Mirasol M. Villaflores

Day 1 – Sunday, 10 March 2019 Time (Hrs) Physician Surveyor & Team Leader Nurse Surveyor Administrator Surveyor Physician Surveyor Nurse Surveyor Dr. Paolo Neno MD Ms. Sara Shahim-Abedi RN, MBA, EdD Mr. M Akbar Khan BE, MBA, CPHQ Dr. Zeeshan B. Ishtiaque MBBS, CPHQ Ms. Helge E. Springhorn RN, MBA, CPHQ Observers: Dr. Aida Darweish Associate Consultant, Emergency Medicine Ms. Hala Ghamdi Nurse Educator, QM Nursing Engr. Meshal Al Aseeri Manager, U&M Operations Dr. Ramatoulie Jack Consultant, Family Medicine / Clinical Performance Ms. Samra Mestadi Nurse Specialist Tour Guides: Mr. John Louie Caneja QM Specialist Ms. Chona Barcelona QM specialist Ms. Noura Abdullah QM Specialist Ms. Kathleen Hart QM Specialist Ms. Anna Liza QM Specialist 0745 - 0800 Team Meeting with Survey Coordinator and Translators SANGHA Conference Room [Dr. Wazzan, Ms. Jessica Wong] 0800 - 0830 Opening Conference and Agenda Review SANGHA Conference Room [Dr. Alzahrani, Brig. Gen. Engr. K. Bakulka, Dr. M. Al Qurashi, Mr. A. Al Buluwi, Dr. T. Al Yafi, Dr. Ashraf AlSahafi, Dr. Y. Faden, Ms. B. Scudder, Dr. M. Jamjoom, Dr. Wazzan, Ms. Jessica Wong, Mr. F. Millan-Minute Taker] 0830 - 0915 Orientation to the Hospital’s Services Dr. Andejani Hall & Al Razi (video link) Refer to Participants’ List , JCI Teams, JCI Tour Guides & Observers, Ms. Azhar - Minute Taker] 0915 - 1115 Document Review Hospital VIP Dining Room 1115 - 1230 Individual Patient Tracer Activity Individual Patient Tracer Activity Facility Tour Individual Patient Tracer Activity Individual Patient Tracer Activity 1230 - 1330 Surveyor Working Lunch Hospital VIP Dining Room 1330 – 1530 Medical Education Leadership Interview Hospital Conference Room Dr. T. Al Yafi, Dr. M. AlQurashi, Ms. B. Scudder, Dr. A. AlSahafi, Dr. Y. Faden, Dr. H. Al Marzouki, Dr. , Ms. Tahani Alfudhail Ms. C. Selda-Minute Taker Individual Patient Tracer Activity Facility Management and Safety Document Review and Facility Tour Individual Patient Tracer Activity Individual Patient Tracer Activity 1530 - 1600 Undetermined Survey Activity 1600 - 1630 Meeting with Survey Coordinator Hospital VIP Dining Room [Dr. Wazzan, Ms. Jessica Wong] Day 2 – Monday, 11 March 2019 (Morning) Time (Hrs) Physician Surveyor & Team Leader Nurse Surveyor Administrator Surveyor Physician Surveyor Nurse Surveyor Dr. Paolo Neno MD Ms. Sara Shahim-Abedi RN, MBA, EdD Mr. M Akbar Khan BE, MBA, CPHQ Dr. Zeeshan B. Ishtiaque MBBS, CPHQ Ms. Helge E. Springhorn RN, MBA, CPHQ Observers: Dr. Aida Darweish Associate Consultant, Emergency Medicine Ms. Hala Ghamdi Nurse Educator, QM Nursing Engr. Meshal Al Aseeri Manager, U&M Operations Dr. Ramatoulie Jack Consultant, Family Medicine / Clinical Performance Ms. Samra Mestadi Nurse Specialist Tour Guides: Mr. John Louie Caneja QM Specialist Ms. Chona Barcelona QM specialist Ms. Noura Abdullah QM Specialist Ms. Kathleen Hart QM Specialist Ms. Anna Liza QM Specialist 0800 -0900 Daily Briefing Dr. Andejani Hall & Al Razi (video link) [Executives, Clinical Chairs, FMS Areas, Allied Health & Other HODs, Clinical Nursing Directors, JCI Tour Guides & Observers, Document Command Center, QM Staff, Ms. K. Royo-Minute Taker] 0900 - 1000 Leadership for Quality & Patient Safety, Culture