תיב תרקב חוד םילשורי St. Joseph 20 ה ךיראתמ 2013 ראורבפב · and then...

האגף לרפואה כללית

בית החולים דוח בקרת St. Joseph ירושלים

20 -ה תאריך מ 2013 פברואר ב

לרפואה כללית הדוח נכתב על ידי האגף

.מחלקת בקרה

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21.5.2013 28127513שרדוקס

To: Maher Deeb, M.D.

, of St Joseph Hospital Director

East Jerusalem

Re: Multidisciplinary Licensing Audit of St Joseph's Hospital Wednesday 20.2.13.

Dear Dr. Deab

Enclosed please find a comprehensive multidisciplinary report of the St. Joseph's Hospital, carried

out by the Ministry of Health staff on February 2nd 2013.

The report consists of 3 parts:

a. Grades Table (scoring)

b. Executive Summary

c. Correcting Instructions in collection with time table.

The hospital's administration is requested to respond to the correcting instructions summarized at

the end, within one month of the date of this letter. The response will be attached to the report

and published at the MOH internet site. Lack of response will be considered as approval of the

report and the report will be published as is.

Following this, a recommendation for license renewal will be forwarded to the Director of Medical

Facilities & Appliances Licensing Division, MOH.

Yours Sincerely,

Dr. M. Dor, M.D Mrs. R. Freund,RN, MPH

Director-Division of General Medicine Departmental Head Hospital Audit

Medical Administration Division of General Medicine

General data

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St. Joseph's Hospital was founded in 1954 and has been functioning as a non-profit general

hospital in the Sheikh Jarrah neighborhood of East Jerusalem .The hierarchy of the administration

is: board of trustees, board of directors and head of departments. During the last year the private

ward, the operating theater and the kitchen were renovated .A new wing of obstetrics and

gynecology departments is under construction. In addition, the hospital management informed the

audit team about the current plans for renovation of the following departments: gastroenterology

unit, laboratories, pharmacy and Intensive Care Unit.

No. of inpatient wards is 4.

Data collected by licensing division MOH

20.2.2013 AUDIT DATE

Saint Joseph NAME OF HOSPITAL

Mrs. Etty Dekel INSPECTORS NAME

ST Joseph sisters OWNERSHIP

Nashashibi st

East Jerusalem

Address

Mr Jamil Kousa

General director

21953 License no Dr Deab MaherMedical director

17677 License no General surgery

Medical director specialty

Mrs. Rima Awwad

Nursing director

SCOPE OF ACTIVITY 2012

NO / % ACTIVITY

21,422

TOTAL HOSPITALIZATION

DAYS 81% MEAN OCCUPANCY

6,288 Total admissions

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3.4 MEAN HOSPITALIZATION STAY IN SURGERY

4.1MEAN HOSPITALIZATION STAY IN INTERNAL

MEDICINE 3,073

(2,531 major, 542 minor) SURGICAL

PROCEDURES

4,482

NO OF VISITS TO EMERGENCY ROOM

20% ADMISSION RATE

FROM EMERGENCY ROOM

5,584 VISITS TO CLINICS

MANPOWER

25 (OUT OF 41)NO OF EMPLOYEES

PROFESSIONS

5641 PHYSICIANS 6325 (OUT OF 41)SPECIALISTS 8756NURSES 22263MEDICAL

PROFESSIONS 87LOGISTICS AND

ACCOMMODATION 222TOTAL

LICENSE : DATA COLLECTED BY LICENSING DIVISION MOH

73 BEDS

0 DAY CARE BEDS

3 OPERATING THEATERE

3 RECOVERY POSITIONS

6 EMERGENCY

ROOM POSOTIONS

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0 DELIVERY POSITIONS

9 CLINICS

4 INSTITUTES

3 LABORATORIES

CT SCAN MEDICAL DEVICES

General surgery, orthopedics, urology, plastic surgery adults and pediatric, gynecology and E.N.T

PERMITTED FIELDS OF ACTIVITY

Grades Table

5

Very

good

4

Good

3

Requires

improvement

2

Poor

1

Failed

Fields of inspection

95-100 80-94 65-79 50-64 0-49

64 Hospital Administration 1

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1. Hospital Administration

Areas audited: committees activities, incidents reports, patients' rights,

informed consent, staff immunization, availability of MOH written standards,

malpractice insurance and fire department permit. Thirty points where taken off

due to absence of the relevant MOH regulations.

The hospital rejoined the JCI (Joint Commission International) accreditation and

certification for health care organizations. During the last year the hospital staff has been

working on preparing protocols according to the standards of the JCI.

Hospital functions are carried out according to ISO program. Malpractice insurance is

valid until July 31st 2013, through "Madanes Company". Fire department certificate is

valid until September 19th 2013.

