physician and Nurse Operated Facilities)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code Date: Date:
Yes No Yes No
13.0 HEALTH CARE POLICIES, PROCEDURES AND GUIDELINES (Cont.)
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
7474
REMOTE AREA URGENT CARE FACILITIES
SURVEY AND COMPLIANCE REVIEW REPORT
Level “A, B and C” Facilities
Final Remarks/Recommendations:
Visit 1 Visit 2
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
75 75
Section 4 – Survey and Compliance Review Report for Category D Facilities
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
7676
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “D” Facilities (First Aid Provisions, Supplies and Training)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code 10/12/08 10/12/08
Yes No Yes No
1.0 FIRST AID PROVISION IN REMOTE AREAS (Cont.)
B. First Aid Requirements
Every proponent organization in this category shall ensure that where
work is performed in multiple locations more than 300 meters (1,000 feet)
1.B.1
apart, a separate first aid kit/first aid cabinet is available for every group of
10 (ten) workers.
Every proponent organization in this category shall ensure that their first
1.B.2
aid cabinet where applicable, is as follows:
1.B.2-1 Made of hard wood or metal and be painted white.
Dimensions: no less than 85 cm long x 45 cm width x 30 cm
1.B.2-2
diameter.
1.B.2-3 Fitted with a lock.
Have the Red Crescent insignia and the words “First Aid
1.B.2-4
Cabinet” written on it.
1.B.2-5 Always be ready for use, restocked after each use.
1.B.2-6 Placed on a strategic location, accessible at all times.
Every proponent organization in this category shall ensure that their first
aid kit at a minimum have the following supplies, as specified in Saudi
1.B.3 Aramco GI-150.002:
For more information see Attachment 23, page 140.
1.B.3-1 Bandage, compress, 5 cm.
1.B.3-2 Bandage, compress, 10 cm.
1.B.3-3 Bandage, gauze roller, 5 cm x 550 cm.
1.B.3-4 Bandage, plastic adhesive, 2.5 cm x 7.5 cm.
1.B.3-5 Bandage, triangular; sterile, 100 cm x 100 cm x 140 cm.
1.B.3-6 Cold pack.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
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77
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “D” Facilities (First Aid Provisions, Supplies and Training)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code 10/12/08 10/12/08
Yes No Yes No
1.0 FIRST AID PROVISION IN REMOTE AREAS (Cont.)
B. First Aid Requirements
1.B.3-7 Compress gauze, 60 cm x 180 cm.
1.B.3-8 Forceps and scissors.
1.B.3-9 Iodine PVP (polyvinyl povidone) crushable ampules.
Green soap swab, crushable; 0.5 ml; width 2 mm x 51 mm (2
1.B.3-10
inches) gauze pad.
Tourniquet supplied with a separate card to note the time
1.B.3-11
tourniquet was applied and the location of tourniquet.
1.B.3-12 First Aid Booklet, Arabic and/or English.
Every proponent organization in this category shall ensure that their first
1.B.4 aid cabinet, if provided, at a minimum includes the following supplies:
For more information see Attachment 24, page 144.
1.B.4-1 Oral airways, sizes include, but are not limited to:
1.B.4-1-1 Medium.
1.B.4-1-2 Large.
1.B.4-2 Non-sterile examination gloves.
1.B.4-3 Sterile gloves, sizes include, but are not limited to:
1.B.4-3-1 7.5.
1.B.4-3-2 8.
1.B.4-4 Band aids.
1.B.4-5 Alcohol swabs.
1.B.4-6 Iodine swabs.
1.B.4-7 Bacitracin ointment.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
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78
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “D” Facilities (First Aid Provisions, Supplies and Training)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code 10/12/08 10/12/08
Yes No Yes No
1.0 FIRST AID PROVISION IN REMOTE AREAS (Cont.)
B. First Aid Requirements
1.B.4-8 Sterile gauze, sizes include, but are not limited to:
1.B.4-8-1 2 x 2 or (5 cm x 5 cm).
1.B.4-8-2 4 x 4 or (10 cm x 10 cm).
1.B.4-9 Roller gauze, sizes include, but are not limited to:
1.B.4-9-1 2 inch.
1.B.4-9-2 3 inch.
1.B.4-9-3 4 inch.
1.B.4-10 Adhesive tape, 1 inch roll.
1.B.4-11 Eye pad.
1.B.4-12 Ace bandage, sizes include, but are not limited to:
1.B.4-12-1 2 inch.
1.B.4-12-2 3 inch.
1.B.4-12-3 4 inch.
1.B.4-12-4 6 inch.
1.B.4-13 Triangular bandage.
1.B.4-14 Safety pins.
1.B.4-15 Bandage scissors.
1.B.4-16 Burn sheet.
1.B.4-17 Abdominal dressing pad, 5 inch x 9 inch.
1.B.4-18 Multi-trauma dressing pad.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
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79
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “D” Facilities (First Aid Provisions, Supplies and Training)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code 10/12/08 10/12/08
Yes No Yes No
1.0 FIRST AID PROVISION IN REMOTE AREAS (Cont.)
B. First Aid Requirements
1.B.4-19 Cold pack.
1.B.4-20 Ammonia inhalant.
1.B.4-21 Padded arm board.
Every proponent organization in this category shall ensure that the
1.B.5
following safety devices are available at work locations:
1.B.5-1 Fire blanket.
1.B.5-2 Limb splints, ready to use, various types: thigh, leg, arm, etc.
Rescue type stretcher (to move injured patients), folding, 72
1.B.5-3
inch long and 10 inch wide.
Splint Stretcher, basket type litter; 4 straps; to carry patient in
1.B.5-4
any position without danger; 24 inch width 8.5 inch height.
Every proponent organization in this category shall ensure that signs
1.B.6
indicating the location of the first aid kits/cabinets are posted.
Every proponent organization in this category shall ensure that there is an
1.B.7 inventory system in place to replenish first aid kit supplies and to monitor
expiry dates. Evidence is available upon request.
Every proponent organization in this category shall ensure that a patient
1.B.8 log must be kept by the first aid attendant to register all injuries/illness
treated.
Every proponent organization in this category shall ensure that personnel
working in remote areas have one (1) vehicle equipped with a well
1.B.9
stocked first aid kit. The vehicle must be marked to indicate it is carrying a
first aid kit.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
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80
SURVEY AND COMPLIANCE REVIEW REPORT
General and Specific Minimum Standards Requirements Category/Level “D” Facilities (First Aid Provisions, Supplies and Training)
Instructions: Tick (9) Yes or No or Write “NA” Where not Applicable
Item Review – I Review – II
Standards Comments
Code 10/12/08 10/12/08
Yes No Yes No
1.0 FIRST AID PROVISION IN REMOTE AREAS (Cont.)
B. First Aid Requirements
Every proponent organization in this category shall ensure that the
1.B.10
designated vehicle is marked to indicate it is carrying a first aid kit.
Every proponent organization in this category shall ensure that the person
1.B.11
in charge of first aid program have the following available and posted:
Contact number (24 hours) of all first aid attendants in his
1.B.11-1
area of responsibility.
Name(s) and contact number of the nearest medical referral/
1.B.11-2
evacuation facility.
Other emergency telephone numbers to call for emergency
1.B.11-3
medical assistance including Security and Red Crescent.
