Appendix RS 1.

RECOMMENDED STANDARDS/LAWS/POLICIES FOR THE HEALTHCARE FACILITIES

Area of Concern Standards Remarks

Human Resource 1. Joint Commission International (JCI)
& Management http://www.jointcommissioninternational.com/
2. Health Professionals Private Sector HA-AD Policies on Medical By-Laws under
http://www.health.ae/privatesector/ review
3. Canadian Council on Health Services Accreditation
www.cchsa.ca
4. HA-AD Policies on:
a. Medical By-laws
b. General Confidentiality
c. http://www.health.ae/
Clinical Practice 1. Institute for Clinical Systems Improvement (ICSI)
http://www.icsi.org/ ICSI is an independent non-profit organization,
2. Joint Commission for the Accreditation of dedicated in championing health care quality
Healthcare Organizations (JCAHO) and to helping its members identify and
http://en.wikipedia.org/wiki/Joint_Commission_In accelerate the implementation of best practices
ternational for their patients. It promotes and supports the
3. Joint Commission International (JCI) use of evidence-based health care in all
http://www.jointcommissioninternational.com/ scientific advances improvement in patient
4. Canadian Council on Health Services Accreditation safety and efficiency. This reference served as
–www.cchsa.ca specific standards on : the basis by the HA-AD Clinical Guidelines
Acquired Brain Injury Committee in developing Clinical Protocols on
Acute Care the most common medical conditions.
Ambulatory Care
Cancer Care JCAHO is a US based non-profit organization
Critical Care formed in 1951 with a mission to maintain and
Home Care elevate the standards of healthcare delivery
Hospice Palliative and End-of-Life through evaluation and accreditation of
Care healthcare organizations
Long Term Care
Maternal/Child JCI extends the Joint Commission’s mission

1
Appendix RS 1.0

Mental Health worldwide. Through international consultation,

Rehabilitation accreditation, publications and education, Joint
5. Pediatric Care – Evidence Based Practice Commission International helps to improve the
Guidelines – quality of patient care in many nations. Joint
www.cincinnatichildrens.org/svc/alpha/h/healt Commission International has extensive
h-policy/ev-based/ international experience working with public
6. Clinical Practice Guidelines for various and private health care organizations and local
conditions governments in more than 60 countries.
a. Johns Hopkins Medicine –
www.hopkinsmedicine.org The mission of Joint Commission International
b. Cleveland Clinic – is to continuously improve the safety and
www.clevelandclinic.org quality of care in the international community
c. Partners Healthcare – www.partners.org through the provision of education and
Link to Agency for Healthcare consultation services and international
Research & Quality, United States accreditation.
Department of Health and Human
Services – Evidence Based Practice
www.ahrq.gov/clinic/epcix.htm
7. Clinical Evidence – British Medical Journal
Clinical Evidence – www.clinicalevidence.com
8. Australian Council on Healthcare Standards
(ACHS) -Equip Standards
http://www.easternhealth.org.au/boxhill/stand
ards-june2002.pdf
9. HA-AD Policies on: http://www.HA-
AD.ae/policies/
a. Referral System
b. Formulating Antiseptic & Disinfectant
Items
Dental 1. Victoria Health Care Global
2. American Dental Association Standards
3. Canadian Dental Association Standards
4. British Dental Association Standards
5. Centers for Disease Control (CDC)
6. JCIA for Ambulatory Care

2
Appendix RS 1.0

Medication/Phar 1. UAE Laws # 4 / 1983 , # 14 / 1995 and There is a new UAE pharmacy law under
macy other related decrees and regulations that set discussion beside other new laws pertaining to
the foundation of practice the pharmacy practice.
2. Dubai , Department of Health and Medical
Services , guideline
http://eapp.dohms.gov.ae/mpt/main/HealthCare
.htm
3. Ministry of Health Guidelines
www.moh.gov.ae
4. US and Canadian Boards of Pharmacy
http://www.nabp.net/
http://www.napra.ca/
Infection 1. Centers for Disease Control & Prevention
Prevention & (CDC) www.cdc.gov
Control, 2. JCI
Sterilization & http://www.jointcommissioninternational.com/
Sanitation 3. ISO 14000 Environmental Management
System www.iso.org
4. Canadian Council on Health Services
Accreditation – www.cchsa.ca
5. UAE Law
Medical Records 1. JCI HA-AD Best Practice Guidelines and General
http://www.jointcommissioninternational.com/ Confidentiality Policy were formulated based on
2. HA-AD Best Practice Guidelines for Health international references by the Task Force on
Information & Medical Record Document medical records management.
Management Health Information Centre Dept of Western
3. HA-AD General Confidentiality Policy Australia provides Patient Information
4. Health Information Centre, Health Department Retention and Disposal Schedule which is being
of Western Australia used as reference by the HA-AD Task Force in
5. Medical Information Systems Standards – the development of the Medical Records
www.cihi.ca Retention Policy
6. Coding Standards for Data Quality and
Consistency – www.cihi.ca
7. Coding and Classification Standards – ICD 10

