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King Abdulaziz University Hospital - Scope of Services

Patient Care Departments, Patient Services and Support Services:

The following departments are an integral component of the organization and allow for optimal provision of patient care and services.

The scope of department services and care, including staff qualifications, hours of operation, staffing plans and additional information is referenced in individual departmental/service manuals.

Anesthesia:

The Anesthesia Department provides complete anesthesia services, including general, spinal, major regional, moderate and deep sedation and pain management.

Anesthesia services are available to all inpatients and outpatients on an emergent, urgent and elective basis, Monday through Friday, with on-call coverage after hours and on weekends and holidays. Anesthesia services are available immediately when anesthesia is determined necessary for all emergency and obstetric cases.

The Anesthesia Department is directed by a board-certified anesthesiologist and staffed by qualified physicians and certified registered nurse anesthetists.

Clinical Laboratory:

The Clinical Laboratory Department provides comprehensive testing and blood bank services for all patients utilizing the facility.

The Clinical Laboratory is open seven (7) days per week, 24 hours per day to inpatient and outpatient patient population. Microbiology, Bacteriology, Hematology, Chemistry, Urinalysis, Serology, immunology, molecular biology, and Blood Bank services are available. Relationships with outside reference laboratories allow for completion of any laboratory test in a timely manner via computerized interface. All outside reference laboratories are approved by the medical staff.

The Clinical Laboratory personnel include personnel certified in medical technology and phlebotomy. Assignments within the department are based upon the complexity of the testing requirements. All personnel evidence proficiency with the Clinical Laboratory computer system and all chemistry and laboratory equipment. All personnel have an understanding and are able to demonstrate knowledge of the laboratory specific safety and infection control policies and procedures, as well as, the organizational safety management and utilities management programs. The physician director of the Clinical Laboratory is board certified in Clinical Pathology.

Communications/Operator:

The Communications Department is responsible for the operation of the organization's communication system. Personnel are responsible for answering all incoming calls in a timely and professional manner and to accurately disperse all calls to their final destination. Staff is also responsible for activating the facility's overhead paging system, the internal and external pocket pager system and monitoring all of the organization wide emergency systems. The department is staffed seven (7) days per week, 24 hours per day.

Diabetic center:

This center is located in KAUH

This center covers all assessment, educational, diagnostic, and therapeutic needs of diabetic patients. It contains a multidisciplinary outpatient clinic as well as well staffed patient education center.

All staff in the diabetic center are board certified.

Emergency Department:

The Emergency Department is a Level one emergency treatment facility which is open 24 hours a day, seven (7) days a week, fully staffed with licensed physicians and nursing personnel at all times.

The department provides evaluation and treatment to patients of various ages and varying levels of illness from minor to critical. All patients presenting to the facility requesting emergency treatment are medically screened by the Emergency Department physician. The Emergency Department patients are then evaluated for response to treatment and are admitted to the hospital, transferred for further necessary treatment not provided by the facility or discharged with follow-up instructions as appropriate.
The Emergency Department is staffed with registered nurses and licensed practical/vocational nurses, who are certified in ACLS, PALS and BCLS. All personnel, additionally, demonstrate competency in the performance of specialized ED skills.

ENT:

The department of ENT is located in KAUH with only a clinic extension in KKUH

All ENT diagnostic and therapeutic procedures and facilities are covered in this well staffed department. 24 hours consultation services is available for both hospitals and multispecialty clinics are a viable throughout the week during working hours.

All staff members are board certified

Engineering:

Engineering is responsible for the organization's equipment management program, condition of the physical plant; including all grounds and equipment. All equipment is inspected and maintained as environment units, in accordance with the equipment preventive maintenance system, either directly through the Engineering Department or via outside vendor contracting. Engineering also assumes oversight responsibility for the safety and security of the organization, including the safety management program, physical condition of the plant and grounds and security of patients, personnel and visitors.

