CBAHI Training Program

and FAQs
2023
CBAHI FAQs

Are you ready for the survey?

(Frequently Asked Questions)

How the survey will be conducted?
Q.3:
Leadership-LD
Q: Describe your scope of service :(All Staff)
The Center includes various medical specialties as follows:

Specialty Clinic per week

Dermatology 6
Obstetrics and gynecology 6
Nutrition 5
Dental 24

Q: Describe your chain of command: (All Staff)

❖ Be familiar with the facility organization chart.
❖ Show how to access your org. chart on the shared folder (if requested).
❖ Be familiar with your delegation of authority.
Q: What’s your mission, vision and values
(All Staff)
 Mission
We commit to provide the most updated medical services with the highest quality to all western region of Saudi
Arabia citizens

Vision
Master's clinics is looking forward to have distinctive leading position in the provision of medical
services at the level of the western region of Saudi Arabia

Values
1. Patient Safety and satisfaction
2. Quality Performance
3. Honesty
4. Respect
5. Trust and confidentiality
6. Teamwork
7. Excellence and creativity
 Executive Committee
Medical Executive Committee
General Director/Deputy General
Medical Director/
Director

❑ Mission, Vision , Values ❑ Medical Staff appointment and

reappointment, evaluation, appraisal
❑ Strategic Plan Heads of Departments

❑ Org, Chart ❑ Credentialing and privileging.

❑ Review and approval of all Quality Director/ ❑ Medical Related KPIs.

organization wide P&P, Programs, Manager
Plans including quality , patient
safety safety and risk management ❑ CDI program,

❑ Review and approval of budgeting All Staff (Clinic shared ❑ Medication management process.
plan folder, emails,
meetings,..) ❑ Antimicrobial stewardship program.
❑ Oversight of contracts
❑ Review and evaluate the clinical care
rendered in the clinic.
❑ Review the patient complaint and
satisfaction reports
❑ All medical related events
❑ Investigate, Discuss and solve any
ethical matter
 Q: How do you access your policies? (All Staff):
All the policies, programs, forms are available on the Quality Portal ( Shared Folder)

Q: How do you ensure having the right budget? (Managers)

• The accounting department asks the heads of the departments to fill their budget plan at the
begining of year .
• Show your budget plan (if requested).
Q: HR related questions:
▪ Can you describe your recruitment process? (HR/ Managers)
• Explain your recruitment process and show the policy on the shared folder (if requested by the
surveyor).

▪ Do all staff have clearly written job descriptions? (All Staff)

• Make sure that all staff have written and signed job description upon hiring and updated every 3
years.
• All staff need to be aware of their job description.
• Staff are evaluated according to their job description.
Q. How do you do your staffing plan? (HR/ Managers)

▪ The HR department communicates with the heads of the departments to fill their manpower plan
At the beginning of the year for the coming year, then communicated with the HR.
▪ Final approval of the manpower plan is granted by the executive committee.
▪ Be familiar with your staffing plan and how to access it.
 Q: Can you describe the credentialing and privileging processes? (HR/Physicians)

▪ To the extend possible, credentials are verified from the original source or through third party
(Dataflow).
▪ For the privileging, upon hiring every physician is requested to fill the delineation of privileges
form, then this list is discussed with the head of department and final approval is granted the
medical executive committee. Finally, the privileges are posted on the shared folder.
▪ Show your policy and procedure (if requested by the surveyor).
▪ Make sure that the personnel file of the physicians includes the “delineation of clinical privileging”
form upon hiring and updated every 2 years with the appropriate qualifications.
 Q: How the employees are oriented to the facility and to their job? (HR)
▪ Upon hiring, all employees attend a mandatory general orientation program.
▪ After the general orientation, the employee will attend a departmental orientation.
▪ Make sure that the personnel file of each employee include an evidence for the general
orientation and the departmental orientation checklist.
 Q: How do you ensure the competencies of nursing and other allied healthcare
staff?(HR/Nursing staff/Technicians)
▪ All nursing staff go through competency testing upon hiring and it’s repeated annually.
▪ Show your policy and procedure (if requested by the surveyor).
▪ Make sure that the personnel file of nurses and other allied healthcare staff include evidence of
competencies done upon hiring and repeated annually.

