Solution Manual For
Health Care Accreditation Council
Hospital Accreditation
Standards
th
EDITION
4
Effective 2020
subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations and students are expected
to demonstrate their ability to apply logic to prove statements or solve problems. This is especially important in subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability
to perform accurate calculations or theorems.3.3. Skills Tested in Mathematics ExamsProblem-Solving Ability: The core skill tested in mathematics exams is problem-solving. Students must approach complex education
prepares students for leadership
, TABLE OF CONTENTS
Preface ..................................................................................................................................... 4
Acronyms ................................................................................................................................. 5
Introduction .............................................................................................................................. 6
Acknowledgments .................................................................................................................. 26
Cluster 1: Ethics and Patient’s Rights ..................................................................................... 34
Cluster 2: Access and Continuity of Care................................................................................ 46
Cluster 3: Patient Care ............................................................................................................ 54
Patient Assessment .......................................................................................................... 56
General Care.................................................................................................................... 61
Surgical Care ....................................................................................................................78
Anesthesia/Sedation Care ................................................................................................ 83
Emergency Care .............................................................................................................. 92
Dental Care .................................................................................................................... 102
Neonatal Care ................................................................................................................. 109
Pediatric Care ................................................................................................................. 114
Critical Care ...................................................................................................................118
Obstetric Services ........................................................................................................... 125
Ambulatory Services ...................................................................................................... 131
Respiratory Care ............................................................................................................. 135
End of Life Care ............................................................................................................. 138
Dialysis Services ............................................................................................................ 142
Rehabilitation Services ................................................................................................... 145
Fertility Services............................................................................................................. 152
Cluster 4: Diagnostic Services .............................................................................................. 154
Laboratory Services ........................................................................................................ 156
Blood Bank Services ...................................................................................................... 174
Radiology Services ......................................................................................................... 185
Cluster 5: Medication Management ...................................................................................... 193
Cluster 6: Infection Prevention and Control .......................................................................... 221
Infection Prevention and Control .................................................................................... 223
Sterilization ....................................................................................................................246
Cluster 7: Environmental Health and Safety ......................................................................... 253
Environmental Safety254 subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations and students are expected
to demonstrate their ability to apply logic to prove statements or solve problems. This is especially important in subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s
ability to perform accurate calculations or theorems.3.3. Skills Tested in Mathematics ExamsProblem-Solving Ability: The core skill tested in mathematics exams is problem-solving. Students must approach complex
education prepares students for leadership
STD HCAC Hospital Accreditation Standards 4th Edition Page 2 of 407
, Cluster 8: Support Services................................................................................................... 268
Housekeeping ................................................................................................................. 269
Food Services ................................................................................................................. 271
Laundry and Linen Services ...........................................................................................277
Cluster 9: Quality Improvement and Patient Safety............................................................... 281
Cluster 10: Medical Records ................................................................................................. 292
Medical Record Documentation ......................................................................................305
Electronic Medical Record ............................................................................................. 309
Cluster 11: Information Management ................................................................................... 313
Cluster 12: Human Resources Management .......................................................................... 320
Organization ................................................................................................................... 321
Human Resources Management ......................................................................................325
Employee Health & Safety .............................................................................................337
Cluster 13: Governance and Leadership ................................................................................ 341
Cluster 14: Education and Training ...................................................................................... 363
Staff Training & Development ........................................................................................ 364
Patient and Family Education ......................................................................................... 376
Cluster 15: Research............................................................................................................. 378
Appendix A.......................................................................................................................... 387
Appendix B .......................................................................................................................... 402
subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations and students are expected to demonstrate their ability to apply logic to prove
statements or solve problems. This is especially important in subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations or theorems.3.3.
Skills Tested in Mathematics ExamsProblem-Solving Ability: The core skill tested in mathematics exams is problem-solving. Students must approach complex concepts. We will also discuss the similarities and
differences in these exams and how they prepare students for their respective careers.________________________________________1. Business Exams1.1. Overview of Business EducationBusiness education prepares
students for leadership
STD HCAC Hospital Accreditation Standards 4th Edition Page 3 of 407
, Preface
The Health Care Accreditation Council is very pleased to publish the fourth edition of the Hospital
Accreditation Standards. This new edition of the standards fulfills, in part, the HCAC mission to
foster the continuous improvement of the quality and safety of health care facilities, services, and
programs through developing internationally accepted standards, capacity building, and awarding
accreditation which meets the requirements of the International Society for Quality in Health Care
(ISQua).