of Safety, and Ethical Framework Interview QPS Education Room [Dr. Alzahrani, Mr. A. Al Buluwi, Dr. K. Abdulkhaliq, Ms. B. Scudder, Dr. Ashraf AlSahafi, Dr. Y. Faden, Dr. M. Al Dakhil, Dr. Wazzan, Ms. Lorraine, Ms. G. Al Amari, Ms. S. Hammad, Ms. M. Sindayen-Minute Taker] 1000 - 1200 Individual Patient Tracer Activity Individual Patient Tracer Activity Facility Tour 1000 - 1130 Individual Patient Tracer Activity Quality Program Interview – Clinical Measures QPS Education Room [Dr. Alzahrani, Ms. B. Scudder, Dr. Wazzan, Ms. Lorraine. Ms. C. Barcelona, Ms. S. Malibari, Mr. Aziz Al Jahdali -Minute Taker] 1130 - 1200 Undetermined Survey Activity - Surveyor Working Lunch Hospital VIP Dining Room Day 2 – Monday, 11 March 2019 (Afternoon) Time (Hrs) Physician Surveyor & Team Leader Nurse Surveyor Administrator Surveyor Physician Surveyor Nurse Surveyor Dr. Paolo Neno MD Ms. Sara Shahim-Abedi RN, MBA, EdD Mr. M Akbar Khan BE, MBA, CPHQ Dr. Zeeshan B. Ishtiaque MBBS, CPHQ Ms. Helge E. Springhorn RN, MBA, CPHQ Observers: Dr. Aida Darweish Associate Consultant, Emergency Medicine Ms. Hala Ghamdi Nurse Educator, QM Nursing Engr. Meshal Al Aseeri Manager, U&M Operations Dr. Ramatoulie Jack Consultant, Family Medicine / Clinical Performance Ms. Samra Mestadi Nurse Specialist Tour Guides: Mr. John Louie Caneja QM Specialist Ms. Chona Barcelona QM specialist Ms. Noura Abdullah QM Specialist Ms. Kathleen Hart QM Specialist Ms. Anna Liza QM Specialist 1300 - - - 1500 Facility Tour Organ and Tissue Transplant Services Interview and Tracer SANGHA Conference Room Dr. A. Malki, Mr. Nashat, Dr. W. Jastaniah, Dr. S. , Dr. Arwa Yamani, Ms. Nur Ashikin, Dr. S. Ghamdi, - Minute Taker Individual Patient Tracer Activity Medication Management System Tracer including Medication Supply Chain ACC Conference Room RPh. H. Hamdan, Dr. M. Aseeri, Dr. S. Esmail, RPh. J. Al Subaie, Ms. F. Byleveld, Ms. S. Mestadi, Ms. C. Barcelona, Minute Taker Human Subjects Research Leadership & Process Interview Hospital Conference Room Dr. A. Banna, Ms. A. Al Dosary, Ms. Noura, -Minute Taker 1500 - - 1600 Undetermined Survey Activity Human Subjects Tracer 1600 - 1630 Meeting with Survey Coordinator Hospital VIP Dining Room [Dr. Wazzan, Ms. Jessica Wong] 1600 – 1700 Day 2 -- Internal Debriefing Dr. Andejani Hall & Al Razi Hall ( ** video link ) Day 3 – Tuesday, 12 March 2019 (Morning) Time (Hrs) Physician Surveyor & Team Leader Nurse Surveyor Administrator Surveyor Physician Surveyor Nurse Surveyor Dr. Paolo Neno MD Ms. Sara Shahim-Abedi RN, MBA, EdD Mr. M Akbar Khan BE, MBA, CPHQ Dr. Zeeshan B. Ishtiaque MBBS, CPHQ Ms. Helge E. Springhorn RN, MBA, CPHQ Observers: Dr. Aida Darweish Associate Consultant, Emergency Medicine Ms. Hala Ghamdi Nurse Educator, QM Nursing Engr. Meshal Al Aseeri Manager, U&M Operations Dr. Ramatoulie Jack Consultant, Family Medicine / Clinical Performance Ms. Samra Mestadi Nurse Specialist Tour Guides: Mr. John Louie Caneja QM Specialist Ms. Chona Barcelona QM specialist Ms. Noura Abdullah QM Specialist Ms. Kathleen Hart QM Specialist Ms. Anna Liza QM Specialist 0800 -0900 Daily Briefing Dr. Andejani Hall & Al Razi (video link) [Executives, Clinical Chairs, FMS Areas, Allied Health & Other HODs, Clinical Nursing Directors, JCI