Standard Survey Agenda

Note 1:

For the Medical and Nursing Surveyors’ Units Visit, please select the units from the following list and
specify it in the particular slot in the schedule, taking in consideration that both surveyors shall not be
visiting the same area at the same time. The sequence of units shall be determined based on the physical
layout of the organization that will allow a smooth flow and ideal utilization of the surveyor time. Please
note that this is a standard agenda so according to the hospital scope of services you may add or eliminate
some units.

Units to be visited by the medical surveyor:

1. ER;
2. OR;
3. Surgical Ward;
4. Medical Ward;
5. Pediatrics Ward;
6. ICU;
7. PICU;
8. NICU;
9. CCU;
10. OPD;
11. Physiotherapy;
12. Radiology;
13. Oncology;
14. Dental;
15. Hemodialysis;
16. L&D;
17. Burn Unit; and (NOT APPLICABLE)
18. Day Surgery. (NOT APPLICABLE)

Units to be visited by the nursing surveyor:

1. ER;
2. OR;
3. L&D;
4. Surgical Ward;
5. Medical Ward;
6. Pediatrics Ward;
7. ICU;
8. PICU;
9. NICU;
General Survey – Alhabib Medical Group (HMG) – Suwaidi Page 1 of 14
 10. CCU;
11. OPD;
12. Oncology;
13. Nursery; and
14. Burn Unit. (NOT APPLICABLE)

The information verification session at the third day of the survey is a specially designed session to
allow more flexibility for the surveyor if he/she wants to verify any of the information collected over
the three survey days

Note 2:

For the FMS Surveyors’ Units Visit, please select the units from the following two lists (external and
internal locations) and specify it in the particular slot in the schedule, surveyors shall not be visiting the
same area at the same time. The sequence of units shall be determined based on the physical layout of
the organization that will allow a smooth flow and ideal utilization of the surveyor time. Please note that
this is a standard agenda so according to the hospital scope of services you may add or eliminate some
units.

Exterior locations to be visited by the FMS surveyor:

1. Construction, renovation or demolition project;

2. Medical Waste Store Room;
3. Hospital roof;
4. Elevator Service Room;
5. Hospital gates/ Entrances / Handicap access;
6. Kitchen;
7. Laundry;
8. Ambulances;
9. Holding Areas;
10. Technical Rooms;
11. Electrical Rooms;
12. Central store;
13. Biomedical Engineering Workshop;
14. Generators;
15. Chillers;
16. Central Medical Gas Station;
17. RO Plant,
18. Fire Pumps;
19. Boilers;
20. Septic Tank; and
21. Parking area/ Handicap slots.

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Interior locations to be visited by the FMS surveyor:

1. Hospital Lobby and gates;

2. Corridors/ Staircases/ Assembly Points;
3. Elevators;
4. MRI;
5. ICU/NICU/ isolation rooms;
6. Operating Rooms;
7. Emergency Room/ Triage Areas;
8. In-Patient Rooms/Bathrooms/ Special Needs Bathrooms;
9. Children Playroom;
10. Laboratory;
11. Radiology Department;
12. Nuclear Medicine; (NOT APPLICABLE)
13. Dermatology Clinic/ Laser room(s);
14. Delivery room;
15. Nursery;
16. Female wards;
17. Central sterilization service department;
18. Medical records;
19. Emergencies Command Center;
20. Nursing Stations;
21. Safety Department;
22. Sub-stores/ Pharmacy store;
23. Pantries and staff lounges;
24. Cardiology Units;
25. Dialysis Unit;
26. Dental Unit;
27. Data Center (servers room);
28. Clean utility;
29. Dirty utility; and
30. Janitorial closet.