Q: How do you evaluate your staff performance? (All Staff)

▪ Staff performance evaluation is done at the of the probation period and is repeated annually.
▪ Evaluation is filled by the direct supervisor and is discussed and signed by the staff.
▪ Evaluation include personal development goals.
▪ Show your policy and procedure (if requested by the surveyor).

Q: How do you identify the training needs for the staff? (HR/ Managers)
▪ Training needs assessment is done by the head of department and discussed with HR in order to
identify the training needs and create the educational calendar on yearly basis.
Q: How do you protect the patient and family rights? (All Staff)
Q: Describe your complaint process. (All Staff)
▪ If a patient wanted to complain, he’ll be directed to the operation/patient relation manager
who’s responsible to hear the patient and try to solve his/her complaint immediately.
▪ Complaints are analyzed on quarterly basis and opportunities for improvement are
identified, discussed in the executive committee and implemented.

Q. How do you measure patient satisfaction? (All Staff)

▪ After each patient visit, a satisfaction link is sent to the patient.
▪ Satisfaction reports are analyzed every quarter and opportunities for improvement are
identified, discussed in the executive committee and implemented.

Q: How do you control your document? (Quality)

▪ Before initiation of any document, the department responsible communicates with the quality
manager who’s responsible for coding/tracking and communicating all approved policies and
procedures/programs.
▪ Show your document control tracking sheet to the surveyor.

Q. How frequent are your documents reviewed? (All Staff)

▪ Policies and Procedures are reviewed every 3 years.
▪ Programs/Plans are reviewed on annual basis.
Q: How do you report incidents? (All Staff)
• All incidents are reported through the incident reporting system (OVR). The quality manager do
the necessary investigation and actions.
• Show the system/form that you use when reporting.

Q: How do you manage your contracts? (Finance/operation/clinic/administrative manager)

• The operation/clinic/administrative manager provide oversight for all contracts.
• The decision to continue or to stop the contract is done based on the evaluation criteria and the
discussion in the executive committee.
• Show the database and the monitoring of these contracts (if requested by the surveyor).
Q: Quality, Patient Safety and Risk Management
Plan

Quality Patient Safety Risk Management

• Document control • Incident • Risk Matrix

• KPI Reporting (OVR) • Risk Register
• Improvement • OVR Analysis • FMEA
project(FOCUS
PDCA)
• Accreditation
• Committee
management.
• Medical Record
Review
Provision of care- pc
Q: How the patients are registered in your facility? (receptionist)
▪ Describe your registration process/ System is in place to book patients in advance.
▪ Show your policy and procedure (if requested by the surveyor).
▪ To be aware of the services that the center offers and to direct patients to the appropriate
services.
Q: How do you identify your patients? (All Staff)
▪ We identify the patient using 2 patient identifiers: Patient Full Name and Medical Record Number.
▪ Show your policy and procedure (if requested by the surveyor).
Q: How do you assess your patients? (physicians/nurses)

Comprehensive patient assessment in the first center’s visit.

▪ Show the documentation of the assessment of your patients on your screen:

o For Nursing: Nutritional Needs, Functional Needs, Presence/Absence of pain, Risk of fall,
Soocial Needs.
o For Physician: History & Physical Examination.
▪ Show your policy and procedure (if requested by the surveyor).
Q: What is the turn around time(TAT) of results:
▪ Turnaround time is the time calculated from receiving specimens till results appearing on the
system.
▪ TAT is not the same for all results,
▪ Know your policy and how to access it.

Q: How do you develop your care plan? Where do you document it? (physicians)
▪ The care plan is developed based on the individual patient needs and goals are set
accordingly.
▪ Show the documentation of the care plan on your SOAP notes.
Q: What is your process for granting informed consents? (Physicians/Nurses)

▪ The physician talks with the patient/family about risks, benefits, alternatives, and potential
complications of the Procedure requiring consent and ask them to sign the required consent form.
▪ Be familiar with the procedures in your clinic requiring informed consent.
▪ Show your policy and procedure (if requested by the surveyor).
Q: What are the main elements that you include when you refer the patient to get
consultation:(physicians/nurses)

▪ The reason for the consultation, the urgency and a brief description of the patient status.
▪ Show your policy and procedure (if requested by the surveyor).
Consultation policy & Consultation Request: MED/F/15/V#1

Q: If a patient become unstable, what do you do? (physicians/nurses)

▪ We activate code blue by shouting “Code blue”.