The Engineering Department is responsible for the organization's equipment management program. The program assesses and controls the clinical and physical risks of fixed and portable equipment used for the diagnosis, treatment, monitoring and care of patients. Equipment that is considered essential for life support, associated with a higher than normal incident risk during routine operation and requiring by reason of complexity a more intensive maintenance schedule, associated with utility systems that maintain a normal hospital environment are supplied or maintained and recorded on an individual basis within the system. Inspection, maintenance and repair of the following categories of equipment and documentation thereof is the responsibility of the following departments:

    Imaging equipment - Imaging Services
    Laboratory testing equipment - Clinical Laboratory
    Anesthetic delivery equipment (including analyzers) - Surgery
    Computer terminal equipment - Data Processing/Information Systems
    Communication lines - Operator/Business Office
    Personal computers - Desktop Publishing/Information Systems
    Telecommunications equipment - Operator/Business Office
    Verification of oxygen purity and nitrous oxide at the point of delivery to the patient - Cardiopulmonary

The personnel in the Engineering Department possess the skill level in order to provide safe, competent and accurate care as defined under the scope of care. Personnel must possess knowledge of safety program policies.

Imaging Services Department:

The Imaging Services Department is a comprehensive service providing sophisticated clinical application of imaging technology 24 hours per day, seven (7) days per week. Services are provided to the inpatient and outpatient population of all ages, both within the Imaging Services Department and at the patient bedside. Diagnostic result reporting is continuously transmitted through the computer system with hard copy printing. Outpatient results are sent to the ordering physician's office. The department consists of Diagnostic Radiology, Interventional Radiology, Nuclear Medicine, CT, MRI, Mammography and Ultrasound services.

Physician orders are entered into the computer order entry system with special needs of the patient identified at the time of ordering. Patients requiring transportation assistance will have this need met by Imaging Services Department personnel. Certain medical conditions may necessitate the accompaniment of a registered nurse based upon the assessment of the nursing personnel. Patient condition, or type of exam may require the procedure be performed outside of the department. This may occur on patient units, in the surgical suite, or any area where emergent imaging is ordered by a physician.

Scope of Services:

The Imaging Services Department provides services for the study of the anatomical processes of the human body by acquiring diagnostic images. Radiology diagnostic procedures are performed on patients of all ages, from the neonate to the geriatric patient. Nuclear Medicine provides for a study of the physiological and metabolic processes of the human body by acquiring diagnostic images after administering radioisotopes, either alone or tagged to chemicals normally utilized by the body. Isotopes are utilized as specified in the radioactive materials license.

Pregnant patients are assessed for risk, with denial of procedure when a potential for patient harm exists unless the risk from the suspected diagnosis outweighs the risk of radiation to the fetus, as determined by the referring physician and the nuclear medicine physician.

Skill Levels of Personnel:

The physician director of the department must be board certified in Radiology or possess equivalent experience and competence in the area of comprehensive diagnostic radiology services. The departmental personnel consist of licensed radiology technicians and other support staff who possess the skill level that allows for the provision of safe, competent and accurate care as defined under the scope of care.

Information Management Department:

The Information Systems Department includes desktop publishing and is a critical component of the organization wide information. Information Systems Department provides for the software, hardware and support needs of the patient care providers. This support includes, but is not limited to, the installation of new software systems, along with the hardware and training necessary to utilize such systems, and ongoing maintenance of current hardware and repair of such hardware. The Information Systems Department is an important part of the decision team used in making selections of appropriate software systems to provide support in short and long-term planning for the patient care information needs of the organization.

Medical Records/Health Information Management Department:

The Medical Records/Health Information Management Department is responsible for overseeing the timely processing, completeness, and when necessary, the retrieval of all patient medical records.

The scope of services provided by the Medical Records/Health Information Management Department is based upon a collaboration and information sharing format to enhance patient care. Medical records services are provided to all areas of the facility, as appropriate to need and security levels. Medical record services include provision of an accurate patient record, with emphasis on the following:

    Record processing
    Record abstracting, analysis and coding
    Transcription of dictation for the medical record
    Correspondence
    Record retrieval, filing and storage

The scope of services also encompasses efforts made to provide:

    Improved data accuracy.
    Demonstrated balance of proper levels of security versus ease of access.
    Use of aggregate data, available through computerized reporting in the Medical Records/Health Information Management Department, to assist all healthcare providers with information that allows for identification of opportunities to improve performance.
    Accessibility of the medical record at all times to only those authorized persons with a need to know for patient care.
    Transcription service is available to all physicians on a 24 hours per day basis. All documents received will be placed in the chart as soon as possible to ensure timely access to this information.
    Availability of Medical Records/Health Information Management personnel seven (7) days per week during regular business hours. During off hours, personnel are available by telephone. The house supervisor has access to the department and all medical records during off hours.