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 GENERAL SURVEY – HMG-SWD

DAY 1 - 03 MAR 2024 (Morning)

Dr. Saleh Rajab Dr. Bishr Adnan Mr. Abdullah Ms. Afaf Alrashidy Ms. Eman Dr. Hala Soliman Eng. Sameer
Time/Activity
LD MD Saadeh (NR) IC Almutairi (MM) LB Abduljawad (FMS)

08:00 Activity Surveyor Planning Session

To
Location Royal Suite (462)
08:30

08:30 Activity Opening Conference

To
Location Basam Alhawari (Large Auditorium)
09:00

Document Document Document Document Document Document

Activity Document Review
Review Review Review Review Review Review

Location Royal Suite (462) & (408)  GATE ACCESS for each Surveyor
09:00 Dr. Mohammed Dr. Mohammad Mr. Adel Tohari; Ms. Hina Bhatti; Dr. Manal Dr. Omar Eng. Fahad
Alshamrani; GD Saad AlSulaimann; AND Acting IC RN Mohammed Al- Alswailimi; Alharbi; FMS
To
Dr. Sameer Sendy, Dr. Ahmed Abu Ms. Abeer Atallah; Ms. Sara Aldosari; Bahnsawi; Director manager
12:00 MD hashim Nurse Manager RN Pharmacy Nabeel Eng. Jalal Bader
Ms. Belinda Dr. Iqra Mr. Mervin Manager Alghannam; Lab Eng. Saleh Alharbi
Counterpart(s)
Lehnerdt; DON Abdulsattar Napalcruz; RN, Aisha Hazazi; Rph Manager Mr. Danish; Safety
Dr. Zuber Shaikh Dr. Husam Abbas QM Specialist Gazwa Almutairi; Mashael Al Lead
Mr. Sattam Dr. Aref Ameen Ms. Sean Delgado; Rph Shamrani
Almurshadi; Senior Ms. Lucile; RN RN Syed Fahad; Rph Ali Al Namazi
HR Manager, Ms. Kath; RN Manar Aldoshan
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 Mr. Ziad Khadijah Oraybi
Alzahrani; QM Masaheer
Abdulmajeed Alkathiri
Almansoor Abdulaziz
Shagaf Kannetah
12:00 Activity Surveyors' Business Lunch
To
Location Royal Suite (462)
13:00

General Survey – Alhabib Medical Group (HMG) – Suwaidi Page 2 of 14

 DAY 1 - 03 MAR 2024 (Afternoon)
Time/Activity LD MD NR IC MM LB FMS
Documents Documents Documents
Activity Unit Visit Unit Visit Unit Visit Unit Visit
Review Review Review
Dialysis / (Inpatient
Location(s) (Social Services) ICU/PICU Royal Suite (408) Royal Suite (462) 6th FL
Physiotherapy Pharmacy)
Nabeel Ghannam
13:00 Mashael Al Eng. Fahad
To Shamrani Alharbi; FMS
Dr. Azam Ibrahim
14:00 Ms. Abeer Atallah; Ms. Hina Bhatti; Ali Al Namazi manager
Dr. Iqra
Batoul Hadadi Nurse Manager Acting IC RN Aisha Hazazi; Rph Manar Al Doshan Eng. Jalal Bader
Abdulsattar
Counterparts abdulaziz anzan Mr. Mervin Ms. Sara Aldosari; Gazwa Almutairi; Khadijah Oraybi Eng. Saleh Alharbi
Dr. Husam Abbas
Nedaa Almalki Napalcruz; RN, RN Rph Masaheer Mr. Danish; Safety
Dr. Aref Ameen
QM Specialist Alkathiri Lead
Abdulaziz Fares Althagafi
Kannetah
Samar Elshahidy
Lab Leadership
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Interview

(CSSD / 6th Floor

Elevators / Data
Location(s) (Patient Affairs) ER / Radiology OR / L&D Endoscopy / (ER / Ambulance) Royal Suite (462)
14:00 Center / Chillers /
Laundry)
To Roof / Biomedical
15:00 IPC Team, CSSD in Dr. Omar
Ms. Batoul Hadadi charge Alswailmi
Dr. Yousef Rabi; Dr. Mohammed
Counterparts Ms. Roaa Arishi Dr. Ibrahim Nabil Ghannam
HOD Nursing Team Hamzah FMS Team
Ms. Basma aldoosh Meshaal
Medical Team Ms. Louwella; RN
Shamlan Esraa Al Gadi; RN Alshamrani; QM
Shehab addin; RN Officer