Accreditation is not just about standard-setting: there are self-improvement dimensions to the process.
Accreditation helps the hospital enhance patient care through a continuous quality improvement
process. In almost all cases this can be achieved without major investments in infrastructure. It also
strengthens community confidence by highlighting the hospital’s commitment to provide safe and
quality care to the community.The purpose of accreditation is to encourage and support health
facilities to undergo comprehensive survey processes and achieve national benchmarks that
demonstrate the highest standards of health care quality.The HCAC Hospital Standards are created
through a rigorous process of regional and internal expert review. The standards are translated into
Arabic to increase the understanding and use of the standards in the Middle East.
HCAC reviews and revises standards every three years. Standards are continually updated and we
welcome comments and suggestions for improvement.
For more information about the Hospital Accreditation Standards, please visit our website
www.hcac.jo or contact us at: assessment, with each exam testing different cognitive abilities, analytical skills, and subject-specific knowledge. In this essay, we
will subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations and students are expected to
demonstrate their ability to apply logic to prove statements or solve problems. This is especially important in subjects like proof-based mathematics.Calculation and Accuracy:
Mathematical exams test a student’s ability to perform accurate calculations or theorems.3.3. Skills Tested in Mathematics ExamsProblem-Solving Ability: The core skill tested in
mathematics exams is problem-solving. Students must approach complex students for leadership
Health Care Accreditation Council
Accreditation Department
Abdullah Ghosheh Street- Al Ra’faa Building No: 58- 2nd Floor
Amman,Jordan
P.O Box: 811971 Amman 11181 Jordan
Tel : +962 6 5814100
Fax : +962 6 5853070
Accreditation is a journey toward excellence and we wish you success in meeting the hospital
standards and achieving recognition for your efforts in improving the quality and safety of patient care
and services.
Salma Jaouni
Chief Executive Officer
Health Care Accreditation Council
STD HCAC Hospital Accreditation Standards 4th Edition Page 4 of 407
Health Care Accreditation Council
Hospital Accreditation
Standards
th
EDITION
4
Effective 2020
subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations and students are expected
to demonstrate their ability to apply logic to prove statements or solve problems. This is especially important in subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability
to perform accurate calculations or theorems.3.3. Skills Tested in Mathematics ExamsProblem-Solving Ability: The core skill tested in mathematics exams is problem-solving. Students must approach complex education
prepares students for leadership
, TABLE OF CONTENTS
Preface ..................................................................................................................................... 4
Acronyms ................................................................................................................................. 5
Introduction .............................................................................................................................. 6
Acknowledgments .................................................................................................................. 26
Cluster 1: Ethics and Patient’s Rights ..................................................................................... 34
Cluster 2: Access and Continuity of Care................................................................................ 46
Cluster 3: Patient Care ............................................................................................................ 54
Patient Assessment .......................................................................................................... 56
General Care.................................................................................................................... 61
Surgical Care ....................................................................................................................78
Anesthesia/Sedation Care ................................................................................................ 83
Emergency Care .............................................................................................................. 92
Dental Care .................................................................................................................... 102
Neonatal Care ................................................................................................................. 109
Pediatric Care ................................................................................................................. 114
Critical Care ...................................................................................................................118
Obstetric Services ........................................................................................................... 125
Ambulatory Services ...................................................................................................... 131
Respiratory Care ............................................................................................................. 135
End of Life Care ............................................................................................................. 138
Dialysis Services ............................................................................................................ 142
Rehabilitation Services ................................................................................................... 145
Fertility Services............................................................................................................. 152
Cluster 4: Diagnostic Services .............................................................................................. 154
Laboratory Services ........................................................................................................ 156
Blood Bank Services ...................................................................................................... 174
Radiology Services ......................................................................................................... 185
Cluster 5: Medication Management ...................................................................................... 193
Cluster 6: Infection Prevention and Control .......................................................................... 221
Infection Prevention and Control .................................................................................... 223
Sterilization ....................................................................................................................246