▪ CPR need to be initiated by the person who witnessed the code.
▪ Show your policy and procedure (if requested by the surveyor).

Q: How frequent do you check your crash cart? (nurses)

▪ We check the crash cart on daily basis & Monthly for the expiry dates.
▪ Demonstrate if requested.
▪ Show your policy and procedure (if requested by the surveyor).
Q: If the patient needed hospital admission, how do you transfer him/her?
(physicians/nurses)

▪ We have an agreement with hospital X , the medical director will contact them
and after hospital acceptance, ambulance will be sent to our clinic and patient will
be transferred.
▪ Show the transfer form(if requested by the surveyors).

Q: How do you receive critical results and to whom you report them?
(physicians/nurses)

▪ The head nurse is allowed to receive critical results from the lab or radiology.
▪ The head nurse shall document the critical result on the “Critical results Reporting Register”.
▪ She then shall relay the result to the ordering physician.
▪ Both receiving and relaying results should follow the read back rule and shall be documented in
the patient file.
Medication Management-MM
Q: What is a drug formulary? (nurses/physicians/pharmacist)
• A drug formulary is a list of pharmaceutical drugs, decided by the medical executive committee
to be used in the clinic.
• Show it to the surveyor (If requested)

Q: Where do you store your medications? (nurses/pharmacist)

• Medication are stored away from the sun and the humidity in a room where we monitor the
temperature and the humidity on daily basis.
• Show the medication storage policy to the surveyor if requested.
• Alternative Power Source for the medication refrigerators.
Q : Do you have a policy for handling expired and nearly expired medications?
(nurses/pharmacist)
• Medications that is nearly expired (within 3 months), shall be placed on the designated shelf for
nearly expired medications.

• Show the policy to the surveyor if requested

Nearly
Expired
Q: What’s the process of Handling LASA, High Alert Medication?
(nurses/physicians/pharmacist)
• The look-alike/sound-alike (LASA) drug names are stored separately.
• All LASA drugs are clearly labeled “LASA”, and High Alert are labeled with High alert label.
• Administration of High Alert require 2 nurses.
• Physicians are requested to clearly specify the dosage form, drug strength, and complete
directions on prescriptions & diagnosis.
• Show your policy to the surveyor (if requested).
• Independent double check should be followed
Q: How do you handle MDVs?: (nurses)
▪ MDVs are labeled with an opening date/ time and initial and expiry date is considered after 30
days.
▪ Familiarize yourself with the policy
Open date :
Expire date :
Time :
Staff initial :

Q: How do you report medications errors? (nurses/physicians/pharmacist)

▪ Explain the incident reporting system and how you report medication errors through the OVR
system/form.
Q: How do you ensure safe prescribing of medications :(physicians)
▪ All prescriptions are identified by accurate patient demographics including name, age and
medical record number.
▪ Allergy status is clearly identified on the prescription.
▪ For pediatric patients and frail elderly prescriptions, weight (kg) is identified.
▪ Abbreviations are not used in prescriptions. (refer to Use of abbreviations and symbols in clinical
documentation Policy).

Q. How do you prepare medications? (Nurses)

▪ Medications are prepared in an aseptic technique.
▪ Medications that are prepared and not immediately utilized are labeled with the medication
name, dose, route of administration, and patient’s identifiers.

Medication Name:
Dose:
Route:
Patient’s Full Name:
MRN:
Management of Information-MOI
Q: What do you do in case of system downtime? (Operation/clinic/manager/physicians/nurses)
▪ We activate “ Code Brown” and start the manual process after 30 min from continuous system
downtime.

Q: How do you ensure that each patient have a single medical record in the clinic?
(Receptionists)
▪ We ask the patient to show his national ID/Iqama and we verify his/her identity when he comes to
the reception in order to ensure retrieving/opening the appropriate file.