85 Medical Administration 2

74 Nursing Administration 3

86.5 Operating Theatre Safety 4

96 Recovery Room Safety 5

93.5 Anesthesiology 6

84 Engineering Systems 7

0 Social Work 8

97.5 Pharmaceutical Services 9

84 Sanitation and Environmental

Health

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82 Physical Therapy 11

95 Laundry Handling 12

76 Infection Control 13

72 Waste Collection and

Disposal

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73 Food and Nutrition 15

Free text Licensing and Distribution of

Beds

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The administrative and financial aspects of the hospital are computerized .Acting hospital

committees include: infectious control, quality assurance , patient safety, mortality,

Helsinki, public complains . The hospital's services complies with the demands for

protecting patients' rights. Informed Consent documents are filled and signed as

required, a copy is not submitted to the patient. Absence of criminal record for new

employees is verified before hiring new staff. Posters containing information regarding

patient's rights and visiting hour for the public, were observed hanging on the walls at the

entrance of the hospital and at each ward .First degree relatives of admitted patients

who stay over more than 30 days, are not allowed parking for free at the hospital parking.

A structured plan to cope with suspected patients to commit a suicide was not found.

Some of the Ministry of Health circulars were found in a designated binder. Only a few

translated into English. Other protocols were found in a local format. Staff immunization:

the hospital's staff follows partially the vaccinations plan according to MOH regulation.

Most of the nursing staff is vaccinated against HBV and performed PPD test. A structured

plan towards dealing with violence against staff has not been completely implemented.

2. Medical Administration

Areas audited: Physicians employed, Medical records.

The audit included examining medical records at selected hospital wards : The Internal

medicine ward, the Surgical ward and Emergency room. Forty physicians are employed

out of which 25 are specialists with Israeli license (8 possess a temporary permits) There

are 4 house doctors with no permit and 4 physicians are general practitioners.

Internal medicine

Medical notes are sufficiently handwritten in English and are partially legible. The medical

files are only partially computerized: admission discharge and lab results are fully

computerized. Follow up records, physicians orders, and x ray results are not . High

alert lab results are informed to the physician in charge by phone. The discharge letter is

signed by an intern (not licensed in Israel ) as well as a licenses specialist. Diagnosis and

surgical procedures are coded by ICD9 as required. Informed consent documents in

Arabic and English are filled and signed as required, still a copy is not given to the patient.

surgical ward

The ward contains: 42 beds of general surgery and sub –surgical activities such as

orthopedics, urology, plastic surgery, gynecology and E.N.T

Patients records are not computerized at all. The discharge letters are written by hand

and then typed by the secretaries and signed by the physician . Discharge letters from

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nurses are added written by hand.

Emergency room

Around 20 patients scheduled for ambulatory surgery are admitted through the

Emergency room every day. There is always a general doctor on duty as well as as

nurse. Documentation is hand written. Discharge is singed by a general doctor (not a

specialist ) not licensed in Israel. Diagnoses are ICD9 coded.

3. Nursing

Areas audited: Nursing Manpower. Nursing Records and Documentation.

Medication Administration. Patients' Environment. Mobile Resuscitation Trolley.

Incidents Reports. Standards and Procedures. Professional Development & In-

service Training. Patient Discharge Process.

Since hospital joined the process of JCI accreditation the nursing management has been

working on preparing protocols according to the standards of the JCI.

Staff:

Total no. of nurses: 49

Registered nurses (RN): 42

Practical nurses (PN): 7

Nursing assistants: 10

Fourteen nurses are licensed to practice in Israel. Six of them hold valid temporary permit.

During September 2012 seventeen nurses attended the Israeli nursing licensing examination. Six of

them passed the examination. The hospital administration invests high efforts in preparing the nurses

for the Israeli licensing process intending to send this year more nurses to take the national licensing

examination.

Nursing Records and documentation

Nursing records are not computerized. Nurse’s notes are written in English according to the

common rules signed and stamped.

Drug administration

Drugs were found alphabetically arranged, labeled, valid and locked in the drug cabinet. Narcotics

are managed according to the standards. Some physicians' drug orders were not written in capital

letters and were partially signed. Time of checking the physicians' orders by the nurse was not

documented.

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Nurses still sign in the medication cardex only by first name.

On the I.V. medication sticker there is no designated place for drug dosage.

Not all "high risk medications" are doubled checked before administration.

The medication refrigerator was checked at the emergency room. Since the last audit a

continuance thermometer has been installed and no vaccine was found on the refrigerator's

door, according to MOH regulation.

No documentation of checking the temperature during the day by the nurses was found on the

refrigerator.

Discharge summary

Nursing discharge summary is not adjusted personally for each patient's needs.