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 Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
5th FL
Corridors / Stair
cases /Pantry/
Staff Lounges /
(Medical Supply / (Utility Rooms / Technical &
Admission Waste (OPD / Outpatient Electrical Room
Location(s) Out Patient (OPD) NICU
Office/ Duty Segregation Pharmacy) 4th FL
15:00 Manager Office) Areas / Morgue) Nursing station /
Clean & Dirty
To Utility / Patient
Room / Special
16:00 Needs Bathroom
Ibrahim Abu
Mushref
Mohammad
Ms. Abeer Atallah;
Mazhar IPC Team,
NR, Nurse
Counterparts Mr. Mohammed Medical Team Nursing Team Security Lab Team FMS Team
Manager
Qubti, FMS
Omar Akkas; Rph
Batoul Hadadi
Saad AlkhAshlan

16:00
Activity Data Entry / Surveyor Meeting
to
17:00 Location Royal Suite (462)

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 DAY 2 - 04 MAR 2024 (Morning)
Time/Activity LD MD NR IC MM LB FMS

08:00 Activity Surveyor Planning Session (list of “Closed Medical Records” should be provided at the end of session)
To
08:30 Location Royal Suite (462)
08:30 Activity Day One Debriefing
To
09:00 Location Basam Alhawari (Large Auditorium)
QM Department
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Visit
(NICU / PICU / (Medical/Surgical)
Location(s) Main Admin Medical Ward ER
ICU/CCU)
Dr. Mohd. Dr. Manal
Mubarak Albahnasawi;
09:00
To
Dr. Fahad.Faqihi Pharmacy
10:00
Ziad Alzahrani; Dr. Nedaa Manager
QM Manager Abdullah Aldairi Aisha Hazazi; Rph
Counterparts Dr. Reham Medical Team Nursing Team Dr. Emmanuel Ako Gazwa Almutairi; Lab Team FMS Team
Alakbani; QM Mohammad Rph
Specialist Farhat; RN Waliah Najeai;
Safa Saleem; RN Rph
Waleed
Almarzooq ; Rph
QM Committee
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Interview
10:00 3rd FL
To (Regular (IV Clean Room Delivery Room
11:00
Location(s) 6th FL Oncology Ward Out-patient (OPD) Ward/Staff &TPN) /Nursery /Female
Health Clinic) Ward / NICU
2nd FL
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 ICU / Isolation
Room / OR

QIPS Committee Medical Team

Counterparts Dr. Sara Nursing Team IPC Team Pharmacy Team FMS Team
member
Dr. Emad
Data
IC Committee
Activity Management Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Interview
Session
11:00 to 11:30 1st FL
Chemotherapy Derma-Laser /
Dental
Counterparts:
GF
Pharmacy Team Hospital Lobby /
6th FL IT
Location(s) Surgical Ward Nursery 6th FL Gates / Assembly
11:00 Department 11:30 to 12:00 points /Cardiology
To Pharmacy Unit /Hospital
12:00
Admin/QI Entrances /
Meeting Handicapped
access
Eng. Imran Khan
Dr. Iqra
Ziad al zahrani
Counterparts Reham al akbani Medical Team Nursing Team IPC Team Pharmacy Team Lab Team FMS Team
Abdulmajeed
Mansoor
Razan Bamefleh

12:00 Activity Surveyors' Business Lunch

To
13:00 Location Royal Suite (462)

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 DAY 2 – 04 MAR 2024 (Afternoon)
Time/Activity LD MD NR IC MM LB FMS
P and T
Activity Unit Visit Unit Visit Unit Visit Unit Visit Committee Unit Visit Facility Tour
Interview
LG
Radiology / MRI /
Lab / ER / Triage
Area / Command
13:00 Center
Location(s) (Medical Records) ICU/PICU Medical Ward (OR) 6th FL
To /Ambulances /
14:00 Medical Waste /
Kitchen /
Generators /
Central Medical
Gas / Heat Boilers
Dr. Fahad Faqihi Pharmacy and
Dr. Nedaa Aldairi therapeutic
Counterparts Medical Team Nursing Team IPC Team Lab Team FMS Team
Medical Team Committee
members
Environmental
Closed Medical Closed Medical Closed Medical
Activity Unit Visit Unit Visit Unit Visit Safety Committee
Records Review Records Review Records Review
14:00 Interview
To
(In patient Unit/ (ER)
15:00
Location(s) OPD/ Hospital (ICU / NICU) Royal suite (462) 6th FL
Royal Suite (462) Royal suite (408)
Tour) (Dental / Kitchen)