Q: Who is allowed to write in the medical records?

(operation/clinic manager/physicians/nurses)
▪ Familiarize yourself with the list of authorized entities to make entries in the medical record:
Healthcare providers, Physicians, Nurses, pharmacists.

Q: What do you do with the incomplete medical records? How do you ensure the effectiveness
of your clinical documentation improvement system?
(operation/clinic manager/physicians/nurses)
• On monthly basis, the team will conduct clinical review using the Medical Record Review Tool
and send the incomplete files to the concerned healthcare provider for completeness.
• Show the policy of Clinical Documentation Improvement Program if requested.
Q. How frequent is your system backed up? (Operation/clinic/administrative /IT manager)
▪ The system is backed up on daily and weekly basis.

Q: Are you allowed to use abbreviations in the medical record: (Nurses/physicians/other

healthcare providers)
▪ Yes, but only approved abbreviations list; Also, be familiar with the prohibited abbreviation list
available on the shared folder.

Q: How do you choose the patient diagnosis on the system? (Physicians)

▪ ICD 10 codes are available on the system.
▪ Training has been done to identify the right codes.
Infection Prevention and Control-IPC
 Q: What is the BEST way to prevent the spread of germs and infections? (All Staff)
▪ Proper hand washing or hand disinfection

Q: When do you perform hand hygiene? (All Staff)

▪ Familiarize yourself with the WHO 5 moments of Hand Hygiene:
o Before touching the patient.
o After touching the patient.
o Before an aseptic procedure
o After body fluid exposure.
o After touching the patient surrounding
▪ Waterless hand disinfectant or soap and water must be used:
o When entering & Leaving the clinic.
o After caring for 1 patient in the clinic, then moving to care for the other patient.
o After handling any equipment, dirty linens, or specimens
▪ You must use soap and water…
o Before eating.
o After using the restroom.
o Any time hands are visibly soiled
o After caring for a patient on specific precautions.
o When you feel a significant buildup of the waterless hand product on your hands (there is no
specified # of times you may use it).
Q: What personal protective equipment (PPEs) available? (All Staff)
▪ Gloves
▪ Masks
▪ Goggles
▪ Face shields
▪ Surgical caps
▪ Gowns
▪ N95 mask.

Q: What kind of isolations protection we have? (All Staff)

▪ Contact Precautions (ex., MRSA, ESBL)
▪ Droplet Precautions (ex., bacterial meningitis & Influenza)
▪ Airborne Precautions (ex., TB, Measles, SARS, Chickenpox, & Bird Flu)

Q: What “signage” do you use to indicate isolation precautions? (All Staff)

▪ Color-coded sign indicating the type of isolation precautions:

o Contact Precautions Green

o Droplet PrecautionsPink
o Airborne Precautions Blue
 Q: As an employee, how do you protect yourself from blood borne pathogens? (All Staff)
▪ I practice “standard precautions:” I wash my hands regularly and I wear the appropriate
personal protective equipment (PPE) as needed, properly, and consistently.
▪ I use safe work practices and safe needle devices: I never recap needles and if needed I apply
the “scoop methodology”, I discard the used needles in the sharp containers.
 Q: What do you do in case of needle stick injury? (All Staff)
▪ I put the wound or exposed area under running water
▪ I report to my supervisor immediately for appropriate actions.
▪ Then, I fill an incident reporting form.

Q: How do you handle waste disposal? (All Staff)

▪ Healthcare providers put the waste in bags according to the waste type and leave it for
housekeeping collection:

o Regular: White/Black bag.

o Medical Waste (infectious): Yellow bag with biohazard sign.
o Blood and blood products: red bag with biohazard sign.
o Sharp container: Placed in yellow biohazard bag when ¾ full.
Note: Sharp container are always hanged on the wall.
▪ Housekeepers collect the bags from the clinic and transport them to waste collection area in
covered trolley.
 Q. What do you do in case of encountering a patient suspected with communicable diseases?
(All Staff)
▪ We ask the patient to wear a mask.
▪ We transfer him/her to the designated isolation room for further assessment.