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
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REMOTE AREA URGENT CARE FACILITIES
SURVEY AND COMPLIANCE REVIEW REPORT
Final Remarks/Recommendations:
Visit 1 Visit 2
SCORE: YES = Meet Standards NO = Does not Meet Standards NA = Not Applicable
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82
Section 5 – Attachments and References
Note: Samples provided in this manual are intended to be used as a reference guide only. If
implemented, it is important that you verify that the information is up-to-date with current standards
and practices.
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83
Saudi Labor Law
Chapter 7
Protection and Social Services
Labor and Workmen Law
Articles 134-6
Article 134
The employer shall provide first aid services for the workmen in accordance with the standards to be
determined by the Minister of Labor in collaboration with the Minister of Health. If the number of his
workmen in a single location or town, or within a radius of fifteen (15) kilometers, exceeds fifty, he
shall employ a nurse who shall be familiar with first-aid services and shall be exclusively assigned to
render such services; the employer shall assign a physician to examine and treat the workmen at the
place to be provided by the employer for this purpose, and the employer shall provide them with the
medicines necessary for their treatment. The aforementioned services shall be free of charge whether
during work hours or otherwise. If in the cases mentioned above, the number of workmen exceeds
one hundred (100), the employer shall, in addition, provide them with all other means of treatment in
cases requiring treatment by specialists, or performance of surgical other operations. In case operations
are performed, as well as in cases of incurable diseases, the expenses shall be taken from the Social
Insurance Funds. The costs of treatment, medicines and hospitalizations in government or charitable
hospitals, as well as the party, who will assume such costs, shall be determined pursuant to the
decision to be made by the Minister of Labor in agreement with the Minister of Health, or to the rules
laid down in the Social Insurance Law.
However, if the number of workmen is less than fifty (50), the employer must provide the workmen
with a medical aid cabinet which shall be maintained in a good condition and shall contain the
bandages, medicines, and antiseptics to be determined by the Minister of Labor in agreement with the
Minister of Health, in order to provide the workmen with first aid.
Article 135
Every employer who employs more than fifty (50) workmen shall inform the appropriate Labor Office
of the name of the physician who he has selected to treat his workmen. In case he employs more than
one hundred (100) workmen, he shall inform the office of the names of the physicians and specialists
whom he has selected to treat his workmen, and of the names of the hospitals which he has
designated for that purpose. In both cases, he must notify the appropriate Labor Office of the
minimum number of days fixed for the examination of workmen, provided that this minimum shall not
be less than three (3) times a week.
Article 136
Every employer shall prepare for each workman a medical file showing the result of the medical
examination performed on the workman upon his employment, a description of the cases of his illness,
the stages of his treatment, and the periods of his absence from work, provided that mention shall be
made in the file of the kinds of ordinary and occupational diseases and labor injuries.
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84
First Aid Facilities at Work
Article I
An employer who employs less than fifty (50) workmen shall provide at the work site a first aid cabinet
containing bandages, medicines, and disinfectants.
Article II
The employer shall assign one or more persons to be responsible for administering first aid to the
injured at all times during working hours, provided the person-in-charge shall be one of the
establishments employees who will either be trained in first aid procedures in accordance with a
program to be agreed upon with the Saudi Red Crescent Society, or who holds a certificate from a
hospital attesting that he has practiced first aid and is qualified to administer it.
Article III
An employer who employs fifty (50) or more laborers shall provide at the work site a first aid room which
meets the following standards:
Section (F) – “A licensed nurse shall be on duty at all times during working hours under the supervision of a
physician.”
Article VI
An employer who employs less than fifty (50) workmen shall assign an appropriate number of his
workmen to receive first aid in accordance with Article II.
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85
Saudi Aramco Safety Manual
28 Medical
28.1 Purpose
This chapter provides the minimum requirements for medical care to personnel performing work
at Saudi Aramco (SA) work locations and shall include the following services:
Disaster Response
28.2 Scope
It covers all SA and contractor personnel operating within SA facilities, on SA job sites outside
of operating facilities, off SA property under a SA contract, and in applicable SA domestic
joint venture companies.
28.3 References
SA General Instructions:
MMSR Manual - Medical Minimum Standards Requirements for Industrial Clinics Manual
28.4.1 Saudi Aramco Proponent Organization (SAPO) and/or the contractor shall
comply, in its entity, with the first aid/medical provisions described below prior
to start of work activities. These provisions are applicable to all work activities
within SA facilities, on SA jobsites outside of operating facilities, off SA
property but under a SA contract, and in applicable SA domestic joint venture
companies.
28.4.2 First aid is the immediate help that is provided at the work location to injured
or seriously ill personnel prior to the arrival of professional medical assistance.
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28.4 Provision of First Aid/Medical Facilities (Cont.)
28.4.3 Employers shall be responsible for ensuring that first aid/Basic Life Support
(BLS) trained personnel and appropriate first aid facilities are available for their
personnel at all work locations.
28.4.4 First aid facilities shall be kept in a sanitary condition and in strict compliance
with the minimum requirements specified in the Medical Minimum Standards
Requirements for Industrial Clinics Manual (MMSR) at all times.
28.4.5 First aid supplies shall be kept readily available in a first aid kit or a cabinet
designated for those supplies only.
28.4.6 A first aid attendant shall be responsible for first aid kits or cabinet and shall
ensure there is sufficient stock of all listed supplies at all times.
28.4.7 A suitable type of stretcher shall be available at all work locations.
28.4.8 Signs/notices shall be posted indicating the following:
a. The name of the person who is in charge of first aid kit or cabinet.
b. The hospital where injured/ill personnel are to be transported.
c. The telephone number(s) of the doctor(s) or first aid attendant(s).
d. The emergency telephone number(s) to be called for assistance.
28.4.9 One (1) vehicle equipped with a well-stocked first aid kit for each crew shall be
available for personnel performing pipeline and power line work or who are
working in remote areas. Vehicles shall be marked to indicate that they carry a
first aid kit. A minimum of one (1) man in every crew shall have a valid first
aid/BLS certificate (See GI 150.002).
28.4.10 A medical logbook shall be maintained at every first aid station and medical facility
by the first aid attendant/nurse who must log all injuries/illnesses treated. (Refer to
MMSR Manual for sample log.)
28.5.1 Employers, employing less than fifty (50) personnel, shall have an appropriate
number of personnel, including those in charge of the first aid kits or supply
cabinets, trained in first aid/BLS (See GI 150.002).
28.5.2 When there are more than fifty (50) personnel employed within a radius of 15
kilometers (9.4 miles), employers shall provide a first aid facility at the work location,
in accordance with the criteria set out in the MMSR Manual. As a minimum, a first
aid/BLS certified nurse shall be assigned to and in charge of the medical/first aid
facility.
28.5.3 Medical professional personnel (physicians/nurses) shall meet the licensing
requirements of the Saudi Arab Government (SAG) Ministry of Health (MOH) and
possess the necessary experience, and minimum qualifications, and required
certifications specified in the MMSR Manual.
28.5.4 Medical professional personnel shall also be provided with continuing education by
their employer as required by the MOH. This continuing education shall include, but
not be limited to: First aid/BLS, safety and infection control, and fire and disaster
training, etc.