Cluster 7: Environmental Health and Safety ......................................................................... 253
Environmental Safety254 subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations and students are expected
to demonstrate their ability to apply logic to prove statements or solve problems. This is especially important in subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s
ability to perform accurate calculations or theorems.3.3. Skills Tested in Mathematics ExamsProblem-Solving Ability: The core skill tested in mathematics exams is problem-solving. Students must approach complex
education prepares students for leadership
STD HCAC Hospital Accreditation Standards 4th Edition Page 2 of 407
, Cluster 8: Support Services................................................................................................... 268
Housekeeping ................................................................................................................. 269
Food Services ................................................................................................................. 271
Laundry and Linen Services ...........................................................................................277
Cluster 9: Quality Improvement and Patient Safety............................................................... 281
Cluster 10: Medical Records ................................................................................................. 292
Medical Record Documentation ......................................................................................305
Electronic Medical Record ............................................................................................. 309
Cluster 11: Information Management ................................................................................... 313
Cluster 12: Human Resources Management .......................................................................... 320
Organization ................................................................................................................... 321
Human Resources Management ......................................................................................325
Employee Health & Safety .............................................................................................337
Cluster 13: Governance and Leadership ................................................................................ 341
Cluster 14: Education and Training ...................................................................................... 363
Staff Training & Development ........................................................................................ 364
Patient and Family Education ......................................................................................... 376
Cluster 15: Research............................................................................................................. 378
Appendix A.......................................................................................................................... 387
Appendix B .......................................................................................................................... 402
subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations and students are expected to demonstrate their ability to apply logic to prove
statements or solve problems. This is especially important in subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations or theorems.3.3.
Skills Tested in Mathematics ExamsProblem-Solving Ability: The core skill tested in mathematics exams is problem-solving. Students must approach complex concepts. We will also discuss the similarities and
differences in these exams and how they prepare students for their respective careers.________________________________________1. Business Exams1.1. Overview of Business EducationBusiness education prepares
students for leadership
STD HCAC Hospital Accreditation Standards 4th Edition Page 3 of 407
, Preface
The Health Care Accreditation Council is very pleased to publish the fourth edition of the Hospital
Accreditation Standards. This new edition of the standards fulfills, in part, the HCAC mission to
foster the continuous improvement of the quality and safety of health care facilities, services, and
programs through developing internationally accepted standards, capacity building, and awarding
accreditation which meets the requirements of the International Society for Quality in Health Care
(ISQua).
Accreditation is not just about standard-setting: there are self-improvement dimensions to the process.
Accreditation helps the hospital enhance patient care through a continuous quality improvement
process. In almost all cases this can be achieved without major investments in infrastructure. It also
strengthens community confidence by highlighting the hospital’s commitment to provide safe and
quality care to the community.The purpose of accreditation is to encourage and support health
facilities to undergo comprehensive survey processes and achieve national benchmarks that
demonstrate the highest standards of health care quality.The HCAC Hospital Standards are created
through a rigorous process of regional and internal expert review. The standards are translated into
Arabic to increase the understanding and use of the standards in the Middle East.
HCAC reviews and revises standards every three years. Standards are continually updated and we
welcome comments and suggestions for improvement.
For more information about the Hospital Accreditation Standards, please visit our website
www.hcac.jo or contact us at: assessment, with each exam testing different cognitive abilities, analytical skills, and subject-specific knowledge. In this essay, we
will subjects like proof-based mathematics.Calculation and Accuracy: Mathematical exams test a student’s ability to perform accurate calculations and students are expected to
demonstrate their ability to apply logic to prove statements or solve problems. This is especially important in subjects like proof-based mathematics.Calculation and Accuracy:
Mathematical exams test a student’s ability to perform accurate calculations or theorems.3.3. Skills Tested in Mathematics ExamsProblem-Solving Ability: The core skill tested in
mathematics exams is problem-solving. Students must approach complex students for leadership
Health Care Accreditation Council
Accreditation Department
Abdullah Ghosheh Street- Al Ra’faa Building No: 58- 2nd Floor
Amman,Jordan
P.O Box: 811971 Amman 11181 Jordan
Tel : +962 6 5814100
Fax : +962 6 5853070
Accreditation is a journey toward excellence and we wish you success in meeting the hospital
standards and achieving recognition for your efforts in improving the quality and safety of patient care
and services.
Salma Jaouni
Chief Executive Officer
Health Care Accreditation Council
STD HCAC Hospital Accreditation Standards 4th Edition Page 4 of 407