Q: How you ensure following appropriate sterilization rules? (nurses/infection control

Coordinator)
▪ Describe the steps you follow starting from the decontamination area, till packing, sterilizing and
distributing.
▪ Inform the surveyor about the competency that is done upon hiring and repeated annually.
▪ Chemical indicator are placed with every package.
▪ Biological indicator is done weekly.
▪ Sterilization parameters are kept for 1 year.
▪ Demonstrate the steps (if requested).
▪ Show the policy (if requested.).

Q: What about reprocessing of single used items:( Nurses/infection control Coordinator)

▪ Currently, we do not reprocess any single used items, we use disposables.
▪ However, in case in the future we had to reprocess single used items, this won’t happen unless
specific written instructions provided by the manufacturer being approved by the executive
committee.
Q. What kind of surveillances do you practice in the clinic (Infection control staff)
▪ Hand Hygiene surveillance.
▪ Bundle of care surveillance depending on the applicability of the bundles: Surgical Site Infection
(SSI).

Q: How do you handle your linen?/How frequent do you wash your curtains (All Staff)
▪ Dirty linen are collected by the housekeeping in closed trolley with hamper bags and then sent to
the laundry (contracted).
▪ Disposable Curtains and as per manufacturer that will be changing after six months.
▪ In case of any splash/in isolation rooms, curtains are immediately removed and sent for washing.

Q. If you have an expansion or construction in the clinic, how do you ensure proper isolation of
the area? When you do Routine environmental culture (Head nurse/infection control)
▪ We inform the staff responsible for infection control in the clinic.
▪ Infection control staff assess the construction prior construction and perform infection control risk
assessment together with the head nurse and the facility management staff.
Facility Management and Safety -FMS
Q. How to ensure the issues related to the facility management and safety shared with the
high administrative ? ( FMS coordinator )
By reporting all issues related to FMS to the Operation Director ,
And the Operation Director will report it to the Executive committee
(As member of the Executive committee)

Q.67: When is the last time you had a fire drill? (All Staff)
Annually we have training on the fire drill
Q: What is code red? (All Staff)
▪ It’s the code we activate in case of fire.

Q: What do you do in case of fire? (All Staff)

▪ Practice RACE!
Rescue anyone in immediate danger.
Activate the fire alarm
(Activate the "code red" by shouting :Shout Your name, ID, Location, Code red to alert the staff,
inform the clinic FMS Specialist, Break the glass)

Confine the fire (close doors, windows).

Evacuate (extinguish if trained by using the PASS procedure).
▪ Practice PASS!
P: Pull the Pin
A: Aim the hose
S: Squeeze the handle.
S: Swipe from side to side.
 Q. Where is the Assembly point:(All staff)

The assembly point in the clinic is located in ………… (Horizontal Evacuation)

The holding areas in the clinic are located in ………… (Vertical Evacuation to the lower level).

Do not use the elevator in evacuation.

Q. : What are the types of extinguishers available in the clinic? (All staff)
 Dry Powder Extinguisher \Sprinkles distributed in the clinic .
 Fire hose located outside the clinic.
 Co2 in the server room
 Fire blanket
Q.72: What is code white? (All Staff)
 It’s the code we activate in case of Aggressive Behavior .

Q.73: What is the action you will take in case of aggressive behavior? (All Staff)
 I inform my immediate supervisor.
 Your area immediate supervisor shall handle the case and if uncontrolled he is the authorized
person to activate the code white .
 The Operation Director will be the Team Leader during the Code White unless he/she is directly
involved with the problem person, then the head nurse will take the lead.
 Code Orang
Chemical Spill
Q. : When do you activate Code orange? (All Staff)
 If the spill is hazardous and too big (more than100 cc), dangerous to handle, or someone is
 injured, then code orange is activated and access to area is restricted.
 But if it is a minor spill, then control access to area and use Safety Data Sheets (SDS) as you have
been trained. Proceed with department cleanup procedures, using spill kit.

Note:
Do not attempt to clean up the spill if you do not have the necessary
protective equipment.
Q. : What is SDS:(All Staff)
 SDS refers to Safety Data Sheet that we refer to when handling hazardous materials.
 Q. : When do you refill the oxygen cylinder? Who’s responsible to communicate with the
supplier (All staff):
 Nurses are responsible to check the oxygen level on daily basis and document it on the
checklist.
 When the Oxygen level is 500, the nurse informs the FMS coordinator who’s responsible to
communicate with the supplier for replacement/refilling.