Medical Staff:

All departments providing patient care have established lines of communication with the medical staff. Established mechanisms for communicating issues are described in the organizational wide Manual.

Scope of care and service of each member of the medical staff is delineated through the clinical privileging process according to the bylaws of the medical staff. The Emergency Department physician is onsite 24 hours per day, seven (7) days per week to meet patient care needs. Individual service committee scope of services is outlined.

Nursing Services:

Nursing Services is under the direction of the Nurse Executive of the organization. Nursing services are provided in all direct patient care nursing units. The Nurse Executive and the individual unit nurse managers are held responsible for the nursing professional standards of the organization, the responsibility for the standards of care and practice, performance assessment and improvement, policies and procedures, nursing staffing plans, personnel competency and nursing licensure within the Nursing Services Department. Collaborative activities have been established to ensure that these responsibilities are addressed in all areas throughout the organization where nursing care is provided.

The Nurse Executive assumes an active leadership role in the hospital's decision making structures and process.

The Nurse Executive assures the provision of nursing services, in the hospital, 24 hours a day, seven (7) days per week. At least one (1) on-premise registered nurse (RN) furnishes or supervises nursing services 24 hours a day, seven (7) days per week.

Nursing care is accomplished through the execution of the nursing process; patient teaching, administering, supervising, delegating and evaluating nursing care and practice. This includes implementation of nursing standards of care and practice.

All nursing care is under the direction of registered nurses and Nursing Aides. ECG monitoring technicians must evidence competency and completion of a certified EKG reading and interpretation program. Unit secretaries must display a thorough knowledge of unit specific as well as organization wide policies and procedures and be proficient in the computer order entry system.

Nutritional Services:

Nutritional Services is responsible for providing the highest quality food services possible to all patients (pediatric through the geriatric population), personnel and visitors. Cost-effective, nutritious, high quality meals are prepared and delivered daily to patient care and public dining areas. Physician meals and catered functions are also provided. Nutritional care is planned, administered and evaluated by the Registered Dietitian according to individual patient need.

The Nutritional Services Department provides cold sandwiches and nutritional supplements, including snacks to all patient care units to be served to those patients who request food after routine meal times. Changes in diet orders are carried out in a timely manner via the computer order entry system which allows for immediate notification of dietary changes and requirements.

The Nutritional Services Department Director is responsible to ensure that all personnel are knowledgeable and competent in infection control, safety and equipment management as this pertains to the Nutritional Services Department. Additionally, the registered dietitians, must evidence competency in those areas relating to clinical nutrition, including patient education and diet counseling. All other Nutritional Services personnel must possess a thorough understanding of infection control and safety management policies, procedures and requirements as they pertain to the Nutritional Services Department.

Ophthalmology:

The department of ophthalmology is located in KAUH with only a clinic extension in KKUH.

All ophthalmic diagnostic and therapeutic procedures and facilities are covered in this well staffed department. 24 hours consultation services is available for both hospitals and multispecialty clinics are a viable throughout the week during working hours.

All staff members are board certified

Pediatric Specialties (see details in Departmental Manual)

A large pediatric department provides integral patient care function

All pediatric specialties are covered including: Cardiology, pulmonology, gastroenterology, rheumatology, endocrinology, neurology, infectious diseases, allergy immunology, genetics, and nephrology. 24 hours coverage of in patient's consultation is available as well as multi specialty out patients clinics during working hours.

All consultant physicians are board certified

Pharmacy Department:

Copies of all physician's orders for medications are provided to the Pharmacy for filling and appropriate processing. Pharmacist and pharmacy technicians routinely make rounds of the patient care units to retrieve copies once they have been removed from the patient's medical record. Orders are filled in the Pharmacy Department after screening is performed for duplication, interactions and allergies against each patient medication profile. The Pharmacy Department is open during the hours of 8:00 AM through 4:30 PM, Saturday to Wednesday for outpatient pharmacy while the inpatient and emergency pharmacy is open 24 hours 7 days a week. A limited set of medications, approved by the hospital, are available when the Pharmacy is closed. These medications are locked and secured in an area outside of the Pharmacy. Only trained, designated prescribers and nurses are allowed access to these medications.