Standards and procedures

Nursing protocols and procedures were found in English, written in a local form. MOH

nursing protocols were not found.

Professional Development and In-service Training

An annual plan for continuing education was found. A structured orientation

program for the novice is implemented. Nursing staff meetings are held monthly ,on all wards . A

structured Annual evaluation is conducted for all staff members.

Incident report

Incident reports are documented and corrective actions are taken as a result of learned lessons.

Patient Environment

Patient Environment was observed at the surgical ward, emergency room and the private

department. Wards in general were found clean and well ventilated. Alcohol based hand rub

was not found attached to patients' beds.

In the surgical ward, few beds were found without rails. Sinks with faucets opening with out

hand touch , were not found in all patients' rooms nor in sinks in the patient's lavatory. Toilets

assistance tools (toilets hand rails) were partially found.

Resuscitation

The resuscitation trolley is managed according to the MOH standards.

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During the last two years all the nurses participated in an ACLS (Advanced Clinical Life

Support) course as required .

Resuscitation committee has not been established yet. In case of emergency the

nurse on site places a call to to the operator who calls up an anesthetist and two resuscitation

trained nurses

4. Patient's Safety in the Operating Theatre

Areas audited: Manpower. Infrastructure. Patient Identification Process. Nursing

Documentation. Standards and Protocols. The use of Medications and Narcotics.

Cleaning Disinfection &Sterilization of Instruments. Incidents Report.

3 operating theatres were observed. The nursing staff consists of a head nurse 9 registered nurses,

and one LPN. All nursing graduates of various nursing schools not prepared by postgraduate

government operating theater course. Three RN own Israeli license . The operating theater nurses

are also part of the recovery team.

Patient identification prior to surgery is performed properly. The nurse verifies the written informed

consent, lab result, and allergies. To complete the identification process there is a structured

"Time-Out" verification performed inside the OR, a process which contains a check list relevant to

the surgery and patient, not in accordance of the MOH requirements. Diathermy equipment data

is documented in the patient file, including assessment of the patient's skin condition before and

after surgery. Documentation is carried out according to common rules . Each file contained: Patient

name: hospital patient number; surgical informed consent (the surgerical procedure; name and

signature of the patient and surgeon); anesthesia informed consent; pre-operative care checklist

(identification of the patient bracelet and allergy check, report of the use of diathermy; report counts

of instruments, sponges and sharps, and "time-out "checklist which lacks some essential data.

Each document is properly signed by the relevant nurse. The Operating Theatre and the adjacent

sterile supply are well organized dirty and clean tracks maintain a consequential continuity. The

work is executed in a professional manner. . Local standards and protocols are organized in a file,

no MOH Circulars were presented.

5. Recovery Room safety

Areas audited: manpower infrastructure. Resuscitation trolley. Nursing documentation and

the registry of medications and narcotics.

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The Recovery Room is an integral part of the OR. There are 5 patient positions. Nurses of the

recovery room and operating theatre are of the same pool. There is one permanent nurse post

graduate of an intensive care course that is daily in charge of the recovery room The patients'

records that were presented, included patients' vital signs: ECG, Pulse, BP, O2 saturation all

medications and fluids after surgery. As required. Resuscitation trolley is well organized; all

medications are updated with expiration dates. There was a list of items on the trolley, and

evidence of check ups on a regular basis. A defibrillator was on the trolley. There is a closed

narcotic cupboard, and an up dated narcotic registry. Daily counts of narcotics is performed as

required. Documentation and patients follow up charts included all essential data. Physicians

orders to be carried out by the nurses are documented in patients' files, they are daily written by

hand according to common standards, clear, in caps, with a coherent signature attached.

6. Anesthesiology

Areas audited: staff and their qualifications, physical conditions; number of operations done

yearly, infrastructure and equipment were checked. Also checked were the anesthetic

machines, the completeness of the operating theatre records, the anesthetic chart, the

post- surgical notes and the consent forms, both anesthetic and surgical.

The anesthetic department is organized well and works according to accepted standards. About 2500

operations are done yearly, of which only about 30 or 40 are emergencies. There are 3 operating rooms,

of which 2 are used for surgery under GA and 1 for surgery done under LA. There are 4 beds in the

recovery room, which doesn’t fulfill the demands of the MOH IE 1and a half beds in the recovery room

for 1 operating room bed. Another operating room is being built and also 2 more recovery beds. These

should be finished within a year.

There is no medical secretary in the operating room area. There is no room or any privacy for the

head of the department of anesthesia or the staff.

There is a pre- operative clinic, no pain clinic and no full-time anesthesiologist treating post-

operative pain.

