king faisal specialist hospital & research center p.o. … · facility tour abdullah 35000 roof...

Date: 11-Mar-14

JCIA Surveyors: Sharon James

Escort: Akram Bashaireh Time: 09:00-12:00

Scribe: Akram Bashaireh

Session Staff Location

Facility Tour abdullah 35000 Roof

Transcriber:

• Went to the roof of DPS and observed the whole area/ no exit sign in

KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTER

P.O. Box 3354, Riyadh, Saudi Arabia

JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• Checked on fire extinguisher from the last tour/ it was done.

need to have the label as long as the employee can use it anytime in the

• Education reccomended to the employee working there in the nature

• She checked on morgue drawers/ they were very clean.

management is aware and will work in removing it.

housekeeping and another vendor.

• Asked whether the window is washed/yes, there is a contract between

• There was big piece of concrete needs to be removed. The facility

• Where it says that the extinguisher is compatible with the MRI field/ No

MRI rooms

of the fire extinguishers in MRI rooms

the roof/ upgrade the hospital signs was explained by safety officer, and

fix it and they are working on it as explained by the project management.

exit sign will be placed there.

• There is broken window in the North Tower wall/ there is a arequest to

Date: 11-Mar-14





Facility Tour Naser 31089

Clinical

Engineering

Transcriber:

• Type of work in clinical engineer and maintenance.



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• Wants to check inventory.

labelled as whole.

• Went through the inventory process/ explained by the engineer

vendor equipment will be assigned to one of the C,E department to work

• Inventory process explained by Engineer Nasser

and oversight with the vendor

• Engr. Nasser gave overview about the department, staffing.

• Asked about the gas control (vacuum, medical care), should be

• Went through the endoscope workshop/ was perfect

31000 equi about 97% of them are in house and 3% contracted. The

• Do all departments use the same the work request No.

• Process of how and who manages outside vendors/ C.E. inventor

Date: 11-Mar-14





Facility Tour

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• Asked if every engineer get his own assignment/ Yes according to

schedule.

• Goes over the retirement plan in C.E./ explained very well

• Asked about the IV pump 82509, last preventive maintenance done.

There was work order done/ case is open which is automatic/ last

service October 2013 completed/ no comments from surveyor

• Asked about smart pumps, the project was explained by the engineer

• IVP 86360 in A4/ Unlocated PM, means that the pumb was not found ,to

generate a amemo for maintenance

• Asked about type of pumps according to department/ explained by

the engineer.

• IVP 099260 in C2, PM completed on August 2013 passed/ no comments

Date: 11-Mar-14





Facility Tour

Pearl RT supervisor

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• IVP 97053/ Anesthesia OR2, PM complete January 2014/ no comments

• IVP 0008821/ this is not a tag number, so the pump information can't

be detected from the system.

• The surveyor asked about the Blood gas machine in ICU-D, who is doing

the point of care testing and the maintenance in such machine/the

answer was that the RT and biomedical engineer do the maintenance

together with vendor/ and C.E. do all the POCT and PM. And if it's a using

issue it will be dealt with the RT

•according to the standard AOP 5.4, labaratory department should have

the oversight over those machines including the POCT testing

External contract with company to fix

• the RT supervisor was called and explained in the phone that the

machine has the character of what called (intelligent QM), where the

POCT will be done internally by machine after each sample

• the surveyor asked what Information that goes to lab When receiving

new device/ Nothing.

• Are you CAP accredited/ No.

Date: 11-Mar-14





Facility Tour

Manhal Radiology

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• What is the CAP survey/ Went through process

• How many blood gas machine you have and where are they located/

22, and the surveyor wrote down the locations

• Who operates those machines/ RT technician and anesthesia

• Back to the Engineer and asked what kind of data you collect before

you participate in purchasing new equipment? The surveyor gave an

example of a request from a physician to buy new device in his unit/ the

engineer went through the process in details highlighting the most

important thing to focus on before the decision will be made to purchase

and use new equipment in KFSH, the surveyor was satisfied with process

• The surveyor asked about the capital budget when purchasing new

equipment/ explained by the engineer .

• The surveyor visited the Radiology department and asked whether the

radiology oversee the whole lead aiprons in the hospital/ yes

• Asked if the inventory in the radiology to the whole hospital in this

regards/ yes

Date: 11-Mar-14





Facility Tour

Transcriber:



JCIA Survey 2014

SCRIBE NOTES

Question/Issue

• Asked about reporting the finding from the CT and MRI/ the radiology

supervisor went through the process in details.

• The surveyor went together with radiology supervisor to her office to

check on certain documents, she did not request anybody to accompany

her

king faisal specialist hospital & research center p.o. … · facility tour abdullah 35000 roof...

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