3
Appendix RS 1.0

– www.cihi.ca
8. Electronic Health Records – Health Level 7
HL7
a. HL7 United States – www.hl7.org
b. Canadian Affiliate – http://sl.infoway-
inforoute.ca/content/hl7
9. Canadian Council on Health Services
Accreditation – www.cchsa.ca
Occupational 1. Occupational Health & Safety Association OSHA are internationally recognized American
Health & Safety, (OSHA www.osha.gov standards for Occupational Health and Safety.
Engineering, 2. National Fire Protection Association (NFPA) 99
Biomedical for Hospitals www.nfpa.org NFPA are internationally recognized American
Equipment 3. UAE Civil Defense standards intended to reduce the worldwide
Management 4. UAE Federal Law # 21/2005 Waste burden of fire and other hazards on the quality
Management in the Emirate of Abu Dhabi of life. NFPA's 300 codes and standards
5. American Institute of Architects "Guidelines for influence every building, process, service,
Design and Construction of Hospitals and design, and installation in the United States, as
Healthcare Facilities" well as many of those used in other countries.
6. Building Institute Code
7. American Society for Heating, Refrigeration &
Air Conditioning Engineering
8. International Electrical Engineering (British)
9. ADWEA Regulations
10.ISO 10012 Measurement Processes and
Measurement Equipment
11.Specifications from Manufacturer's Manual
12.FDA Code of Federal Regulations (CFR# xxx)
13.JCI
http://www.jointcommissioninternational.com/
14.JCAHO
http://en.wikipedia.org/wiki/Joint_Commission
_International
15.Association for the Advancement of Medical
Instrumentation (AAMI)
16.British Standards for Medical Gas and Piping

4
Appendix RS 1.0

System HTM 2022

Emergency 1. JCI
Services http://www.jointcommissioninternational.c
om/
2. JCAHO
http://en.wikipedia.org/wiki/Joint_Commis
sion_International
3. JCIA Standards for Medical Transport
Organizations
http://www.jcrinc.com/7689/
4. Canadian Association of Emergency Physicians
– www.caep.ca
a. Guidelines and Standards
b. Triage & Acuity for Emergency
Operating 1. JCI
Theatre http://www.jointcommissioninternational.c
om/
2. JCAHO
http://en.wikipedia.org/wiki/Joint_Commis
sion_International
3. Canadian Council on Health Services
Accreditation – www.cchsa.ca
4. Anesthesiology
a. Royal College of Anaesthetists –
Standards in Anaesthesia, Critical
Care and Pain Management –
www.rcoa.ac.uk
b. Canadian Anesthesiologists Society
Guidelines – www.cas.ca
5. Nursing
a. European Operating Room Nurses
Association Standards –
www.eornac.com
b. Association of Peri operative
5
Appendix RS 1.0

Registered Nurses (American) –

www.aorn.org
c. Operating Room Nurses Association
of Canada – www.ornac.com

Radiology 1. JICA for Ambulatory Care

2. International Electro-technical Commission
(ICE) 60601-2-33 for MRIs
Optometry JCIA for Ambulatory Care
Traditional,
Complimentary &
JCIA for Ambulatory Care
Alternative
Medicine
Assisted
Reproductive 1. American Society for Reproductive Medicine –
Technology www.asrm.org
• Guidelines and Minimum
Standards
2. Canadian Council on Health Services
Accreditation – www.cchsa.ca
a. Assisted Reproductive Technology
Clinical Services
b. Assisted Reproductive Technology
Laboratory Services
Patient Safety 1. Joint Commission International Accreditation
–
www.jointcommissioninternational.com
2. Canadian Council on Health Services
Accreditation – www.cchsa.ca
3. WHO Collaborating Center – Patient Safety –
www.jcipatientsafety.org