The doors to the operating rooms open automatically. There is no person who checks the anesthetic

machines, which are checked daily by the anesthesiologists themselves. There is no sticker giving the

date of the next examination. Some of the pre-operative charts were not complete. The consent forms

were completed as demanded, as were the anaesthetic charts.The surgical charts are complete, as is

the reporting in the operating room book, though certain of the information is kept in the anaesthetic

chart. The chart for “Time Out “needs to be revised. The patient is handed over to the staff in the

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recovery room with all the necessary information. The patients are released from the recovery room by

an anesthesiologist. There is no area in the recovery room for a patient who needs isolation as this isn’t

relevant. All necessary equipment is in place, except for antiseptic bottles next to each bed.. The

resuscitation cart is complete. The cart for “difficult intubation” is still not complete but will be so with the

opening of the new area.

All the circulars from the Ministry of Health are known and within easy reach.

7. Engineering Systems and Infrastructures

Areas audit : Infrastructure. Medical Gases. Electricity. Air conditioning. Central Sterile

Supply (CSS)

The general impression regarding the electro- mechanical systems in the

operating wing and the entire infrastructure is good.

The OR range area is of high safety standard. There is a distinct separation between clean and

dirty tracks. Sprinklers and smoke detectors are installed all over the OR range. Medical gases

are provided safely piping in the machinery rooms are not painted according to common

codes. There are two evacuating anesthetic gases systems functioning in each room, as

required. The electrical system is well maintained apart from the emergency connection to an

external generator. Air conditioning in the OR is sufficient, temperature and humidity can be

adjusted by the staff. The air purifying units and the filtration levels are according to the

guidelines. Positive pressure is kept permanently although not monitored in a conspicuous place.

Sterilization at the central supply is adequate.

Processes at the Central Sterile Supply are carried out promptly .The autoclave are validated

periodically. The different areas clean versus dirty are separated .

8. Social Work

At St. Joseph Hospital there are no social work services. A local nun is in charge of the patients'

emotional and economical necessities. Although she is trying her best to fulfill the patients' needs,

there is no trace or any signs of professional social work.

According to Israeli law only a licensed social worker can practice social work. Furthermore,

according to the Ministry of Health's regulations every general hospital must provide social work

services in its settings.

9. Pharmaceutical Services

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Areas audit : Infrastructure. Medication Distribution. Dangerous Drugs

Management. Documentation.

The pharmacy is managed by an Israeli licensed pharmacist, Mrs. Rana Rabadi. The pharmacy is

clean and well organized despite its small area.

The pharmacy is located temporarily, near to the main entrance (in the same building). A plan for

the new pharmacy was handed over for approval. The plan was approved by the ministry of

health. An audit will be performed before start operating the new pharmacy.

The pharmacy serves the hospital sections according to their requirements.

The expiry date of the drugs is computerized and checked monthly.

The dangerous drugs in the pharmacy's safe were counted and found in compliance with the

registrations. Drugs transfer between the pharmacy and the hospital sections (mainly operating

room) is managed by suitable forms. The supply of dangerous drugs to the operating room is done

weekly according to their demand.

Following the police investigation and closure of the file relating to the missed dangerous

ampoules event, on October 14th 2010, the amounts of dangerous drugs sent to the operating

room from the pharmacy has been reduced to a weekly supply. Since the hospital services will be

expanded and new sections will be added, the requirements for the pharmacy services will be

enlarged and will need adequate manpower.

10. Environmental Health

Areas audit: Drinking water network, food hygiene, sanitary condition in the wards and

the auxiliary departments, sorting and disposal of various types of refuse and laundry

arrangements

Generally, good sanitary conditions were found during the audit. Most of the faults found in the

previous audit have been rectified, nevertheless, some faults were still found in different areas.

11. Physical Therapy Service

Areas audit: scope of service, management, consulting and staff education, compliance

with standards, documentation, professional development, work environment, equipment

patients right .

All the above is managed in accordance with professional regulation

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The service consists of 1 Physiotherapist with a bachelor degree (BPt.) from Jenin who works 8

hours, 6 days per week. The staff to beds ratio is appropriate. The head is Physiotherapist:

Bashar Ayaseh.

Bashar is a dedicated, professional and caring physiotherapist who has taken steps to promote

patient care, such as structured record keeping, exercise handouts and provision of

comprehensive treatment.

The physiotherapist treats all patients, according to written physician orders. Medical records

include a structured page which includes all required fields, for physiotherapy documentation.

12. Laundry Handling

Areas audit: Implementation of guidelines instructed in the Medical Administration Circular

no. 29/08 dated 26/6/98.

The hospital divides dirty laundry into two sub-categories: "dirty" and "infected", the latter being in

cases where it has come into contact with patients suffering from infectious diseases. This division

is in direct contrast to Ministry regulations, which define all dirty laundry in hospitals and treatment

facilities as infected. The dirty laundry is collected in strong non-porous bags, which were found to

be over 75% full. At ward level, these bags are stored in rooms used for purposes other than

laundry storage.

