For healthcare settings, many policies are required to be existing for better standardized performance. These policies should assist health professionals in acquiring and maintaining patient-centered care skills, as well as encourage organizations to build a patient-centered culture. Aim this study aims to is to identify the available policies and procedures at nephrology unit of Kasr Alainy tertiary hospital in order to improve the quality of care Methods: Health system exploratory study executed at pediatric nephrology unit by reviewing the existing policies and procedures documents through two steps: quantitative analysis using an adaptive checklist from Joint Commission International Accreditation Standards for Hospitals to identify the existing and missing unit policies and procedures compared to required written policies and procedures, then qualitative analysis through reviewing the existing policies documents according to policy definition, presence of approvers, quality written procedures, attached measurement list, and attached data collection forms. Results: for the quantitative analysis: health care organization management standards policies achieved the highest score, while patient centered standards policies achieved the least score (91.5 % and 70.2% respectively). The international patient safety goals revealed absolute absence of the policies and procedures (0 %). On the other hand, patient and family rights, care of patients, quality improvement, governance leadership and direction, and management of information domains achieved absolute completeness of the required written policies and procedures (100%). According to qualitative analysis: document content analysis revealed that although the policies were written in a structured pattern but most of them have no attached measurement indicators list. Conclusion: Based on policies and procedures document review, unit written policies account for 80.4% out of recommended JCI required written policies and procedures. On the other hand unfortunately patient safety goals policies are absent.