Hospital Random Inspection Checklist N/A Remarks

1 Hospital Random Inspection Checklist Checklist 1 Ref. No. HRD/QAS/FMU/009 Hospital Random Inspection Checklist Hospital Name: Facility License No.: Date of Inspection : / / Start time: End time: Ref. Description Yes No N/A Remarks 13. Operation Theatre Operation room is equipped with the following: minimum of one back up anesthesia machine Cautery equipment ECG machine Emergency/ crash cart Suction machine Appropriate size pediatric medical equipment must be available if services are provided to infants/children Calling station The scrub facility shall be located adjacent to the operation room(s) -Staff changing area shall be separate for males and females. It must contain special entrance for the staff and suitable place for changing of clothes with a minimum of one toilet for the staff in this area.

2 -Toilets air pressure should be kept negative pressure with respect to any adjoining areas -Sterilizing area can be located near operating room(s) with adequate high-speed autoclave machine Hospital Random Inspection Checklist Checklist 2 Ref. No. HRD/QAS/FMU/009 -Sterilizing area air pressure should be kept negative pressure with respect to any Adjoining areas - Relative humidity should be maintained at 30% to 60%. -Recovery area must be properly equipped with at least one bed for each operation room - Each recovery area shall be at least square meters per bed. -Recovery area air pressure should be kept at balanced pressure with respect to any adjoining areas -Relative Humidity should be maintained at 45% to 55%. High efficiency filters should be installed Medical store located in operation area should have: -Adequate number of all types of intravenous solutions -Emergency medications -Required anesthesia medications -Store's air pressure should be kept positive -Relative humidity should be maintained at 30% to 60%.

3 14. Critical Care All general Hospital shall provide Critical Care services; this may include -Intensive Care Unit (ICU) -Coronary Care Unit (CCU) -Neonatal Intensive Care -Unit (NICU) or Burns Unit. Hospital should provide one critical care bed for each operation theater Critical care unit has the following necessary equipment & supplies: Ventilators (see appendix 1 regarding ventilator specifications) Tracheotomy set Hospital Random Inspection Checklist Checklist 3 Ref. No. HRD/QAS/FMU/009 Emergency/ crash cart with a plastic breakable seal that can be easily removed during emergency. It must be equipped with defibrillator, necessary drugs & other CPR equipment & test strips. A log book must be nearby to indicate the maintenance & regular check of the crash cart & its components Pulse Oximetry & vital signs monitor Transfusion pumps Vital Signs Monitors Blood gas analyzer with capability for electrolytes measuring should be available in the Hospital (preferably at ICU facility) -Temperature maintained at 21 C 24 C.

4 -Relative humidity 30 % to 60% 15. Airborne Infection Isolation (AII) Room At least 1 airborne infection isolation room Applicable to ICU, NICU, ER & General ward Isolation rooms design requirements shall include but not limited to the following: The isolation room should be independent from other critical care area A separate toilet with bathtub (or shower) shall be provided for each Patient room. A hand-washing station shall also be provided for each patient room Additional hand-washing or hand rub station outside the room entrance maybe provided An area for gowning and storage of clean and soiled materials shall be located either directly outside or inside the entry door to the patient room -should be kept at negative pressure relative to the adjacent areas. -The area temperature should be maintained at 24 C plus or minus 1 C.

5 High-efficiency filters should be installed in the air handling system 16. Emergency Area Emergency Entrance Waiting Area Hospital Random Inspection Checklist Checklist 4 Ref. No. HRD/QAS/FMU/009 Consultation room 1 Triage room Observation bed area Minimum of 2 treatment rooms Resuscitation Area Patient toilet At least one dedicated toilet for handicapped patients/visitors equipped with safety hand rails and suitable hand washing sink Storage areas Ambulance vehicle: well-equipped ambulance vehicle(s) should be ready with qualified medical staff for patient transportation -Temperature maintained at 24 C + 1 C. -Relative humidity 30% - 50% 17. Delivery Suite Obstetrical program models vary widely in their delivery methodologies.