Q.77: What do you in case of utility failure? (All Staff)

 If the failure (power cut, water cut, ventilation system) was for more than 30 min, then code
brown will be activated.

Q.78: What is “PPM”? (All Staff)

 PPM stands for Periodic Preventive Maintenance” provided by the contracted company in the
clinic on regular basis.

Q. : What do you do with broken medical equipment? (All Staff)

 I report to the FMS coordinator , then the machine will be tagged with “defective equipment”.
 Code Pink
Child Kidnap

Q. When Code Pink will be activated? (All Staff)

When A child is missing or known to have been kidnapped.

 All exits will be closed by security guards until the case is terminated.
 The Nursing manager, in cooperation with the FMS coordinator will be managing the search in the
clinic.
 In case the child did not find the Operation Director has to communicate with local authority.
 The Operation Director will Assure the child’s parents.

Clearance of the code

When the search is concluded and the missing child is found, FMS coordinator shall announce code pink – all
clear and release all the doors.
 The use of any type of extension cord is strictly prohibited for safety reasons.
In exceptional cases, only taking approval from FMS Specialist\ Operation
Director.
Q. : What is Code Yellow? (All Staff)
In case of an external disaster happens, such as a nearby building collapse
or a major car/bus accident, or any community-wide disaster

Q. : Do you conduct any FMS rounds? How frequent? What are the most common findings?
To whom are they reported? (FMS Coordinator )
 FMS rounds are conducted Quarterly by the (FMS coordinator , Operation Director, Nursing
Manager, Infection Control Officer , Head of Quality Department)
 Most common findings are related to ……
 bi-annually report is discussed in the executive committee where opportunities for improvement
are identified and action plans are then discussed and implemented.

Always wear your ID

dermatology & AESTHETIC (da)
 Q. Who’s managing the derma department? (Derma Staff)
❖ The Head of derma consultant….. appointed by the medical director.

Q. How do you know if the physician is able to perform a particular procedure? (Derma Nurses)
❖ Each physician has clinical privileges that are accessible on the shared folder of the clinic.

Q. What happen if a physician performs a procedure that he’s not privileged to?
(Derma Nurses)
❖ Nurses are empowered by the head of derma to stop and report physicians performing outside the
scope of their privileges.

Q. How do you know how to operate the machines in your section? (Derma Nurses)
❖ Education and competency assessment are done at the initial appointment and for every newly
introduced equipment.
❖ This education and competency is repeated annually.
 Q. How do you ensure safety in derma clinic? (Derma Staff).
The head of department performs weekly documented safety visits to all procedural rooms to ensure the
following:
▪ Safety signs are posted outside the room
▪ Laser procedural rooms do not have reflecting surfaces and do not store flammable material.
▪ Personal eye protective goggles are worn by patient and team performing laser procedure.
▪ Laser generated airborne contaminants are controlled by local exhaust ventilation.
▪ Only registered trained nurses perform aesthetics procedures “under physician’s supervision”.

Q. What kind of procedure do you perform in the derma clinic? (Derma Staff)

▪ Familiarize yourself with the derma scope of services.

Q. How do you ensure that your procedures are evidence based? (Derma Staff)
▪ Implemented evidence based clinical practice guidelines are developed by the unit physicians and
approved by the head of department for all procedures performed in the unit.
Dental services (dn)
 Q. What the dental assessment comprise? (Dental Physicians)
❖ A comprehensive assessment is performed and documented for each patient
❖ Chief complaint, chronic illnesses, medication history and allergies are assessed and documented
for each patient before dental procedures.
❖ Show the dental assessment (if requested by the surveyor)

Q.What does the dental treatment plan comprise? (Dental Physicians)

❖ The required radiological procedures.
❖ The type of antibiotic prophylaxis when needed.
❖ The procedure(s) to be performed and highlights the teeth involved.
❖ The type and dose of local anesthesia or moderate sedation if needed.
❖ The material used for filling.
❖ The need for informed consent is highlighted.
 Q. What are your infection control practices? (Dental Staff)
❖ A new pair of gloves and a new mask are used by the dentist and assistant for every case.
❖ Protective eyewear is used by the dentists and assistant for every case.
❖ Patients receive eye protection by the assistant.
❖ Working area surfaces are cleaned by the assistant between patients.
❖ Evidence-based disinfection and sterilization practices are maintained and updated by the assistant.

