[Clinic name]
Controlled document
[Address]
[Registration or licence number]
GAHAR inspection checklist
1Before you apply
- The facility licensed as the law requires, and operating for at least six months.
- Four months of compliance with the handbook before the first survey.
- Every service and its volume matching what the application says.
- Scope changes over 20% sent to GAHAR a month ahead.
2Safety
- Two identifiers checked and recorded on every sheet of the record.
- Verbal and telephone orders read back and recorded in a set timeframe.
- Critical results recorded with time, sender, receiver and read-back.
- An approved do-not-use abbreviation list in daily use.
3Records
- A unique identifier for every patient, and one standard record format.
- Author, date and time visible on every entry.
- A quarterly review of about 5% of records, reported to leaders.
- Backup, downtime and retention written down and tested.
4Quality
- An incident reporting system every member of staff can use.
- Sentinel events to GAHAR within 48 hours, root cause analysis inside 45 days.
- A complaints process the public can see, with set response times.
- Staff files and clinical privileges current for every clinician.
5What a GAHAR inspector may ask
- How do you identify a patient before care? What to show, the policy naming two personal identifiers, and records with both on every sheet.
- Who can make entries in the medical record? What to show, the list of authorised people, and entries showing author, date and time.
- Who has access to a patient's record? What to show, a list of authorised individuals and signed confidentiality agreements.
- Show me a recent incident and what you did about it. What to show, the report, the investigation and the corrective action, inside the defined timeframe.
- How is informed consent obtained and recorded? What to show, the consent list, the form, and a signed consent kept in the record.
- How do patients complain, and how fast do you answer? What to show, a public complaints route and feedback inside the approved timeframes.
- How do you use AI in care? What to show, where AI is used, and who decides.
AAppendix, GAHAR application plan
- A.1Facility ______ Governorate ______
- A.2Licence number ______ Operating since ______
- A.3Handbook applied from ______ Four months reached on ______
- A.4Portal account created on ______ Application issued on ______
- A.5Fee paid on ______ Receipt emailed on ______
- A.6Survey date ______ Decision due by ______
- A.7Accreditation lead ______