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28.6 Medical Care at Work Site
88
28.8 Medical Transfer
28.9.1 Contractors shall ensure that Medivac procedures are incorporated into their
emergency response procedures as a part of their Loss Prevention Program (LPP).
28.9.2 The procedures to initiate a Medivac are covered in GI 1321.015.
Saudi Labor and Workmen Law, Chapter 7 - Protection and Social Services, Labor
and Workmen Law, Articles 134-6.
Article 134
The employer shall provide first-aid services for the workmen in accordance with the
standards to be determined by the Minister of Labor in collaboration with the Minister of
Health. If the number of his workmen in a single location or town, or within a radius of
fifteen (15) kilometers, exceeds fifty (50), he shall employ a nurse who shall be familiar
with first aid services and shall be exclusively assigned to rendering such services; the
employer shall assign a physician to examine and treat the workmen at the place to be
provided by the employer for this purpose, and the employer shall provide them with the
medicines necessary for their treatment. The aforementioned services shall be free of
charge whether during work hours or otherwise. If in the cases mentioned above, the
number of workmen exceeds one hundred (100), the employer shall, in addition, provide
them with all other means of treatment in cases requiring treatment by specialists, or
performance of surgical other operations. In case operations are performed, as well as in
cases of incurable diseases, the expenses shall be taken from the Social Insurance Funds.
The costs of treatment, medicines and hospitalizations in government or charitable
hospitals, as well as the party, who will assume such costs, shall be determined pursuant
to the decision to be made by the Minister of Labor in agreement with the Minister of
Health, or to the rules laid down in the Social Insurance Law.
89
However, if the number of workmen is less than fifty (50), the employer shall provide the workmen with a
medical aid cabinet which shall be maintained in a good condition and shall contain the bandages,
medicines, and antiseptics to be determined by the Minister of Labor in agreement with the Minister of
Health, in order to provide workmen with first aid.
Article 135
Every employer who employs more than fifty (50) workmen shall inform the appropriate
Labor Office of the name of the physician who he has selected to treat his workmen. In
case he employs more than one hundred (100) workmen, he shall inform the Office of the
names of the physicians and specialists whom he has selected to treat his workmen, and
of the names of the hospitals which he has designated for that purpose. In both cases, he
shall notify the appropriate Labor Office of the minimum number of days fixed for the
examination of workmen, provided that this minimum shall not be less than three (3)
times a week.
Article 136
Every employer shall prepare for each workman a medical file showing the result of the
medical examination performed on the workman upon his employment, a description of
the cases of his illness, the stages of his treatment, and the periods of his absence from
work, provided that mention shall be made in the file of the kinds of ordinary and
occupational diseases and labor injuries.
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Government Licensure of Professional Medical Personnel
Kingdom of Saudi Arabia Licensing Requirement Statement
Health profession practitioners must be licensed by the Ministry of Health (MOH)/Saudi Council for Health
Specialties (SCFHS) of the Kingdom of Saudi Arabia (KSA) to practice their profession in the Kingdom.
Purpose
To ensure that health profession practitioners:
1. Meet the licensure requirements of the MOH/SCFHS of the KSA prior to employment.
2. Are properly licensed by the MOH of the KSA to practice their profession in the Kingdom.
Definitions
1. Health Profession Practitioners – A term used to describe Clinicians, Pharmacists, Nurses and
Technicians.
2. Government Licensure – The issue of a license to practice the appropriate profession in the KSA, issued
by the MOH/SCFHS of license from the Ministry of Health.
Registration Objectives
1. Verify the practitioner’s competency.
2. Evaluate and classify practitioner’s certificates and experiences.
3. Introduce practitioners to the standards and ethics of practicing health professions in the Kingdom.
4. Monitor the practice of health professions to detect any incompetence or malpractice and deal with
them.
5. Emphasize that practitioners pursue continuing medical education programs to improve their skills and
keep up with the latest developments in their filed of specialty.
6. Protect the society from incompetent practitioners.
Registration Procedures
1. Fill out and sign each page of the SCFHS “Application form for Accreditation and Professional
Registration.”
2. Enclose originals of educational and experience certificates or authenticated copies.
3. Two (2) recent photos.
4. Sign the form of compliance with the standards with the standards and ethics of practicing health
professionals in Saudi Arabia.
Background History
In its session held on 14 Dhu al-Qa’dah 1416 (April 2, 1996), the Board of Trustees of the Saudi Council for
Health Specialties (SCFHS) approved the registration list of health profession practitioners. On 30 Muharram
1417 (June 16, 1996), it approved the regulations governing the registration of physicians and dentists. HE,
the Minister of Health and Chairman of SCFHS Board of Trustees, issued ministerial decision No. 1476/11,
dated 5 Rajab 1418 (November 5, 1997), stipulating the registration at SCHS in order to approve the practice
of health professions in both the public and private sectors in the Kingdom. This was circulated to all health
areas by letter No. 298/6093/20, dated 12 Rajab 1418 (November 12, 1997).
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Scope of Service
Care Provided
Care includes triage, assessment, diagnosis, first aid, treatment, stabilization and transfer or Medivac to an
inpatient hospital for definitive care and response to disaster situations.
Treatment
Includes treatment of encounters of varying complexities, such as acute trauma, medical emergencies and
prescribing medicines.
Basic BLS and other first aid intervention. Use of AED, incorporating life saving measures with stabilization
techniques.
Investigations
Patient Eligibility
Clear policy statement regarding who is eligible for care and what are they eligible for, e.g.:
a. For all employees.
b. For general public or non-employee with potentially serious or life threatening condition.
Scope of Service
ATTACHMENT – 4
Page 1 of 1
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92
Injury Summary
Brief Description
Carry Nature of Injury
Injury Date of Days Lost of Accident. State
Name Injured Badge Number Craft Over and Body Part
No. Accident this Month What, Where,
Yes/No Affected
How and Why.
Signature: _______________________________
Date Given Patient Name Company ID Batch/Lot No. Nurse Signature ID No.
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94
Cleaning of Blood Spills
Spills of blood can occur in your medical facility. So, it is essential to keep in mind that it is not possible to
identify patients with Hepatitis B virus (HBV) and/or Human Immunodeficiency Virus (HIV). Therefore, all
blood and blood borne pathogens “shall be considered infectious.”
A Blood Spill Kit shall be placed in all areas where blood spills are likely to occur, including medical facilities
in remote areas.
Each Spill Kit shall have the following items and supplies:
x One two-compartment plastic pail (dual bucket).
x Disposable shoe covers.
x Disposable safety glasses or plastic goggles.
x Disposable mask.
x Disposable gloves.
x Two (2) trigger sprayers or peri-bottle, labeled #1 and #2.
x One (1) measuring glass.
x Container of detergent/disinfectant mixed to correct ratio.
x Container of 5.25% sodium hypochlorite (Clorox).
x One (1) roll paper towel or disposable cleaning cloths (J-cloths).
x One (1) roll color-coded plastic bags for disposable of infectious waste.
x One “WET FLOOR” sign.
x One (1) laminated copy of these instructions.
Cleaning Procedure:
1. Place “WET FLOOR” sign near to the spill.
2. Wear disposable gloves and mask.
3. If splashing is anticipated, protective eye wear, such as disposable goggles should be worn. Wear
disposable coverall/gown if soiling of clothes is likely.
