DHMOSH
United Nations
Department of Peace Operations
Department of Operational Support
Ref. DHMOSH/SOP/January/2020

Policy

United Nations Standards for Healthcare Quality and
Patient Safety

Approved by: Dr. Jillann Farmer
Effective date: January 2020
Contact: Dr. Adarsh Tiwathia
Review date: 1 January 2021

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POLICY ON UNITED NATIONS STANDARDS FOR
HEALTHCARE QUALITY AND PATIENT SAFETY

Contents:
A. Purpose
B. Scope
C. Rationale
D. Policy
E. Roles and Responsibilities
F. Abbreviations and Definitions of Terms
G. References
H. Monitoring and Compliance
I. Contact
J. History

A.

Purpose
1. The over-arching goal of this policy is to introduce standards of Healthcare Quality
and Patient Safety. These standards are intended to help reduce preventable harm
to all UN Personnel and others treated in UN Health facilities, by standardizing
performance, improving safety and quality of the treatment provided in all UN Level
1 +, 2 and 3 healthcare facilities (both UN Owned, contracted and TCC). This goal
is actualized through the publication of the United Nations Standards Manual for
Healthcare Quality and Patient Safety (“Manual”) and the supporting
Implementation Guide for United Nations Standards Manual for Healthcare Quality
and Patient Safety (“Guide”). The Manual and Guide complement the UN Medical
Support Manual for United Nations Field Missions 3rd Edition and the Contingent
Owned Equipment Manual (COE).
2. The goal of the manual for health care quality and patient safety is to equip UN
and TCC medical personnel with the knowledge and guidance to optimize patients’
outcome in every healthcare facility of the UN Peacekeeping Operations.
3. This Policy has been prepared by the Department of Operational Support (DOS,
Office of Support Operations (OSO), Division of Healthcare Management and
Occupational Safety and Health (DHMOSH).

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B.

Scope
4. This policy applies to all United Nations Healthcare facilities and its personnel in
field missions administered by the Departments of Operational Support,
Department of Peace Operations (DPO) and Department of Political and Peacebuilding Affairs (DPPA). It covers all medical personnel in the UN Healthcare
facilities in the field.
5. This policy should be read in conjunction with the most current editions of the
Medical Support Manual (MSM) for United Nations Field Missions, the Contingent
Owned Equipment Manual (COE) and all other relevant documents pertaining to
medical care in field missions.

C. Rationale
6. Due to the increasing demands and challenges, a multiplicity of current and
emerging threats and hazards faced by the peacekeepers in field missions it is
critical that the UN be able to provide a robust, timely and consistent medical
support system for all personnel. To this end, DOS/OSO/DHMOSH has
undertaken to standardize the procedures for health care quality management
and patient safety through the development of standards of care. These
standards will apply to all Level 1+,2 and 3 medical facilities in the field.
7. This policy through the implementation standards outlined in the UN Healthcare
Quality and Patient Safety Manual will ensure that the healthcare provided to
patients in UN medical facilities is standardized.

D.

Policy
8. Quality in healthcare is currently described across several domains. The UN’s
healthcare quality approach broadly adopts the framework put forth by the
Institute of Medicine (IOM)1 , which includes the following six aims for the health
care system:
•
•
•
•

Safe: Avoiding harm to patients from the care that is intended to help them.
Effective: Providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit
(avoiding underuse and misuse, respectively).
Patient-centered: Providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions.
Timely: Reducing waits and sometimes harmful delays for both those who

Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington,
D.C: National Academy Press; 2001
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•
•

receive and those who give care.
Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and
energy.
Equitable: Providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status.

9. This policy sets the requirement for all UN field healthcare facilities.

E.

Roles and Responsibilities2
10. Member States Contributing Health Facility
All Member States contributing Level 1 +, 2 and 3 medical facilities shall be
expected to comply with the Healthcare Quality and Patient Safety Standards.
Compliance shall be assessed in an Assessment and Advisory Visit (AAV) and
after deployment to the mission.
11. Division of Healthcare Management and Occupational Safety and Health
(DHMOSH)
The DHMOSH is responsible for medical standards for the United Nations and
subsidiary organs. This role includes the formulation and review of UN medical
standards, medical policies and guidelines and ensures coordination and
monitoring for their system-wide implementation. DHMOSH will provide overall
governance, oversight and advice on the standards and the hospital assessment
process, including advise during the Assessment and Advisory visits and predeployment visit and the on-site hospital assessment visit.
12. Chief Medical Officer (CMO)
The CMO is the senior ranking civilian medical officer in a field mission. The
CMO’s authority supersedes the authority of all other medical officers (military
and civilian) in the mission. It is the responsibility of the CMO to plan, organize,
manage, supervise and coordinate all medical services in missions, in
accordance with standards published in the Manual. S/He will be accountable for
ensuring that all health facilities in the mission comply with the United Nations
Standards Manual for Healthcare Quality and Patient Safety.
13. Force Medical Officer (FMO)
The FMO is the senior ranking military medical officer within the peacekeeping

2

See Medical Support Manual for United Nations Field Missions, 3rd Edition, Chapter 1

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force. S/He is the medical adviser to the Field Commander on all military and
operational tactical medical matters. Under the authority of the CMO, the FMO
shall conduct functional inspections, assessments, surveys and exercises in TCC
medical facilities to ensure adherence to professional and clinical standards
including the standards set forth in the Healthcare Quality and Patient Safety
Manual.
14. Commanding Officers of Military Medical Facilities

The Commanding Officer of each medical facilities is responsible and accountable
for ensuring that all the UN standards as listed in the Manual are complied with.

F. Abbreviations and Definitions of Terms
15. Abbreviations
MSM

Medical Support Manual

COE

Contingent Owned Equipment Manual

16. Definitions
Compliance with Standards

Demonstrated performance by the hospital
that conforms to the Standards in the
Manual.

Manual

Set of healthcare standards that require
compliance by Level 1+,2, and 3 field
hospitals.

Guide

Companion publication to the Manual
containing direction and tools for effective
implementation of the standards.

Assessment

The process of determining compliance with
the standards through on-site clinical
observation, staff interviews and document
reviews.

On-site visit

A visit by UN staff to the hospital to assess
compliance with the standards.

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G. References
17. Joint Commission International Accreditation Standards for Hospitals, 5th Edition
Medical Support Manual, Who Health Organization (WHO), Institute of Medicine
(IOM)
http://www.ihi.org/resources/Pages/OtherWebsites/TheInstituteofMedicine.aspx

H.

Monitoring and Compliance
18. DHMOSH has the overall authority for oversight , monitoring and assessment of
the compliance with this Policy.

I.

Contact

19. All enquiries about this policy and requests for amendment should be sent to
medicaldirector@un.org and clinicalgovernance@un.org .

J. History
20. This is the first issue of this policy and it has not been amended.

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DHMOSH

APPROVAL SIGNATURE:
Director, Division of

Healthcare Management
And Occupational
Safety and Health

Date: 20/' /20R0
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