Q. How do you ensure safety in the dental lab? (Dental Lab Staff) Not Applicable
❖ Fire detection and abatement equipment is available.
❖ Butane and other flammable gases are stored safely outside the laboratory.
❖ A hooded exhaust is available in the casting area.
❖ Oxygen cylinders are safely stored.
❖ Fumes and dust are safely evacuated.
❖ An eyewash station is available and in good functioning condition.
Radiology services (rd)
Dental
Q. How do you ensure safety in radiology? (Head of Dental Assistant)
❖ Radiation Safety program is available.
❖ Familiarize yourself with the program and how to access it.
❖ Show it to the surveyor (if requested).
❖ Radiation safety program comprises the following:
▪ All areas utilizing ionizing radiation, such as the dental panorama and mobile x-rays.
▪ Radiology rooms are tested initially to ensure the absence of a radiation leak.
▪ Equipment are tested quarterly to ensure the absence of a leak. The same testing is done for the
dental panorama.
▪ Warning signs are clearly posted.
▪ Women in childbearing periods undergo a pregnancy test if they have missed a period.
▪ Staff exposure to radiation are monitored using thermoluminescence dosimeters that are examined
quarterly , and staff replacement cards during the test time.
▪ Radiation protection aprons are also tested quarterly for their integrity.
▪ The radiology director quarterly reviews the radiation safety report and the maintenance reports of
the radiology machine(s).
 Q. How do you monitor staff exposure?
Testing of TLD badges is done on regular basis quarterly , actions are taken accordingly.
❖ What do you do if a staff was overexposed? (Head of Dental Department, RSO)

HOD will write a report regarding TLD result and will write a report regarding the incident and
further action shall be taken regarding the involved staff according to management decision to
assure his/her safety.

Q. How do you handle your medical equipment's? (Dental Assistant staff)

❖ Radiology medical equipment program is available.
❖ Familiarize yourself with the program and how to access it.
❖ Show it to the surveyor (if requested).
❖ An operation and service manual is available for all equipment.
❖ Maintenance and repair records are properly maintained, including corrective actions.
❖ Equipment is periodically inspected and calibrated for proper functioning.
 Please Memorized :
- Correct patient identification
- Patient assessment and care planning.
- Consultation process between specialties.
- Safe prescribing of medications.
- Informed consent.
- Patient and family education.
- What to do in case of cardiopulmonary arrest.
- Reporting of medication errors, allergic reactions and adverse
events.
- What to do in case of fire.
- Knowledge on clinical practice guidelines
Laboratory services (lb)
 Q. How do you handle specimen? (Nursing Staff)
❖ We follow the lab specimen manual that explains the process of specimen collection, the
labeling procedure, the quality and quantity of sample, the requisition and required clinical data,
the specimen packing, handling and transportation, specimen receipt and inspection and
specimen rejection reasons.
❖ Be familiar with your specimen manual and how to access it.
❖ Show it to the surveyor if requested.

Q. What kind of test do you perform in your Laboratory? (Nursing Staff)

❖ Be familiar with the Lab scope of service and how to access it.
❖ Show it to the surveyor if requested.
Q. Describing the lab role in selecting and evaluating providers of reference laboratory
services (Operation Director )???

❖ Reference Lab policy is available, familiarize yourself with the policy and how to access it.
❖ Show it to the surveyor if requested.
❖ The agreement with the reference lab include the following essential:
▪ Selection criteria, including accreditation status.
▪ Scope of service
▪ Agreement conditions (including accreditation status).
▪ Sample requirements
▪ Turn Around Time
▪ Result reporting
▪ Release of information to the third party
▪ Solving disputes
▪ Validity of the agreement and review schedule
THANK YOU