4. If there is a chance that shoes could become contaminated, wear shoe covers.
5. Prepare the disinfectant/detergent solution according to the following prescribed ratio:
a. One 1 ounce of Beaucoup solution per one (1) gallon of sweet water.
b. One 1 ounce of Clorox solution per nine (9) ounces of sweet water.
Note: For other chemical dilution ratios, see page 97.
6. Arrange the required color coded (yellow) bio-hazardous plastic waste bags, so they are ready to receive
contaminated waste.
7. Use disposable paper towels to soak up and remove all spilled blood or body fluid. Place soiled disposable
paper towels in the color coded (yellow) bio-hazardous bag. Repeat until all spilled blood or body fluid
has been removed.
8. Spray or apply adequate approved disinfectant solution (Beaucoup) on the spillage area. Clean the area
with fresh paper towels, being sure to remove all visible blood or body fluid. Dry with fresh paper towels.
Place soiled disposable paper towels in the color coded (yellow) bio-hazardous waste bag.
95
Spray or apply adequate Clorox solution on the spill area, ensuring that the entire spillage area is covered
with Clorox solution. Allow a two minute contact time and then wipe the area thoroughly with disposable
paper towels. Dry with fresh paper towels. Place soiled disposable paper towels in the color coded (yellow)
bio-hazardous bag.
9. Wait for the area to completely dry before removing the WET FLOOR sign.
10. Clean and disinfect the trigger spray bottles and other nondisposable items, as these items are
considered potentially contaminated.
11. On completion of the task, place all disposable protective garments, such as gloves, shoe covers,
goggles and mask in the yellow plastic bag. Wash hands thoroughly using antiseptic soap, such as
Scrubstat.
12. Replenish all disposable items in the spill kit and ensure it is ready for future use.
Spills/Splashing of Walls:
1. Wear disposable gloves and mask.
2. If splashing is anticipated, protective eye wear (goggles) should be worn. Wear gown if soiling of
clothes is likely.
3. Wear shoe covers if there is a chance of shoes becoming contaminated.
4. Prepare the disinfectant/detergent solution according to prescribed ratio.
a. One 1 ounce of Beaucoup solution per one (1) gallon of sweet water.
b. One 1 ounce of Clorox solution per nine (9) ounces of sweet water.
5. Arrange the required color coded (yellow) bio-hazardous plastic waste bags, so they are ready to
receive contaminated waste.
6. Use disposable paper towels to soak up and remove all of the spilled blood or body fluid. Place
soiled disposable paper towels in the color coded (yellow) bio-hazardous waste bag.
7. Spray or apply adequate SAMSO approved disinfectant solution (Beaucoup) on the spillage area.
Clean the area with fresh paper towels, being sure to remove all visible blood or body fluid. Dry
with fresh paper towels. Place soiled disposable paper towels in the color coded (yellow) bio-
hazardous waste bag.
8. Spray or apply adequate Clorox solution on the spill area, ensuring that the entire spillage area is
covered with Clorox solution. Allow a two minute contact time and then wipe the area
thoroughly with disposable paper towels. Dry with fresh paper towels. Place soiled disposable
paper towels in the color coded (yellow) bio-hazardous waste bag.
9. If it is found absolutely necessary to use a yellow scouring pad, this scouring pad should then be
treated as infectious waste.
10. Double bag the scouring pad in yellow color plastic bag for disposal.
11. Clean and disinfect the trigger spray bottles and other nondisposable items, as these items are
considered to be potentially contaminated.
12. On completion of the task, place all disposable protective garments, such as gloves, shoe covers,
goggles and mask in the yellow plastic bag. Wash hands thoroughly using antiseptic soap, such
as Scrubstat.
13. Replenish all disposable items in the spill kit and ensure it is ready for future use.
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Chemical Dilution Ratios
One (1) ounce (30 milliliter) of Beaucoup per 1 gallon (3.7 liters) of sweet water.
Three (3) ounce (30 milliliter) of Floor Maintainer per one (1) gallon (3.7 liters) of sweet water.
Six (6) ounce (60 milliliter) of Floor Maintainer per two (2) gallons (7.5 liters) of sweet water.
One (1) ounce (30 milliliter) of Upgrade per three (3) gallons (11.3 liters) of sweet water.
One (1) ounce (30 milliliter) of Biotek per three (3) gallons (11.3 liters) of sweet water.
One (1) ounce (30 milliliter) of Deb per one (1) gallon (3.7 Liters) of sweet water.
One (1) ounce (30 milliliter) of Breaker per three (3) gallons (11.3 liters) of sweet water.
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Medical Equipment Minimum Requirements
The minimum quantity of medical equipment listed below is only a sample. The amount of equipment required to operate a Remote Area Clinic depends on the
clinic’s category and utilization rates.
Category A Category B
Minimum Minimum Category C Urgent Minimum
Description Urgent Care Urgent Care
Quantity Quantity Care Facility Quantity
Facility Facility
Bag Mask Valve (BMV) with built-in CO2 detection
x 2 x 1 x 1
device (e.g., AMBU) adult, disposable.
Backboard, long with straps. x 2 x 1 x 1
Dressing cart, stainless steel. x 1 x 1 x 1
Drug cupboard, lockable. x 2 x 1 x 1
Automated External Defibrillator (AED), portable with
x 1 x 1 x 1
monitoring capabilities.
Emergency response bag.
x 1 x 1 x 1
See Attachment 15, page 120.
Exam/emergency stretcher with or without lockable x
x 1 1 x 1
wheels, as applicable.
Bed observation. x 1 x 1 NA
Entonox/nitronox unit, portable. x 2 x 2 x 1
Examination light, wall mounted. x 2 x 1 x 1
Refrigerator for staff, small, medium or large. x 1 x 1 x 1
Refrigerator for chilled items/drugs, small, medium or
x 1 x 1 x 1
large.
Hare traction unit. x 1 x 1 x 1
Infusion pump. x 2 x 1 x 1
Intravenous (IV) stand, mobile. (Any device which
facilitates the hook up of IV bag/bottle is acceptable at x 2 x 1 x 1
single room clinic).
Laryngeal mask (LMA), disposable sizes: 3, 4 and 5. x 2 x 2 x 2
Laryngeal mask airway holder. x 2 x 1 X 1
Ophthalmoscope/otoscope, desk top and/or wall
x 2 x 1 x 1
mounted.
99
99
Medical Supplies Minimum Requirements
The minimum quantity of medical supplies listed below is only a sample. The amount of supplies required to safely operate a Remote Area Clinic depends on the
clinic’s category and utilization rates.
Item Description Unit Category “A” and “B” Facility Category “C” Facility Quantity
Abdominal pads. Each ¥ ¥
Adhesive tapes, sizes:
½ inch. Each ¥ ¥
1 inch. Each
2 inch. Each
Automated External Defibrillator (AED) electrodes and other
Each ¥ ¥
accessories.