Tour Guides & Observers, Document Command Center, QM Staff, Ms. K. Royo-Minute Taker] 0900 - – 1100 Individual Patient Tracer Activity 0900 - 1030 Individual Patient Tracer Activity 0900 - 1100 Individual Patient Tracer Activity Facility Management and Safety Document Review Hospital VIP Dining Room FMS Representatives SQE File Review – Nursing & Allied Health Orientation Room [Ms. B. Scudder, Dr. E. Bukhari, Mr. O. Abu Skout, Ms. Aziza , Ms. Alia, Ms. J. Calica - Minute Taker 1100 - 1200 1030 - 1200 1100 - 1200 Medical Student & Trainee Interview ACC Conference Room Ms.– Minute Taker Quality Program Interview – Hospital Operations QPS Education Room Patient Group Interview Hospital Conference Room - Surveyor Working Lunch Hospital VIP Dining Room Day 3 – Tuesday, 12 March 2019 (Afternoon) Time (Hrs) Physician Surveyor & Team Leader Nurse Surveyor Administrator Surveyor Physician Surveyor Nurse Surveyor Dr. Paolo Neno MD Ms. Sara Shahim-Abedi RN, MBA, EdD Mr. M Akbar Khan BE, MBA, CPHQ Dr. Zeeshan B. Ishtiaque MBBS, CPHQ Ms. Helge E. Springhorn RN, MBA, CPHQ Observers: Dr. Aida Darweish Associate Consultant, Emergency Medicine Ms. Hala Ghamdi Nurse Educator, QM Nursing Engr. Meshal Al Aseeri Manager, U&M Operations Dr. Ramatoulie Jack Consultant, Family Medicine / Clinical Performance Ms. Samra Mestadi Nurse Specialist Tour Guides: Mr. John Louie Caneja QM Specialist Ms. Chona Barcelona QM specialist Ms. Noura Abdullah QM Specialist Ms. Kathleen Hart QM Specialist Ms. Anna Liza QM Specialist 1300 - 1600 SQE File Review – Medical Staff Orientation Room Dr. K. alAbdulkhaleed, Mr. B. Shami, Ms. S. Hayat, Ms. Amal, Ms. Malou, Ms. L. Ibre-Minuet Taker Individual Patient Tracer Activity 1300 - 1500 Individual Patient Tracer Activity 1300 - 1500 Facility Management and Safety Document Review Hospital VIP Dining Room FMS Representatives Infection Prevention and Control System Tracer Hospital Conference Room Dr. A. AlSaedi, Dr. M. Lamfon, Dr. F. Farahat, Dr. A. Mufti, Dr. S. Khoshhal, Dr. B. Al Subyei, Mr. W. Al Ghamdi, Mr. M. Yaseen, Ms. H. Tabsh, Ms. R. Taguas, Ms. V. Litan-Minute Taker] 1500 - 1600 1500 - 1600 Undetermined Survey Activity Undetermined Survey Activity 1600 - 1630 Meeting with Survey Coordinator Hospital VIP Dining Room [Dr. Wazzan, Ms. Jessica Wong] 1600 – 1700 Day 3 -- Internal Debriefing Dr. Andejani Hall & Al Razi Hall ( ** video link ) Day 4 – Wednesday, 13March 2019 Time (Hrs) Physician Surveyor & Team Leader Nurse Surveyor Administrator Surveyor Physician Surveyor Nurse Surveyor Dr. Paolo Neno MD Ms. Sara Shahim-Abedi RN, MBA, EdD Mr. M Akbar Khan BE, MBA, CPHQ Dr. Zeeshan B. Ishtiaque MBBS, CPHQ Ms. Helge E. Springhorn RN, MBA, CPHQ Observers: Dr. Aida Darweish Associate Consultant, Emergency Medicine Ms. Hala Ghamdi Nurse Educator, QM Nursing Engr. Meshal Al Aseeri Manager, U&M Operations Dr. Ramatoulie Jack Consultant, Family Medicine / Clinical Performance Ms. Samra Mestadi Nurse Specialist Tour Guides: Mr. John Louie Caneja QM Specialist Ms. Chona Barcelona QM specialist Ms. Noura Abdullah QM Specialist Ms. Kathleen Hart QM Specialist Ms. Anna Liza QM Specialist 0800 -0900 Daily Briefing Dr. Andejani Hall & Al Razi (video link) [Executives, Clinical Chairs, FMS Areas, Allied