They are then transferred to a central storage point by trolleys that are physically differentiated

from those used for distributing clean linen, but that are not fitted with a cover made from strong

porous material. The trolleys are collected by the servicing laundry twice weekly. The central store

does not have walls that can be cleaned.

At present the hospital does not check the servicing laundry to ensure that trolleys used for

transporting dirty laundry are cleaned and disinfected in accordance with the procedures laid down

in the regulations.

13. Infection Control

Areas audit: : implementation of the General procedures insulation, prevention of

antibiotic resistance, the use of standards precaution's, prevention of viruses infecting

HBV HCV HIV, prevention of sepsis caused major blood vessels, and hand hygiene.

There is no designated infection control unit, the field is managed by a male nurse, a WHO

infection control graduate from Ramallah, who works part time (four hours a week). His time is

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spent mostly in the emergency room, but he also gives occasional lectures to nurses on

infection control. Guidance and counseling are provided by a specialist in Infectious diseases

from the French hospital in Nazareth.

Staff are not familiar with Ministry of Health standards; but use those of the JCI, CDC and the

WHO .The work of the infection control nurse is limited to:

‐ The monitoring of infection- acquired morbidity

‐ monitoring resistant bacteria such as CRE MRSA .VRE. A report is submitted to the

microbiological laboratory and the head nurse, but not passed on to the national center for

infections control.

‐ partial implementation of procedures to prevent antibiotic resistance.

‐ Training new employees inr: hand hygiene, standard precautions, isolation measures and

exposure to blood and body fluid (prevention and treatment) – performed only once in every 4

years.

Standard precautions are properly enforced. Protective equipment is available and used, while

hand hygiene guidelines are implemented. There are written instructions prohibiting of the

wearing of jewelry and artificial nails. There are instructions for dealing with staff skin problems.

Hand hygiene performance is not monitored.

Areas visited and examined

Surgical and intensive care wards

There were no sinks in patients rooms,.

There was no antiseptic soap at nurses' station sinks or in bedside dispensers

There were no pamphlets instructing the method and the necessity of hand washing at relevant

sites .

Operating room:

The surgical hand washing station was equipped with the necessary equipment - sink, faucet,

timer and brushes for antiseptic hand washing. Surgical hand scrubbing is properly performed.

ICU

Precautions to prevent sepsis caused by "pick-line" are implemented. Central line catheter

management procedures are implemented according to commonly accepted standards. There

are written guidelines that include:

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- the daily monitoring of patients with central line catheters

- the use of transparent dressings

- the frequency of replacement dressings and of infusion fluids once every 24 Hours

- in cases of suspected infection catheter removal is obligatory, and sending the tip culture is

performed, as required. (The data on central catheter precautions was collected from the

nurse in charge, as at the time of the inspections there were no patients receiving this

treatment.)

Precautions to prevent Hepatitis B, HCV, or HIV following needlestick

injuries or exposure to blood, are implemented.

Documentation on procedures to control contact isolation showed that the

procedure is carried out as required (observation was not possible as there

were no patients in isolation).

There is no procedure for the control of air isolation. In cases of tuberculosis or chicken pox, etc.,

patients are transferred to Hadassah Ein Karem.

14. Waste Collection and Disposal

Areas audit: Implementation of guidelines instructed in the Medical Administration

Circular no. 34/98 dated 17/5/98 guidelines.

Pedal bins are used for collecting regular waste in treatment rooms. Sharp infectious waste is

collected in special sharps boxes. Infectious waste from the microbiology laboratory is collected in

open bins.

The plastic bin used for storing expired medicines in the pharmacy is not suitable, and is not

labeled or locked, as required.

The number of large bins in the infectious waste store was insufficient, as they overflowed with

waste, while sharps boxes were placed on the floor. The store was left open for the inspection.

The hospital receives from the waste disposal company confirmation that the infectious and

dangerous waste that is collected is dealt with according to all regulations.

15. Food and Nutrition

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Areas audit: Manpower, menu composition, standards and procedures , scope of clinical

practice, documentation, entral &paraentral feeding

There is one part time employed (9 hours a week) dietician , Monera Iklebo. R.n.11-98814. The

lack of sufficient manpower has an immediate averse effect on patients who need nutritional

therapy.

The dietician together with the the kitchen's manager prepare the weekly menu, the composition

of the menu is dictated by the dietician. There are four kinds of diet: standard diet, low sugr, low

salt , low fiber.

Special diet for diabetes /hypertension is noted by special sheet and the name of the patient.

menu heT

Weekly menu is planned in advance.