Alcohol preps. Box ¥ ¥
Aluminum foil, roll. Roll ¥ ¥
Ambu bag and mask with CO2 indicator, adult, disposable. Each ¥ ¥
Anal scope, disposable. Each ¥
Applicators, sterile, 6 inch. Each ¥ ¥
Applicators, non-sterile, 3 inch. Each ¥ ¥
Apron plastic. Each ¥ ¥
Bag: paper bag, preferable waxed. Each ¥ ¥
Band aids. Box ¥ ¥
Bandages: Stockinet bandages, sizes:
¥ ¥
2 inch. Roll
4 inch. Roll
Bandages: Ace bandages, sizes:
2 inch. Roll
3 inch. Roll ¥ ¥
4 inch. Roll
6 inch. Roll
Bandages: triangular bandages. Each ¥ ¥
100
100
Item Description Unit Category “A” and “B” Facility Category “C” Facility Quantity
Basin, kidney, disposable. Each ¥ ¥
Batteries, size:
1.5 volts (D cell). Each ¥ ¥
1.5 volts (AA). Each ¥ ¥
1.5 volts (AAA). Each ¥ ¥
Battery: Chargeable battery for EKG machine, spare. Each ¥ ¥
Bandage scissor. Each ¥ ¥
Betadine swabs and/or solution sticks. Each ¥ ¥
Blood spill kit.
Each ¥ ¥
For details and contents, see Attachment 7, page 95.
Body bags. Each ¥ ¥
Burn dressing: Sterile burn sheet 60 x 90 cm. Each ¥ ¥
Burn pad 55 x 75 cm. Each ¥ ¥
Butterfly cannula, sizes: ¥
19 gauge.
21 gauge. ¥
23 gauge.
Catheter: Nasal catheter, sizes:
16 french. EA ¥ ¥
18 french. EA ¥ ¥
Catheter: Suction catheter, sizes:
14 french. EA ¥ ¥
16 french. EA ¥ ¥
Catheterization set: urethral catheterization set, #14 french,
EA ¥ ¥
disposable.
Cervical collars, hard, stiff neck brand only, sizes:
No neck adult. Each ¥ ¥
Small adult. Each ¥ ¥
Regular adult. Each ¥ ¥
105
105
Item Description Unit Category “A” and “B” Facility Category “C” Facility Quantity
Spandages, sizes 1 to 7. Each ¥ ¥
Splint: cardboard Sam splint: ¥ ¥
Leg splint 24 inch. Each
Leg splint 18 inch. Each ¥ ¥
Leg splint 12 inch. Bottle ¥ ¥
Arm splint 18 inch. Each ¥ ¥
Arm splint 12 inch. Each ¥ ¥
Stretcher straps. Each ¥ ¥
Saline for irrigation, 1,000 cc, sterile. Bottle ¥ ¥
Steri-strip, sizes:
¼ inch. Box ¥ ¥
1/8 inch. Box ¥ ¥
Suction machine with accessories and consumables. Each ¥ ¥
Suture: Surgical suture, sizes:
Ethilon 4/0 W 1612T NDL. Box ¥
Ethilon 5/0 W 1616T NDL. Box ¥
Mersilk 4/0 W329 NDL. Box ¥
Vicryl 5/0 W9106 NDL. Box ¥
Suture tray, disposable. Each ¥
Syringes with needles, disposable, sizes:
2½ cc 20 gauge, 1 inch. Each
2½ cc 22 gauge, 1 inch. Each
2½ cc 22 gauge, 1½ inch. Each
Insulin, 50 unit/cc. ¥ ¥
Syringes, disposable, sizes:
5 cc. Each
10 cc. Each
20 cc. Each
50 cc. Each
107
107
Linen Supplies Minimum Requirements
The minimum quantity of linen supplies listed below is only a sample. The quantity of each item required to supply a Remote Area medical facility will vary
depending on the clinic’s category and utilization rate.
Blankets. Each
Pillows. Each
108
108
Drug Formulary List Minimum Requirement
Minimum
Quantity Minimum
Class Generic and Presentation (Example) Remarks
Required per Stock Level
Class
Acetaminophen 500 milligram (mg) tablets
Analgesic/Antipyretic Tablets 2
Acetaminophen with codeine
Acetylsalicylic acid 325 or 500 mg tablets
Diclofenac 50 mg tablets
Analgesic/Anti-Inflammatory
2 Ibuprofen 400 mg tablets
Tablets
Indomethacin 25 mg capsules
Naproxen 250 mg tablets
Analgesic/Anti-Inflammatory
1 Ketorolac tromethamine 15 mg/ml ampules
Injection
Diphenhydramine hydrochloride
Cough Medication, Syrup 2 Dextromethorphan 100 ml bottle
Rinofed
Cetirizine 10 mg tablets
Diphenhydramine 25 mg capsules
Antihistamine Tablets/Capsules 2
Promethazine hydrochloride (HCL)
25 mg tablets
Hyoscine-N-butylbromide 20 mg/ml,
Antispasmodic Injection 1
1 ml Ampule for IM, IV or SC use
Note 1: Generic and Presentation - Supply of generic alternatives from the local market is acceptable.
Note 2: Formulary list/crash cart and other emergency drugs supplies:
Formulary list (a selection from each class of drug for category “A, B and C” Medical Facility) and crash cart contents is at the discretion of the company assigned
responsible physician who must comply with all Ministry of Health (MOH) drugs supply and administration regulations, and take into consideration the competency of
the staff and required training before such drugs are administered.
115
Ambulance Medical Equipment and Supplies Minimum Requirement
1. External:
a. Red Crescent insignia.
b. Ambulance sign painted on the outside.
2. Drivers Cabin:
a. Gloves, heavy duty.
b. Note pad and pen.
c. Fire extinguisher, ABC type - small.
d. Safety hard hat.
e. Flashlight, 9 volt.
f. Tire gauge.
g. Safety triangle.
h. Communication equipment (radio).
i. Safety vest, reflective with identity clearly labeled (e.g., medical).
3. Patient Compartment:
a. First aid kit (36 unit size) with the following items: ace
bandages, kerlix, cold packs and scissors.
b. **Emergency response bag.
c. **Automated External Defibrillator (AED).
d. **Suction machine, portable with accessories, suction catheters
and tubing.**
e. Stretcher collapsible (Ferno or other).
f. Backboard short with straps.
g. Long Board with straps, van type only.
h. Kendrick extrication device (KED).
The quantity of each listed below depends on the medical facility category and utilization rate.
Quantity
Item Drug Name and Strength Physician Nurse Operated Check (¥)
Operated Facility Facility
Category A & B Category C
Adenosine 6 mg/2 ml ampule. Five (5) Not applicable
Amiodarone Injection, 150 mg/3 ml ampule. Three (3) Not applicable
Atropine sulphate 1 mg/10 ml, pre-filled syringe. Three (3) Not applicable
Albuterol inhaler, 200 inhalations, inhaler. One (1) One (1)
Calcium Chloride 10%, 1gm/10 ml, pre-filled syringe. Two (2) Not applicable
Diphenhydramine 50 mg/1 ml vial. One (1) One (1)
Dopamine infusion, 200 mg/5 ml vial. Four (4) Not applicable
Dextrose 50% injection, 50 ml pre-filled syringe. One (1) Not applicable
Epinephrine 1: 1,000, 1 mg/1 ml. Six (6) Six (6)
Epinephrine 1: 10,000, 1 mg/10 ml pre-filled syringe. Six (6) Not applicable
Glucose powder, oral, bottle. One (1) One (1)
Emergency Drugs Glucagon injection. Two (2) Two (2)
Hydrocortisone injection, 100 mg/2 ml vial. One (1) Not applicable
Inderal (propanolol) ampule. Three (3) Not applicable
Magnesium sulphate injection, 1 gm/2 ml ampule. Four (4) Not applicable
Nitroglycerin tablets, 0.4 mg bottle. One (1) One (1)
Nitroglycerin 50 mg vial. Two (2) Not applicable
Normal saline, 10 ml ampule. Five (5) Five (5)
Sodium bicarbonate, 50 mEq/50 ml pre-filled syringe. One (1) Not applicable
Vasopressin injection, 20 units/ml vial. Two (2) Not applicable
Xylocard 2% (20 mg/ml), abboject. Two (2) Two (2)
Xylocard 20% (200 mg/ml), abboject. Two (2) Not applicable
Xylocaine spray 10%. One (1) Not applicable
Date Name and Badge No. Time In Time Out Treatment Comments
123
Examination and Treatment Protocol (TP) for Nurses
TP-xx
Backache
6.