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 Dr. Mohammed Dr. Mohd.
Dr. Ahmed Abu Hamzah Mubarak
Dr. Azam Ibrahim EOC Committee
Counterparts Hashim Ms. Louwella Ms. Safa Saleem
Ms. Rose; RN members
Mr. Mervin; RN Ms. Sultana Mr. Mohammad
alotaibi Farhat
Closed Medical Closed Medical Closed Medical
Activity Unit Visit Contract Review Unit Visit Contract Review
Records Review Records Review Records Review
(Finance / (Pharmacy
Purchasing / Warehouse /
Location(s) Royal Suite (462) Royal suite (408) 6th FL Royal suite (462)
15:00 Academic Affairs Narcotics)
To / IT)
16:00
Khaled Al Aisha Hazazi; Rph
Qawasmeh Gazwa Almutairi;
Dr. Ahmed Abu
Mr. Mohamed Dr. Azam Rph
Counterparts Hashim HR Team
Qubti Ms. Rose; RN Waliah Najeai;
Mr. Mervin; RN
Abdul Razzak Rph
Waleed ; Rph
16:00 Activity Data Entry / Surveyor Meeting
To
17:00 Location Royal Suite (462)

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 DAY 3 - 05 MAR 2024 (Morning)
Time/Activity LD MD NR IC MM LB FMS

08:00 Activity Surveyor Planning Session (list of “Personnel Files” should be provided at the end of session)
To
08:30
Location Royal Suite (462)

Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour

(L&D, OR,
Radiology,
Pediatric B1
(Dialysis / Water Conscious Sedation
Location(s) HR Department L & D / OR Ward / CSSD / Safety
Plants) Area and
Surgical Ward Dept / Dialysis /
extemporaneous
RO Plant /
preparations)
Parking area
08:30 Dr. Maha haroon Handicapped
To Dr. Shatha Adelaide B2
10:00 Dr. Sumaira Islam
Sub-stores /
Ghada.Jamea
Dr. Saima Najm Pharmacy Stores
Eunice.Tayer
Dr. Hosam Thalji Dr. Azzam / Laundry /
Sarwat.Ishaq
Yazeed; RN Ms. Sara Saraan Central Store
Counterparts HR Team Dr. Ahmed Abu
Nosaibah FMS B3
hashem
IPC team
Dr. Abdulmohsen Janitorial Closet
Medical Team
Dr. Amer Aqeel / Fire Pumps /
Asma Alqahtani Septic Tank
Muneera Thanallah
Rami Algorashi

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 Personnel Files
Personnel Files Personnel Files Personnel Files Review and Personnel Files Personnel Files Personnel Files
Activity
10:00 Review Review Review Closed Medical Review Review Review
To Records Review
11:00
Location Royal Suite (462) & (408)
Counterparts
11:00 Activity Information Verification
To
Location(s)
12:00
Information Verification
12:00 Activity Business Lunch and Preparation for the Executive Leadership Interview
To
Location Information Verification
13:30 Royal Suite (462)
Information Verification

Information Verification

Information Verification

Information Verification

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 DAY 3 - 05 MAR 2024 (Afternoon)
Time/Activity LD MD NR IC MM LB FMS

13:30 Activity Executive Leadership Interview

To
14:30 Location
6th FL

14:30 Activity Data Entry and Preparation of the Exit Report

To
16:00 Location
Royal Suite (462)

Activity Pre-Exit Conference Meeting with Hospital Leadership (Optional Session)

16:00
Location
To 6th FL
16:30
Counterparts GD, MD, AED, AMD, DON, AND, QM

16:30
Activity Exit Conference (Optional session if the facility opt to have “Pre-Exit Conference”)
To
Location
Bassam Hawari (Large Auditorium)
17:00

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