6 The models are essentially of three types: Traditional Model Labor-Delivery-Recovery (LDR) Model Labor-Delivery-Recovery-Postpartum (LDRP) Model LDR and LDRP rooms shall include an infant stabilization and resuscitation space with a minimum clear floor area of at least square meters and shall be equipped with the following: Hand washing sink Satisfactory equipment and supplies required for delivery Call systems Medications Each LDR or LDRP room should be for single occupancy Hospital Random Inspection Checklist Checklist 5 Ref. No. HRD/QAS/FMU/009 Newborn nursery equipped with adequate infant beds & incubators for the premature babies Delivery Suite must be maintained at 20 - 23 C & relative humidity 45% to 55% 18. Inpatient Service Areas Calling system shall be next to each bed.

7 Appropriate dedicated area for medical equipment, medications & supplies is provided Temperature maintained at 24 C or less. Relative humidity 30 % to 60% 19. Outpatient Areas A reception/information counter or desk shall be located to provide visual control of the entrance Male and Female waiting area for patients and escorts shall be under staff visual control Waiting area is provided with of drinking water & public telephone The seating area shall contain not fewer than two spaces for each examination and/or treatment room Pediatrics service - a separate controlled area for pediatric patients Wheelchair is accommodated within the waiting area Male and Female toilet(s). A hand-washing station shall be provided in the toilet room Consultation, Examination and Treatment Rooms at least shall meet the following: Must be provided with hand washing station Hand sanitization dispensers shall be provided Provisions for hand drying shall be available at all hand-washing stations Treatment rooms for minor procedures, specific treatment or casting shall have: Hand-washing station shall be provided in all treatment rooms.

8 Documentation space or counter for writing shall be provided A lockable refrigerator for medication use. Hospital Random Inspection Checklist Checklist 6 Ref. No. HRD/QAS/FMU/009 Locked storage for controlled drugs (if used) Temperature maintained at 23 C + 1 C. Relative humidity 30% to 60% 20. Clinical Laboratory Kindly use the Clinical Lab Random Inspection Checklist . Ref. No. HRD/HRS/FRU010 21. Diagnostic Imaging Kindly use the Diagnostic Imaging Services Random Inspection Checklist . Ref. No. HRD/HRS/FRU000 22. Pharmacy Pharmacy shall consist of the following A room or area for receiving, breakout, and inventory control of materials used in the pharmacy Work counters and space for automated and manual dispensing activities A compounding area. This shall include a sink and sufficient counter space for drug preparation.

9 An area for temporary storage, exchange, and restocking of carts Security provisions for drugs & personnel in the dispensing counter area, if one is provided Secure storage is provided for narcotics & controlled drugs as per the Ministry of Health (MOH) laws & regulations If the functional program of the Hospital requires dispensing of medication to Outpatients, an area for consultation and patient education may be provided. Optional A hand-washing station shall be provided either in an anteroom or immediately outside the room where open medication(s) are prepared Intravenous (IV) solutions are prepared in the pharmacy, a sterile work area with a laminar- flow workstation designed for product protection Separate room shall be provided for preparation of Cytotoxic IV admixtures under a Class II: Type B1, B2, B3 or Class III biological safety cabinet Cabinets, shelves, and/or separate rooms or closets shall be provided for bulk and Hospital Random Inspection Checklist Checklist 7 Ref.

10 No. HRD/QAS/FMU/009 refrigerated storage Drugs & devices must be stored according to the manufacturer s instructions The supply of drugs, devices & biologicals must be checked on a regular basis Temperature should be maintained at 23 C plus or minus 1 C & relative humidity 30% to 60% 38. Nutrition Services Strict hygienic conditions should be maintained in the kitchen during preparing, storing & serving food An experienced, qualified & DHA licensed clinical dietitian with at least bachelors degree in nutrition supervises this service. Catering Service area ventilation & air exchange is maintained as per ASHRAE requirements Catering Services (Health Facilities Guidelines: Planning, Design, Construction and Commissioning) Equipment sanitization Fire protection systems Administration areas Pest controls Kitchen waste collection, segregation and removal from site Emptying of grease and waste traps LPG Storage and Leak Detection System 39.