Urinalysis:
Yes
No If yes, list result: _____________________________________
124
Examination and Treatment Protocol for Nurses
TP-xx
Headache
125
Standing Orders Guidelines for Nurses
In the event nurses are authorized to administer and dispense drugs in the absence of a physician or pharmacist, clear
written administration and dispensing guidelines in line with MOH regulations must be in place. This could be in the form
of a “standing order” or a “routine order” from the responsible physician.
Note: The guidelines listed below are to be used as a reference to assist you in developing your own standing
orders/protocols.
126
Standing Orders (SO)
Refer to Physician
Treatment/Education
Give isopto cetamide eye drops every 4 hours.
Check G6PD status. Refer severe cases.
Conjunctivitis (mild)
Give erythromycin eye ointment to be applied at bedtime. Erythromycin and isopto
cetamide require a physician’s
If no improvement in 48 hours, refer to physician. order.
Patch the affected eye with an eye pad. Refer all cases.
Flash Burn of Eye Analgesics require a physician’s
If indicated, apply analgesic.
order.
Check vision on eye chart and record prior to eye
examination.
If simple foreign body, apply novesine 0.4%, 2 drops; Refer all cases Stat.
remove foreign body with sterile cotton bud.
Foreign Body in Eye
Use normal saline as eyewash after removal. Novesine requires a physician’s
Other foreign objects: perform first aid treatment only, order.
apply novesine 0.4%, 2 drops, cover eye with eye patch.
Reevaluate in two hours.
If no evidence of acute irritation, recommend cold
compress 3 times a day.
Itching Sensation in Prefrin-A requires a physician’s
Give prefrin-A 1-2 drops, every 6 hours.
Eyes order.
Advise patient to return If no improvement in 48 hours,
refer to physician.
Apply warm, moist compressed for 15 minutes four times
a day (qid).
Give isopto cetamide eye drops every four hours and
Sties Erythromycin eye ointment at bedtime.
Check G6PD status.
Advise patient to return if condition worsens or persists
longer than 3 days.
Give first aid treatment.
Cover both eyes with normal saline pads.
Trauma to Eyes Refer all cases.
Immobilize impaled object.
Check tetanus status.
Refer if foreign body appears
If foreign body (such as fly) appears easy to remove,
impacted (such as a bean or small
Foreign Body in Ear irrigate with warm normal saline solution using bulb
stone) or is difficult to remove by
syringe.
irrigation.
Other Eye Complaints Refer all cases.
Apply otosporin ear drops every (q) 6 hours.
Ear Discharge, Ear Never plug ears with cotton.
Refer all cases.
Pain Give panadol per schedule dosage for pain.
Give Auralgan ear drops for earache.
127
Standing Orders (SO)
Refer to Physician
Treatment/Education
Irrigate with warm saline solution only if patient has no
history of perforation of tympanic membrane or otitis
media.
Impacted Cerumen Refer all cases.
If unable to remove, use murine ear drops (carbamide
peroxide), 5-10 drops twice a day (bid).
Examine ears for underlying infection.
Refer if not previously diagnosed.
If this is the first instance of allergy, give antihistamine
Allergic Rhinitis Refer if no improvement after
and refer to a physician.
taking medication.
Examine nasal passages.
Keep patient’s head erect, pinch side of nose against
septum for five (5) minutes.
Epistaxis (minor)
May apply vaseline gauze nasal packing if necessary.
Check and record blood pressure and pulse prior to
physician referral.
Mild Throat Irritation
with Normal Recommend warm saline gargles or mouth spray.
Temperature
Mild Sore Throat with Give panadol per schedule dosage.
Temperature of 38 °C Recommend warm saline gargles or mouth spray.
Tonsillitis with Recommend warm saline gargles or mouth spray.
Refer all cases.
Temperature of 38 °C Give panadol per schedule dosage.
Give romilar expectorant, 2 teaspoon (tsp) every 4-6 Refer if persistent or recurrent
hours, as needed. cough.
Cough Associated Refer if cough is associated with
with Common Cold any of the following: weight loss,
See nursing protocol for upper respiratory infection.
elevated temperature, purulent
sputum or hemoptysis.
Give liquid Maalox (antacid) 2 teaspoon every 4 hours or
Maalox tablets, 2 tablets every 4 hours. Refer recurrent cases.
Heartburn/ Provide dietary advice: reduce spices, fried foods, etc.
Indigestion
Refer if chest pain remains a
possibility.
Nothing by mouth (NPO) till evaluated.
Monitor vital signs.
Vomiting Refer all cases.
Give anti-emetic for severe cases.
Close observation.
Refer in sickle cell disease and if
severe cases associated with any
Abdominal Pain Refer to facility’s Nursing Protocol. of the following: nausea,
vomiting, fever, tenderness and
abdominal guarding.
Refer to facility’s Nursing Protocol. Refer severe diarrhea.
Refer all severe cases associated
Diarrhea Give imodium (Loperamide HCL), 2 capsules (4 mg)
with any of the following:
initially, then 1 capsule every bowel movement (qbm);
nausea, vomiting, fever, blood in
maximum of 8 capsules (16 mg) in 24 hours.
stool and dehydration.
128
Standing Orders (SO)
Refer to Physician
Treatment/Education
Give milk of magnesia 2 tablespoons (tbsp) (2 oz) or
dulcolax 1-2 tablets at bed time. Refer constipation associated
Constipation with abdominal pain, nausea
Advise patient to increase fluid intake, fruit and and/or vomiting.
vegetables in diet and moderate exercise.
Give anusol suppository and advise sitz baths, 20-25
Hemorrhoids minutes daily. Repeat process every day until relief is Refer all cases.
obtained.
Rectal Bleeding Refer all cases.
Burning and
Refer to facility’s Nursing Protocol on Urinary Tract
Frequency of Refer all cases.
Infection.
Urination
Refer to facility’s Nursing Protocol on Urinary Tract
Urethral Discharge Refer all cases.
Infection.
Pain Suggestive of
Refer all cases.
Renal colic
Gross Hematuria Refer all cases.
Acute Scrotal
Refer all cases.
Swelling and Pain
Apply analgesic balm and give panadol per schedule Refer if more than two days
Generalized dosage. duration.
Musculoskeletal Ache
or Pain If associated with common cold or sore throat, treat as Refer if temperature is elevated
common cold or sore throat. over 38 °C.