The amount served fruit (variety of 4) , is about 300 g/day- as required

The use of Canola/olive oil dose not reach the required amount : 2/3 of the oil used by the

hospital.

Frequency providing meat and fish products- as required

The size of the served meat is adequate , checked regularly by the dietician

Frequency providing milk and milk products -

Processed meat is served once a week -as required

45-65% of the calories from carbohydrate - as required

- 30% 20% of the calories from fat -- as required

5-10% polyunsaturated acids - as required

10 -35% of the calories from protein - as required

The menu provide 13-15 mg/d of iron - as required

The menu provide 1000 mg/d calcium - as required

Computerized nutritional analysis of various menus (vegetarian, children's, etc.) signed by the

dietician is- partially executed

Procedures and protocols

Procedures:,

The Nutrition Department of MOH written standard "patients requiring nutrition consultation" No

9/1 2000 - is not available nor practiced.

Updating procedure for the food basket for a medicated food in emergency situation, standard No

3.023, January 2007 - is not available nor practiced

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Local written standard for the patient with no food intake 48 hours – is not available

Local written standard concerning verification and accuracy of weight of food – is not available

Work protocols for diet and nutrition service, MOH written standard No 9/2000

Procedure for adult food basket, Procedure number 85/91- is not available nor practiced

Procedure Prenteral Feeding, procedure number 43/90 - is not available

Procedure Enteral Feeding procedure number 29/94 - is not available

Medical food

An up-to-date list of the existing medical food was presented.

The dietician dose not participate in the hospital medical food committee

The dietician is not the main responsible consultant for distribution of medical food for the hospital

wards.TPN orders are written by physicians and carried out by the nurses

Clinical diet and nutrition service department

Regulation No. 13/93 (40 hours of dietician work per 100 beds/weekly), the hospital 9 hours of

dietician work/weekly is not sufficient.

Performing nutrition status and detection risk factors in malnutritioned patients, treatment and

follow-up patients who need nutritional consultation- is only partially executed

Currently the wards don't enjoy dietitian's nutritional consulting

The short dietician work hours do not allow administrative or management tasks.

Professional update promotion to attend workshops and educational meetings for the dietitian is

not provided by the administration

Multy-professional staff meeting - partially exist

Periodic reports about activity of the diet and nutrition service department to the management - are

hardly transferred

Satisfaction surveys from the diet and nutrition service - are partly performed

Actions to improve finding of surveys - are partly performed

medical recordocumentation in the D

Documentation of risk to develop bedsores (nursing front) were not found

Documentation anthropometric measurements and nutritional status in patients at risk of

developing bedsores (dietitian front

Documentation nutritional follow up for patients defined with low nutritional status were not found

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Documentation of relevant laboratory tests depicting nutritional status in patients with defined low

nutritional status were not found

Nutritional treatment protocol for patients with low nutritional status were not found.

Nutritional treatment to non-balanced nutritional diabetic- partially exist

Nutritional treatment protocol for patients with albumin less than 3 g/dl was not available.

Inclusion of nutritional status and/or therapy when needed is missing

Weekly menu was found on the hospital wards

The food served to the patients is fully suitable to the menu

Specific menus for patient with special nutritional requirements was not found

Observation of dietician on the meals - done partial

Guidance by dietician for professional team of (nurses and doctors kitchen employees) - are not

performed

No written procedures computerizes or in an arranged binder were to be found.

16. Licensing The current hospital license will be corrected

Recovery room posts will be changed from 3 into 5

Emergency room posts will be changed from 6 into 5

Number of institutions will count 3 instead of 4

***

For your convenience the instruction for corrections in collection

1. Hospital Administration

For immediate correction

‐ A copy of informed consent should be submitted to all patients.

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‐ Free parking at the hospital yard, should be facilitate for first degree relatives of patients

hospitalized more than 30 days.

‐ Security measures should be applied on suspected patient to commit suicide.

For correction within 3 months from the date of this report:

‐ Hospital staff should abide with staff vaccination plan according to

MOH regulation.

‐ Prevention of violence against staff, intervention program should be implemented case of

violence.


‐ All relevant regulations of MOH should be translating (into English or

Arabic). All protocols can be retrieved from our website

http://www.moh.health.gov.il

‐ Each sector should implement it's relevant protocols.

‐ All medical and paramedical professionals should be licensed or carrying Israeli permits

according to the Israeli law

‐ Enhance the process of computerizing the patient's medical file.

‐ Apply for approval of the MOH Licensing Division to practice neuro and thoracic surgeries .

2. Medical administration

months from the date of this report:correction within 12 For

‐ Expedite computerization of patients' records.

3. Nursing


‐ Efforts for promoting the nurses licensing process should be continued to enable the

nursing staff to obtain authorized Israeli license

‐ I.V. medication sticker should include a designated place for drug dosage.