Health & Other HODs, Clinical Nursing Directors, JCI Tour Guides & Observers, Document Command Center, QM Staff, Ms. K. Royo-Minute Taker] 0900 - 1100 Closed Patient Medical Record Review ACC Conference Room -Minute Taker Closed Patient Medical Record Review Hospital Conference Room -Minute Taker Supply-Chain Management & Evidence-Based Purchasing Interview SANGHA Conference Room Brig. Gen. Engr. K. Bakulka, Dr. E. AlZimaiti, RPh. J. Al Subaie, Ms. B. Scudder, Engr. H. Al Wafi, Dr. T. Nasser, Engr. S. Khallagi, Dr. S. Khoshhal, Mr. A. AlBarakati, Ms. K. Ting Hie Hee, Ms. -Minute Taker Individual Patient Tracer Activity Individual Patient Tracer Activity 1100 - 1200 Undetermined Survey Activity Undetermined Survey Activity Undetermined Survey Activity Undetermined Survey Activity Undetermined Survey Activity- Surveyor Working Lunch Hospital VIP Dining Room 1300 - 1500 Individual Patient Tracer Activity Individual Patient Tracer Activity Individual Patient Tracer Activity Closed Patient Medical Record Review ACC Conference Room - Minute Taker Closed Patient Medical Record Review Hospital Conference Room - Minute Taker 1500 - 1600 Individual Patient Tracer Activity Individual Patient Tracer Activity 1600 - 1630 Meeting with Survey Coordinator Hospital VIP Dining Room [Dr. Wazzan, Ms. Jessica Wong] Day 5 – Thursday, 14March 2019 Time (Hrs) Physician Surveyor & Team Leader Nurse Surveyor Administrator Surveyor Physician Surveyor Nurse Surveyor Dr. Paolo Neno MD Ms. Sara Shahim-Abedi RN, MBA, EdD Mr. M Akbar Khan BE, MBA, CPHQ Dr. Zeeshan B. Ishtiaque MBBS, CPHQ Ms. Helge E. Springhorn RN, MBA, CPHQ Observers: Dr. Aida Darweish Associate Consultant, Emergency Medicine Ms. Hala Ghamdi Nurse Educator, QM Nursing Engr. Meshal Al Aseeri Manager, U&M Operations Dr. Ramatoulie Jack Consultant, Family Medicine / Clinical Performance Ms. Samra Mestadi Nurse Specialist Tour Guides: Mr. John Louie Caneja QM Specialist Ms. Chona Barcelona QM specialist Ms. Noura Abdullah QM Specialist Ms. Kathleen Hart QM Specialist Ms. Anna Liza QM Specialist 0800 -0900 Daily Briefing Dr. Andejani Hall & Al Razi (video link) [Executives, Clinical Chairs, FMS Areas, Allied Health & Other HODs, Clinical Nursing Directors, JCI Tour Guides & Observers, Document Command Center, QM Staff, Ms. K. Royo-Minute Taker] 0900 - 1030 Individual Patient Tracer Activity Individual Patient Tracer Activity Individual Patient Tracer Activity Individual Patient Tracer Activity Individual Patient Tracer Activity 1030 - 1200 Undetermined Survey Activity Undetermined Survey Activity Undetermined Survey Activity Undetermined Survey Activity Undetermined Survey Activity- Surveyor Working Lunch Hospital VIP Dining Room 1300 - 1500 Survey Integration and Report Preparation Hospital VIP Dining Room 1500 - 1530 Leadership Exit Conference Dr. Andejani Hall Video Linked in Al Razi Hall Executives – Medical & Operations, College of Medicine, Postgraduate Education, KAMRC-WR, Clinical Chairmen, Deputy Clinical Chairmen, Dept/Services HODs, Other Staff, Dept Heads, Operations, FMS Areas, QPS Champions, QI Champions, Clinical Nursing Directors, Nurse Managers, Asst. Nurse Managers, In-Charge, JCI Tour Guides & Observers, QM Staff, All Staff, Ms. Azhar - Minute Taker