Localized with no redness or swelling, give panadol per Refer if associated with any of
schedule dosage and analgesic balm for local application. the following: redness, swelling,
Joint Pains Advice hot compresses or sitting in hot bath. elevated temperature.
If associated with common cold or sore throat, treat as Refer if condition worsens or
common cold or sore throat. persists.
Apply vaseline ointment.
Dry Skin Give lanolin, ½ ounce (oz).
Dry Lips Give vaseline ointment.
Apply calamine lotion locally.
Heat Rash Advise patient to keep skin dry, bathe only once a day,
avoid bathing in hot water, wear lightweight clothing.
Advise warm water or saline compresses.
Refer if boil is on nose or upper
Give bacitracin ointment four times a day (qid) if lesion lip.
not ready for incision and discharge (I&D).
Boils
Give panadol to relieve pain per schedule dosage. Refer if signs of cellulitis.
Refer if multiple boils, recurrent
Change dressing daily.
or with abscess formation.
Refer if acute with maceration or
In chronic phase with scaling, give daktarin powder or infected.
Athlete’s Foot
canesten cream and advise good hygiene. Medication requires physician’s
order.
For removal of corns apply 1 drop of collomack solution
in the morning and evening. After a few days of
Corns Refer if diabetes or infection.
treatment, soak foot in hot bath to loosen the corn for
removal.
Apply 1 ounce of kwell shampoo and rub vigorously for 4
Kwell shampoo requires a
Lice (Head) minutes, then wet hair with warm water and rinse
physician’s order.
thoroughly. Repeat treatment in one week.
129
Standing Orders (SO)
Refer to Physician
Treatment/Education
Give Kwell cream or lotion.
Apply a thin layer to hairy infected areas and adjacent
areas.
Leave on overnight (8-12 hours) then wash off. Kwell shampoo requires a
Lice (Body)
physician’s order.
Repeat application in one week.
Discuss hygiene/contagion.
Family members may need treatment.
Apply povidone-iodine 10% (clonidine) or 70% alcohol to
Herpes Simplex the affected area. Requires a physician’s order.
Lacerations (if Minor) Evaluate need for tetanus toxoid immunization and
immunize as indicated. Refer if patient returns with
persistent pain or signs of
Advise patient to return if pain persists or signs of infection.
infection appear.
130
130
Standing Orders (SO)
Refer to Physician
Treatment/Education
131
131
Staff Competency Assessment and Development
The provision of patient care in healthcare is a very challenging and dynamic profession. Therefore, each
proponent organization shall ensure that their facilities’ employees have the knowledge, skills, ability and
behavior required to perform task(s) correctly and skillfully in order to provide quality care to all patients.
Since employees are required to demonstrate their competency levels, the facility must conduct competency
assessment before the employee is assigned to the task(s) and on an annual basis.
A training plan shall be developed based on individual assessment outcome(s).
Assessing the knowledge, skills, and abilities of an employee requires more than the use of a checklist and a
test. It entails the assessment, maintenance, demonstration, tracking, and improving/correcting the
competence of the target staff. As an ongoing process, competency assessment must have the initial
development, maintenance of knowledge and skills, educational/training sessions and correction of the
deficiency.
The Staff Competency program is a comprehensive program that begins with the hiring of competent staff
and continues with a competency-based orientation. This is made up of general orientation competencies,
specific competencies, mandatory and annual competencies. Continuing education and annual competency
evaluation of healthcare providers provides a means of improving and reinforcing their abilities.
x General Competencies – are competencies which are common to all medical positions in the remote
area clinics (RACs) and which start at the education unit and continue in the assigned medical facility.
x Specific Competencies – are competencies which are unique to the facility where the nurse and other
healthcare providers are assigned. These include: Emergency skills competencies, ambulance equipment
familiarization and basic operation for ambulance drivers. This involves teaching new skills required to
perform the job safely and effectively.
x Mandatory Competencies – are topics of high importance and for which periodic training is mandatory
and without which employee cannot continue to practice, such as Basic Life Support (BLS) certification.
x Annual Competencies – are competencies based on each clinic needs and are mandatory for each
employee. These include fire safety, infection control, etc.
2. Ensure new hires meet the minimum qualifications for clinical practice and that nurse demonstrates
competency in all privilege areas. The assignment to specified areas of clinical practice and the type of
frequency of clinical supervision is decided by the review of the employee’s background and experience.
3. Reevaluate the clinical competence factors, should a change in job function/assignment and/or a
new/additional area of practice be added.
4. Develop a training and development plan based on the results of individual evaluation(s) with specific
target dates for completion.
132
Apply the following methods for correcting deficiencies, taking into account the extent and seriousness of
the determined deficiency:
a. In-service education.
b. Consultation.
c. Change in type of supervision of employee.
d. Change in clinical practice area.
5. Incorporate additional activities to assist in ensuring continued competence. These include: review of
approved nursing standards/practices, nurse's attendance of workshops/seminars for continuing
education and in-service education programs.
133
133
Emergency Skills Competency Assessment
Competency Assessment
NO.: Item to Assess - Nurse shows competency by demonstrating the following: YES NO
1 Airway Management:
1-1 Able to use naso and oropharyngeal airway.
1-2 Able to use pocket mask and bag-valve mask resuscitator/ambu.
1-3 Able to perform suctioning.
1-4 Able to perform laryngeal mask airway (LMA) insertion.
1-5 Able to administer oxygen with different type of masks.
2 Able to administer basic life support (BLS).
3 Able to use automated external defibrillator (AED).
4 Electrocardiogram (ECG) Management:
4-1 Able to use a 12 lead ECG machine.
4-2 Able to differentiate between normal and abnormal rhythms.
5 Able to use an infusion pump.
6 Able to apply immobilization techniques (neck/limbs/spine).
7 Able to apply hare traction.
8 Able to use a Kendrick extrication device.
9 Able to manage external bleeding.
10 Able to administer Entonox.
11 Able to manage anaphylactic shock.
12 Able to manage acute chest pain – chest pain protocol.
13 Able to manage the initial management of burns – burn protocol.
14 Able to activate a disaster response.
15 Able to complete the pharmaceutical, drug familiarization program.
Yes Scores 7.1 Points No Scores 0 Total Score
Remarks:
Action Plan:
Action in the event of failure is to enroll the employee into the appropriate competency development program and
conduct a second competency assessment exactly one month from the initial assessment.
134
Ambulance Driver Competency Assessment
Competency Assessment
NO.: Item to Assess - Driver shows competency by demonstrating the following: YES NO
1 Able to administer basic life support (BLS).
2 Able to administer first aid (FA).
3 Able to operate ambulance communication device(s).
4 Able to operate ambulance siren and flashing lights.
5 Able to perform basic operation of the following ambulance equipment:
5-1 Oxygen.
5-2 Suction machine.
5-3 Collapsible/other stretchers.
5-4 Kendrick extrication device (KED).
5-5 Hare traction.
6 Able to apply standard precautions.
7 Able to apply patient and scene safety.
8 Ambulance maintenance:
8-1 Able to properly clean the ambulance, interior and exterior.
8-2 Able to perform daily vehicle condition checks.
8-3 Able to conduct ambulance preventive maintenance.
9 Able to verbalize his role and responsibilities in the event of emergency/disaster response.
10 Safety: Management:
10-1 Able to apply general road safety/speed limits.
10-2 Able to appropriately use safety triangle.