‐ An alcohol based hand rub should be placed near each patient bed, accessible to the

staff.

‐ Drug administration should be signed with the nurse's full name (first name & family

name), according to the MOH regulation.

‐ Time of checking the physicians' orders by the nurse should be documented.

‐ High risk medication should be double checked before administration.

דרך הוריד" "מתן תרופות בנות סיכון 6.1.2009מתאריך 1/2009חוזר מנהל רפואה מספר ‐ Ref:

‐ Side rails should be attached to each patient bed.

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‐ Refrigerator temperature should be checked and documented by the nurses, according to

MOH regulation.Ref: MOH Public Health Department regulation: "Logistic management of the

vaccination array" No.8\10 from December 23rd 2010.


‐ A Nursing discharge summary should be submitted for each patient.

‐ A resuscitation committee should be established and activated according to MOH regulation.

Annual report from the Resuscitation Committee should be submitted to the hospital

management

Ref: 21/2006ניהול מערך החייאה בבי"ח כלליים מנהל הרפואה

‐ Toilets assistance tools (toilets hand rails) should be installed in all patients' lavatories.


‐ Local protocols should be adjusted to all relevant MOH regulations.

1 year from the date of this report:For correction within

‐ Sinks and non-touchable taps should be installed in each patient's room, in addition to the sink

in the patient's lavatory.

4. Operating theatre safety


‐ "Time Out" process :Verification of data prior to anesthesia has to be improved. The hospital

needs to download TIME OUT protocol , in a form of a checklist , from the internet either from

the MOH site (in hebrew) "Verification of Data Prior to Surgery " Minhal Hrefuah circular no

18/2009" or from the WHO site where it is written in English:

http://www.who.int/patientsafety/safesurgery/en

‐ The procedure should performed in presence of the surgeon, the

‐ nurse, and the anesthetist and should be implemented immediately

‐ Lryngoscopes blades should be sterilized after each use. -

‐ All OR relevant regulations of MOH should be translating (into English or Arabic) . All

protocols can be retrieved from our website

‐ http://www.moh.health.gov.il

‐ Handling pathology specimens should be performed in a ventilated area

or under a hood.

5. Recovery Room safety


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‐ MOH regulation relevant to anaesthasia and recovery should be translated into Arabic or

English to be internalized and implemented by the anaethesits and the nursing staff.

6. Anesthesiology

immediate correctionor F

‐ Rewrite and implement “Time Out” standard according to MOH regulation.

‐ .Install an antiseptic container next to each bed in recovery room.

‐ Verify there is a sticker on each anaesthetic machine giving the date of the next examination..


‐ Make sure there is a dedicated cart for “difficult intubation.”

‐ Improve the conditions of the head of the department and his staff. Provide an area, or room,

where they can have prrivacy.

7. Engineering Systems and Infrastructures


a. The system's drawing and the preventive maintenance check list has to be installed in

the power generator container and main electricity room.

b. Near the generator container a metal armoire containing all the safety items such as

rubber gloves, goggles, ear protectors, flashlight etc. must be installed.

c. Emergency lights in every machinery room have to be installed, the generator container

included.

d. All the medical gas piping in the machinery rooms must be marked and painted

according to codes in the G-01 specs for medical gases.

e. The medical gases room should be well signed with warning signs: " Smoking

prohibited"," Oxygen- keep away oil", etc.

f. In the CSSD in the clean area the light intensity must reach 500 lux at least.

g. An exhaust pipe from the vacuum pumps reaching 2 meters above the roof level is

required.

h. A 30 cm. height concrete threshold at the entrance to the liquid oxygen tank is a must.

i. At the medical gases machinery room surroundings fire extinguishers are required.

For correction within 3 months

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a. In each operating room and the recovery, temperature and relative humidity regulators

are needed.

b. In each operating room and the recovery a thermometer and relative humidity meter are

required.

c. A pressure differential gauge in each O.R.is required.

d. A central alarm indicating a fault in the medical gases systems must be installed in a

central place in the hospital with 24 hours per day personal presence.


a. A dedicated air handling unit must cool and filter the income fresh air to the O.R. air

condition units.

b. On the air handling units drain pipe a vacuum breaker must be installed.

c. The liquid oxygen tank and the evaporator must be stabilized against earth quake.

d. An outside main electric socket on the main switch board is warmly recommended to

enable an outside emergency generator connection.

8. Social Work

or immediate correctionF

‐ Promote the employment of a professional social-worker.

In order to provide a structured policy of how to activate the social work service on the wards,

please consult Mrs Orit Bershtling, our social work coordinator at General Medicine mobile

0506243850

9. Pharmaceutical Services

For correction with the enlargement of the medical activity

‐ Adequate manpower should be taken into consideration when the requirements for additional

pharmacy services takes place

10. Environmental Health

For correction within 1 year from the date of this report

laundry.