Community Canadian Council on Health Services Accreditation –

Health Services www.cchsa.ca
Laboratory Joint Commission on Accreditation of Healthcare Gives general standards for laboratories, but
6
Appendix RS 1.0
Organizations. Joint Commission International
Accreditation (JCIA) Standards for Hospitals 2nd ed.
Oakbrook Terrace, IL: Joint Commission Resources;
2002.
Laboratory Joint Commission on Accreditation of Healthcare
Organizations. Joint Commission International
Accreditation (JCIA) Standards for Clinical
Laboratories. Oakbrook Terrace, IL: Joint
Commission Resources; 2002.
Laboratory ISO 15189 Medical Laboratories – Particular
requirements for quality and competence. Geneva:
ISO copyright office; 2003.
not specified enough for benchmarking,
checklists and inspections. Refers to local
National Standards to follow if they exist.
The very first standard for Laboratory services
states in AOP.5.1: Clinical pathology services
are provided by the organization to meet
patient needs or are readily available
through arrangements with outside
sources.
The background to this standard is that very
few hospitals or laboratories can provide the
required expertise and quality for all laboratory
services to meet patient needs and must have
an efficient organization for referral of
specimens.
Gives more specification on what has to be
done, and sometimes how it should be done. It
also gives references to specifications how it
should be done. Refers to local National
Standards to follow if they exist.
Similar to JCIA Standards for Clinical
Laboratories. Has to be used together with
local National Checklists
From Wikipedia, the free encyclopedia
ISO 15189:2003 Medical laboratories -
Particular requirements for quality and
competence specifies the quality management
system requirements particular to medical
laboratories. The standard was developed by
the International Organisation for
Standardisations's Technical Committee 212
(ISO/TC 212). ISO/TC 212 assigned ISO 15189
7
Appendix RS 1.0

to a working group to prepare the standard

based on the details of ISO/IEC 17025:1999
General requirements for the competence of
testing and calibration laboratories. This
working group included provision of advice to
users of the laboratory service, the collection of
patient samples, the interpretation of test
results, acceptable turnaround times, how
testing is to be provided in a medical
emergency and the lab's role in the education
and training of health care Laboratory staff.

While the standard is based on ISO/IEC 17025

Laboratory Clinical Laboratory Improvement Amendments
(CLIA) http://www.phppo.cdc.gov/clia/regs/toc.aspx
Laboratory Clinical and Laboratory Standards Institute (CLSI)
http://www.clsi.org/
and ISO 9001, it is a unique document that
takes into consideration the specific
requirements of the medical environment and
the importance of the medical laboratory to
patient care.
The Centers for Medicare & Medicaid Services
(CMS) regulates all laboratory testing
performed on humans in the U.S. through
CLIA. It is very useful base for local National
Standards, especially for staffing requirements
and proficiency testing. It gives also a good
background for the reimbursement system for
laboratory testing introduced through the
Health Insurance and Daman.
Clinical and Laboratory Standards Institute
(CLSI) provides an extensive library of
voluntary consensus standards and guidelines
(>250) for clinical laboratory professionals
seeking to meet accreditation requirements.
Numerous CLSI documents are referenced in
the College of American Pathologists (CAP)
Laboratory Accreditation Program Inspection

8
Appendix RS 1.0

Checklists and serve as key resources in

satisfying regulatory requirements. JCIA also
refer to some of these standards.

College of American Pathologists (CAP) CAP gives wide general standards for clinical
http://www.cap.org/apps/cap.portal?_nfpb=true&_p laboratories and blood banks, and also detailed
ageLabel=accreditation checklist with references to detailed procedures
that have to be followed.

Laboratory Centers for Disease Control and Prevention. Good These GLP standards are especially valuable for
Laboratory Practices for Waived Testing Sites. MMWR clinics who want to perform low complexity
2005;54(No. RR-13:1-25. testing within there own organization.
http://www.cdc.gov/mmwr/PDF/rr/rr5413.pdf

Point of Care 1. American Society for clinical Laboratory

Testing- Science – www.ascls.org
Laboratory 2. American Association for Clinical
Chemistry – www.aacc.org

Laboratory and Canadian Council on Health Services

Blood Bank Accreditation – www.cchsa.ca
Biomedical Laboratory, Blood
Banks, and Transfusion Services
Specific Standard Requirements
for Biomedical Laboratory
Services
Specific Standard Requirements
for Blood Bank and Transfusion
Services

Blood Bank JCIA, JCIA Standards for Clinical Laboratories, ISO

15189, CLIA, CAP and CLSI have standards that are
applicable for Blood Banks. There are also special
standards for Blood Banks.