A pharmacist is available on-call or at another location to answer questions or provide medications that designated staff cannot access.

The Pharmacy Department is designed to meet the primary needs of all customers. The customer base is composed of all patients, both inpatients and outpatients, who require medications, medication counseling and/or education. The customer base also includes the physicians prescribing medications and other healthcare providers who administer medications to the patient population. The Pharmacy Department's services includes dispensing of pharmaceuticals, appropriate inventory maintenance functions, drug monitoring, patient drug assessment functions, appropriate record keeping, drug information, education services and performance improvement functions. The Pharmacy Department also serves in an advisory capacity through the P&T Committee, Primary Care Committee and the administrative leaders to ensure the development, coordination and review of all professional standards, procedures, policies and controls relating to procurement, storage, dispensing and safe use of medications.

The Pharmacy Department is organized to provide services directed at meeting the needs of the patient population. Services are directed toward providing care to patients in all phases of development from newborn to geriatric states.

Pharmacy Department personnel must possess the skill level in order to provide safe, competent and accurate care as defined under the above scope of care for the Pharmacy Department. Pharmacists must be registered and, with training and experience that emphasizes an acute and long term care hospital environment. Technician personnel must meet the licensing/certification requirements and should possess national certification. Ancillary and support personnel must possess basic educational requirements and be trained to assist the professional personnel as appropriate. All personnel are provided with regular continuing education and training to maintain proficiency and competence. Technicians and Pharmacists are required to demonstrate active participation in continuing education courses as required by the State Board of Pharmacy by providing documentation of attendance.

Physical Therapy:

The Physical Therapy Department provides prescribed therapies/tests for the inpatient and outpatient population. Therapy is performed at the patient bedside or in the Physical Therapy Department. Physical Therapy personnel have the responsibility to transport patients to the department for treatment and services.

The Physical Therapy Department delivers comprehensive services to individuals with physical dysfunction secondary to disability, disease or injury in accordance with professional standards of practice, departmental policies and procedures and organizational standards. Services include comprehensive assessments, development of treatment plans, delivery and documentation of care, consultation, re-evaluation, discharge planning and patient/family education.

The personnel in the Physical Therapy Department possess the appropriate skill level to provide safe, competent and accurate care as defined under the scope of care. Physical Therapists must be licensed and possess a BS or MS from an institution that meets accreditation for physical therapy licensure requirements. Physical Therapy Assistants must possess licensure. Physical Therapy Aides within the department must evidence appropriate degree of competency in physical therapy practice.

Safety/Security:

The organizational safety and security program is provided for the purpose of maintaining a safe and secure environment for patients, visitors and hospital personnel. The program assesses risks through the multidisciplinary Environment of Care Committee, monitors sensitive areas and serves as a resource for security/safety information, equipment, supplies and training.

The program includes the following:

Access control to hospital facilities, motor vehicle parking control, traffic control and direction, response to calls for assistance in assaultive/combative behavior incidents, infant/child security personnel and visitor escort and a 24-hour patrol and monitoring function of the campus.

Clinical Social Work Department:

Referrals for all Social Service/Discharge Planning Services are accepted from physicians, hospital personnel, patients, families, outside agencies and other healthcare professionals as appropriate. Referrals may be made in person, by telephone or written contact. Treatment modalities of psychosocial services are available including crisis intervention, situational counseling, discharge planning and referral to appropriate community agencies. The Social Worker works closely with the interdisciplinary teams to develop a holistic plan of care for the patient. The plan is successfully executed by all team members working together with the patient/family.

The Social Service/Discharge Planning Department provides clinical social work services to inpatients, outpatients and hospital personnel. Discharge planning assistance is provided for all inpatients with follow-up referrals and assistance provided to outpatients as necessary and requested. Routine hours are from 8:00 AM through 4:30 PM, Saturday to Wednesday with Social Service access afterhours available through pager contact and Social Service response. Discharge planning activities are conducted after hours through the nursing personnel and administrative leaders, as appropriate. The Department coordinates coverage to ensure that the continuity of care needs of all patients are met in all service areas.

The Social Worker is a graduate from an accredited School of Social Work with oversight consultation and responsibility by a Licensed Clinical Social Worker.

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King Abdulaziz University Hospital - Scope of Services