‐ There e should be a separate elevator for evacuation and transportation of regular waste and dirty

laundry.

‐ The regular waste trash container should be kept in a room with a sealed floor covering and

washable walls.

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‐ The waste disposable center should be relocated in a manner that completely excludes it from the

public.

‐ There should be a separate room for sorting dirty and infectious laundry.

water

‐ The back flow prevention valves should be checked by an authorized installer once a year, the

checking results should be sent to Mr.Mussa Bajali - Environmental Health Engineer ,the Jerusalem

Health Bureau

waste

‐ There should be a special place for cleaning and disinfecting containers designated for collecting

regular waste.

‐ Center for collecting infectious waste should be completely isolated with no access to the

public.

11. Physical Therapy

For correction within 6 months from the date of this report

‐ An effort should be made to assist physiotherapists in professional enrichment. The

physiotherapy unit in the Ministry of Health can serve as advisor.

12. Laundry Handling


‐ All laundry should be classified and treated as infected.

‐ Laundry bags should not be filled beyond 75% of their capacity.

‐ The ward area for storing full bags of dirty laundry should be for that use only.

‐ Dirty laundry trolleys should be fitted with a strong non porous cover.

‐ The new area being built as a dirty laundry central store should have cleanable walls and a

drainage point.

‐ Hospital staff should carry out 2 spot checks a year on the servicing laundry to see if trolleys

are being cleaned and disinfected in accordance with Ministry regulations.

‐ The frequency of dirty laundry collection should be increased to once in 48 hours when the

additional planned beds are made operational.

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13. Infection Control


‐ 4 essential Ministry of Health infection control standards as elaborated here, should be

translated into Arabic or English and implemented

1. "Hand hygiene in medical institution" circular no 24/09

24/09"הגיינת ידיים במוסדות רפואיים" חוזר מינהל הרפואה מס'

2. "Infection control in medical institution and prevention of resistance to antibiotics" circular

no 9/2012

9/201חוזר מס' "בקרה ומניעת זיהומים במוסדות רפואיים ומניעת עמידות לאנטיביוטיקה" מינהל הרפואה 2

3. "Standard precousions in medical institution" circular no 10/2010

10/2010 חוזר מינהל הרפואה אמצעי זהירות שיגרתיים במוסדות רפואיים""

4. "Prevention of sepsis related to central lines" circular no 13/2011

הרפואה מס' חוזר מינהל" "הנחיות למניעה של אלח דם הקשור בצנתר מרכזי בכלי דם 13/2011

‐ Hand hygiene monitoring based on the above MOH standard should be implemented

‐ Dispenser containing antiseptic liquid should be attached to all patients' beds

‐ A hand washing sink should be installed in each patients' room.

‐ Antiseptic soap should be available at the sinks

‐ Pamphlets promoting correct hand hygiene should be posted at all hand wash location

‐ Monitoring resistant bacteria - active coverage of the bacterium patients should be reported

to the national CENTER OF INFECTION CONTROL

14. Waste Collection and Disposal


‐ Pedal bins should be used for the disposal of regular waste in treatment areas and infectious

waste (other than sharps) in the microbiology laboratory.

‐ in the pharmacy, expired medicines should be stored in a locked cupboard or solid container,

labeled: "Dangerous Waste".

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‐ The number of large bins in the infectious waste store should be increased to ensure all waste

is stored within closed bins. The store should be locked at all times.

15. Food and Nutrition


‐ Increase nutritionist manpower: employ a full time dietician.

‐ The dietician should be involved in decision making process concerning Nutritional therapy

‐ Dietician documentation should be included in the medical record and discharge letter

‐ Compose and execute protocols regarding

Description of diet and nutrition service

Patients requiring nutrition consultation.

Assessment of nutritional status

Food basket for a medicated food in emergency

Patient with no food intake 48 hours

Verification and accuracy of weight of food

Adult food basket,

Prenteral Feeding

Enteral Feeding

***

On behalf of the audit team we would like to express our appreciation to the St John's

administration for the openness and cooperation during the visit.

Yours Sincerely,

Dr. M. Dor, M.D Mrs. R. Freund,RN, MPH

Director-Division of General Medicine Departmental Head Hospital audit

Medical Administration Division of General Medicine

Copies

Prof. Arnon Afek- Director of Medical Administration

Dr. Chen Stein-Zamir– District Health Officer, Jerusalem Health Bureau

Dr. Yoram Lotan – Head, Medical Facilities & Appliances Licensing Division

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תיב תרקב חוד םילשורי St. Joseph 20 ה ךיראתמ 2013 ראורבפב · and then...

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