9
Appendix RS 1.0

Blood Bank American Association of Blood Banks (AABB) AABB have published standards for 60 years.
Standards, 22nd edition. They have accredited Blood Banks in 80
http://www.aabb.org/Content/Newsletters_and_Jour countries.
nal/AABB_Standards_Source/

Stem Cell Bank AABB Hematopoietic Progenitor Cell (HPC) AABB Hematopoietic Progenitor Cell (HPC)
activities include educational programs,
publications and accreditation for HPC
programs.
The list of AABB Accredited HPC Facilities
specifies those HPC facilities, in the US and
throughout the world, which have attained
AABB accreditation. These facilities are
responsible for collecting, processing and
storing hematopoietic progenitor cells that can
be used for transplantation.
Stem Cell Bank Cord Blood AABB Cord Blood (CB) activities include
educational programs, publication and
accreditation for CB programs. The list of AABB
Accredited Cord Blood (CB) Facilities specifies
those cord blood banks, in the US and
throughout the world, which have attained
AABB accreditation (this list is updated
periodically). These facilities are responsible for
collecting, processing and storing umbilical
cord blood stem cells that can be used for
transplantation
Stem Cell Bank National Marrow Donor Program Standards 19th edition, 2004.

http://www.fda.gov/ohrms/DOCKETS/dailys/02/Oct02/102302/80
03518d.pdf

Blood Bank/ Guide to the preparation, use and quality assurance of blood This guide contains a compendium of measures

10
Appendix RS 1.0
Stem Cell Bank components - 11th edition, 2005.
http://book.coe.int/EN/ficheouvrage.php?PAGEID=3
6&lang=EN&produit_aliasid=1870
Stem Cell Bank
Foundation for the Accreditation of Cellular Therapy (FACT).
FACT-JACIE International Standards for Cellular Therapy
Product Collection, Processing and Administration
http://www.factwebsite.org/main.aspx?id=55
Stem Cell Bank Foundation for the Accreditation of Cellular Therapy
(FACT).
designed to ensure safety, efficacy and quality
of blood components and is particularly
intended for all those working in blood
transfusion services. It describes the different
blood components and gives information on
their clinical indications and possible side
effects.
This guide continues to be the "golden
standard" for blood transfusion services and
forms the basis for many national guidelines in
Europe and outside.
During the preparation of this 11th edition, the
Council of Europe and the European
Commission worked closely together to ensure
that the requirements under Article 29 of the
European union Directive 2002/98/Ec were
compatible with the ones of this guide.
These Standards apply to hematopoietic
progenitor cells isolated from bone marrow or
peripheral blood and to all phases of collection,
processing, and administration of these cells.
FACT in collaboration with the Joint
Accreditation Committee–ISCT & EBMT (JACIE)
has developed international standards in the
field of cellular therapy. JACIE was founded by
the European Group for Blood and Marrow
Transplantation (EBMT) and the International
Society for Cellular Therapy (ISCT), the two
leading scientific organizations involved with
cellular transplantation in Europe.
NetCord-FACT International Standards for Cord
Blood Collection, Processing, Testing, Banking,
11
Appendix RS 1.0

Selection and Release. These Standards apply

Standards for Cord Blood Banking to facilities and individuals performing cord
blood collection, processing, testing, banking,
http://www.factwebsite.org/main.aspx?id=56 selection and release of cord blood units.

FACT in collaboration with NetCord has

developed international standards for cord
blood collection, processing, testing, banking,
selection and release. NetCord is an
international foundation created to promote the
establishment of high quality cord blood banks
and improve the quality of cord blood products
through study and research.
TB WHO 1998a. Laboratory services in Tuberculosis
Control Part I: Organization and Management. World
Health Organization, Geneva.
http://whqlibdoc.who.int/hq/1998/WHO_TB_98.258_
(part1).pdf

TB WHO 1998b. Laboratory services in Tuberculosis

Control Part II: Microscopy. World Health
Organization, Geneva.
http://www.phppo.cdc.gov/dls/ila/documents/lstc2.p
df
TB WHO 1998c. Laboratory services in Tuberculosis
Control Part III: Culture. World Health Organization,
Geneva.
http://www.phppo.cdc.gov/DLS/ILA/documents/lstc3
.pdf
TB WHO, 2006. Guidelines for the programmatic
management of drug-resistant tuberculosis.
WHO/HTM/TB/2006.361. Geneva: World Health
Organization, 2006.
http://whqlibdoc.who.int/publications/2006/9241546
956_eng.pdf

12
Appendix RS 1.0

13