Yes Scores 10 Points No Scores 0 Total Score
Remarks:
Action Plan:
Action in the event of failure is to enroll the employee into the appropriate competency development program and
conduct a second competency assessment exactly one month from the initial assessment.
135
Employee Orientation
Orientation is a comprehensive process that introduces new hires to the organization and to their roles and
responsibilities within the facility.
Types of Orientation
1. General Orientation
2. Unit/Area-Specific Orientation
Core Elements of General Orientation include but are not limited to:
1. Infection Control.
2. Environment of Care Program (security, fire, Hazmat, disaster, etc.).
3. Confidentiality/privacy of health/patient information.
4. Patients’ Rights and Responsibilities.
5. Organization’s Mission and Vision, operation, organizational chart and chain of command.
6. Reporting occurrences/incident.
7. Official forms of communication (policies and procedures, operating manuals, etc.).
8. Prevention of injuries in the work place.
9. Familiarization of new employees with general work rules and contract agreement as applicable.
Unit/Area-Specific Orientation
An “on-site” specific orientation designed to introduce the new nurses to their new work environment, area
of medical response, local policies and procedures and the day-to-day specific activities of the facility they are
assigned to.
Unit/Area-Specific – Benefits:
1. Introduces new employees to all aspects of the work.
2. Provides job-specific orientation to the individual’s specific job description, provided in his/her assigned
area.
3. Helps new employees become acquainted with the correct way to perform their job and help him/her
know what to expect and what is expected of him/her in their new job.
4. Acquaints new employees with individuals and resources available to help them perform their jobs more
effectively.
Employee Orientation
ATTACHMENT – 21
Page 1 of 3
136
136
Core Elements of Unit/Area Specific Orientation include but are not limited to:
1. Job responsibilities and work practices.
2. Facility’s policies and procedures.
3. Necessary requirements to maintain professional status.
4. Work schedule and work distribution.
5. Environment of Care Program:
a. Disaster Plan.
b. Fire safety and fire plan.
c. Equipment handling safety.
d. Material Safety Data Sheets (MSDS).
e. Preventive maintenance.
f. Occurrence reporting.
6. Quality Improvement Activities:
a. QI/QA/QC programs.
b. Annual Competency requirements.
c. Performance appraisals.
7. General infection control practices:
a. Cleaning.
b. Waste management.
c. Personal protective equipment (PPE).
d. Standard precautions.
e. Hand washing.
Employee Orientation
ATTACHMENT – 21
Page 2 of 3
137
137
Ambulance Driver Specific Orientation
All items listed below shall be completed within two (2) weeks of site assignment, except for items marked
with an asterisk (*), which must be successfully completed prior to site assignment.
The company will implement and administer an ambulance driver orientation and competency program to
include the following:
1. Facility orientation.
2. Work site orientation.
3. *First aid.
4. *Basic Life Support (BLS).
Basic Ambulance operation:
5. a. Use of communication device.
b. Use of siren and flashing lights.
Ambulance equipment familiarization and
basic operation:
a. Oxygen.
b. Suction machine.
6.
c. Collapsible/other stretchers.
d. Kendrick extrication device (KED).
e. Hare traction.
f. Other.
7. Standard precautions.
8. Patient and scene safety.
Ambulance maintenance:
a. Cleaning.
9.
b. Daily vehicle condition checks.
c. Preventing maintenance schedule.
Emergency/disaster response, role and
10.
responsibilities.
Safety:
11. a. General road safety/speed limits.
b. Use of safety triangle.
12. Other.
138
138
Continuing Education and Training
Education and training provide employees with the knowledge and skills necessary to provide a high standard
of patient care.
Types of Education and Training Programs
1. Ongoing Education and Training
2. Continuing Education (CE)
Purpose
The CE program is intended to maintain and improve the knowledge and skills of certified healthcare
providers (i.e., nurses, doctors), therefore enhancing the quality of service provided to patients. Therefore, it is
necessary that every proponent organization establish a CE service design to provide administrative oversight
and program coordination for continuing education.
139
First Aid Kit
First Aid Kit (36 unit size) shall be available with the following supplies.
1000132641 Tourniquet.
Safety Devices
140
140
First Aid Kit
141
141
First Aid Kit
142
First Aid Kit
143
143
First Aid Cabinet and Contents
Specification:
1. Must be no less than 85 cm long x 45 cm width x 30 cm diameter.
2. Must be made of hard wood or metal and be provided with a lock and the Red Crescent insignia and the
words “First Aid Cabinet.”
3. Must be ready for use and accessible at all times.
4. Must be restocked up after each use.
144
144
Policies and Procedures
Policies and procedures are facility specific instructions and guidelines regarding the day-to-day
activities/operation of the medical facility.
General Guidelines
1. Each organization is responsible for developing specific policies and procedures for its medical facility.
These policies must be updated and revised every three (3) years. Revisions are approved by an
authorized medical representative, and dated to identify the review date.
2. Policies and procedures shall be available to all concern staff. These policies include but are not limited
to:
General Guidelines
Note: Should you require a sample of any of the above policies, please contact the Remote Area Urgent Care
Facilities Group Leader. He can be contacted at 03-877-3459 or 03-877-3338.
Policies and Procedures
ATTACHMENT – 25
Page 1 of 1
145
145
Floor
Floor PlanPlan Specifications for
Specifications for Category
Category“C”
“C”Facility
Facility
Multiple rooms and integrated staff accommodation.
Multiple rooms and integrated staff accommodation.
With central or split-level filtered air conditioning unit (A/C), covered ambulance parking and ramp for stretcher.
5. Saudi Aramco Medical Services Organization’s Medical Services Policies (MSPs) and
Operating Manuals (OMs).
148
148
Section 7 – Appreciation
Our thanks and appreciation to the following subject matter experts (SMEs) for their valuable
contribution to this manual:
x Ali Hammoud, QI Advisor, Remote Area Clinics Group/Medical Consulting and Quality
Assurance Division (MC&QAD)/Medical Designated Facilities Department (MDFD)/Healthcare
Development Organization (HDO)/Saudi Aramco Medical Services Organization (SAMSO).
x Curtis Roberts, QI Advisor, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
x Eduarte B. Cocos, QI Advisor, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
x George Williamson, QI Advisor, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
x Hamed J. Said, Group Leader, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
x Dr. Hatem K. Herzallah, Unit Head, Medical Professional and Technical Support/MC&QAD/
MDFD/ HDO/ SAMSO, for allocating the time for the collation of this manual.
x Russel Isaiah, QI Advisor, Remote Area Clinics Group/ Remote Area Clinics Group/MC&QAD/
MDFD/ HDO/ SAMSO.
x Terry Nihil, QI Advisor, Remote Area Clinics Group/MC&QAD/ MDFD/ HDO/ SAMSO.
x William McDowall, many thanks for all the help in putting together the first draft of this manual
and widely admired for his vast and unrivalled knowledge and experience in this field, for his
valuable input and diligent proofreading.
And our special thanks and appreciation to our distinguished Management (Dr. T.Q. Al-Daiel, Dr.
Saad A. Missmar and Dr. Moh’d Fawzy Younis), without whom this manual would not have been
possible.
Sincerely,
_______________________________________
Jacques D. Cheong, Quality Assurance
Coordinator
Remote Area Urgent Care Facilities Group
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