1

Introduction form CBAHI chairman

Session 1

Introduction

Session 2

How CBAHI Supports

Hospitals?

Session 3

Survey Process

Session 4

Hospital Survey Activities

Session 1

Introduction

Introduction
Accreditation
Accreditation Organizations
The CBAHI Accreditation Standards
The CBAHI Accreditation Purpose
Mission, Vision, & Values
CBAHI Theme
5

Accreditation
An organization is assessed by an

external body to determine its performance

compliance with agreed standards and
the impact of its services on the patients.




6

Accreditation Organizations
International Accreditation National Accreditation Body
Body(Joint
J.C.A.H.O.
CBAHI:
Commission on Accreditation
of Healthcare Organization)

N.C.Q.A. (National Committee

for Quality Assurance)
I.S.O. (International Standard
Organization)
JCIA
A.C.H.S. (Australian Council on
Healthcare Standards)

Central Board for

Accreditation
of Health care

CCHSA Canadian Healthcare

Accreditation Body

Institutions

The CBAHI Accreditation Standards were developed by a

consensus process of health care experts representing
MOH
national guards hospitals
KFSH&RC
University hospitals
Private hospitals
Security Forces hospital
Saudi Council for Health Specialties
MRQP team
the standard have been approved by DR. HAMMED
ALMANE (Minster of health) National Standards
Preparation committee on 21-24 May 2006.

CBAHI Accreditation Purpose

The purpose of the accreditation process is to improve
the services of healthcare sector in SAUDI ARABIA,
ensure the safety of our patients and establishing
hospital infra structure

Mission
Improvement of healthcare quality standards in the
Kingdom by supporting healthcare institutions to
implement

and

accredit

the

medical

quality

standards and patient safety by national origin

working systems, universal implementation, and
distinguished efficiency.

Vision
Prestigious Global Commission in Healthcare
quality development field.
Values
Commitment to excellence
Belief in team work
Application of quality standards
Holistic approach
Integrity

CBAHI Theme
PREPARATION

ACCREDITATION

MONTIRING

Session 2

How CBAHI Supports Hospitals?

13

How CBAHI Supports Hospitals?

Providing hospitals with

Resource Manual
Hospital Self Assessment
Hospital Accreditation guide
Hospital Accreditation Specialists
(HAS) preparatory visits
Consultation visits
Provision of training programs

WWW.CBAHI.ORG/RM

cbahi

15

Std. Statement
Std. Intent

Preparation
Tool (PT)

Teaching tools
Sample

SELF ASSESSMENT
The process starts with the Hospital completing
the self assessment
www.cbahi.org/hospital

Hospital Accreditation Guide

The hospital can download the HAG from
this site

www.cbahi.org/hospital

Hospital Accreditation Guide

Hospital Accreditation Guide

Hospital Reporting Site

Preparation Tools (PT) are statements that detail
the specific performance expectations and/or
structure or process that must be in place


PT are evaluated by the following scale:
0 = insufficient compliance
1 = minimal compliance
2 = partial compliance
3 = satisfactory compliance

Example of MS chapter
MS.23. The department head shares his/her findings with the
Medical Director and works closely to improve and correct their
deficiencies.
Preparation Tool(s)
Code
Preparation Tool
PSOI
Evidence of communication
MS.23.PT1 between the head of department
Interview
and medical director

Sampling of quality improvement

project in the medical
MS.23.PT2
Observation
departments ref;etc. sharing
findings
The meeting minutes contain
evidence that the department
MS.23.PT3 head shares his/her findings with Document Review
the Medical Director

Example of pharmacy chapter

PH.2. The pharmacy has a clear mission, vision, and values.
PH.2.1 Mission is clearly written, posted, and verbalized by pharmacy staff.
PH.2.2 Vision is clearly written, posted, and verbalized by pharmacy staff.
PH.2.3 Values are clearly written, posted, and verbalized by pharmacy staff.
Preparation Tool(s)
Code
Preparation Tool
Pharmacy mission, vision, and values are
clearly written
PH.2.PT1

PH.2.PT2

Pharmacy mission, vision, and values are

posted

PH.2.PT3

Pharmacy mission, vision, and values are

verbalized

PSOI
Document Review

Observation

Interview

Example of IC chapter
IC.16. There is a system that separates patients with communicable diseases
and those who are colonized or infected with epidemiologically important
organisms from other patients, staff and visitors.
IC.16.1 There are written policies & procedures that address standard &
isolation precautions.
Preparation Tool(s)
Code
Preparation Tool
PSOI
Written Policies and procedures
IC.16.PT1
on standard and isolation
Document Review
precautions.
Evidence of staff awareness of
standards and isolation
IC.16.PT2
Interview
precautions (Interview)
IC.16.PT3

Evidence of compliance with

standard and isolation precautions

Observation

Session 3

Survey Process

25

Survey Process

CBAHI Surveyor Team

CBAHI Survey Process
Applicability of Chapters and Standards
Scoring Method

Accreditation Decision Rules

CBAHI Surveyor Team

(3) or four (4) days

(1) or two (2) days)

All seven will go together first day during accreditation

surveys and may be on different day during mocks.

CBAHI Survey Process

1.

Hospital accreditation Result has to be

approved by the Central Board before it is
given to the hospital.

2. The surveyors are not permitted to provide

hints to the hospital regarding the

accreditation status .

Applicability of Chapters and Standards

In general, organization wide chapters are mandated
chapters.
They are:
Leadership, Medical Staff and provision of care,
Nursing, Quality and Patient Safety, Patient and
family rights, patient and family education, Infection
control, Pharmacy, laboratory, facility management
and safety, Management of Information and Medical
Records. Ambulatory services, Emergency Room,
Anesthesia, Dietary Service, and Social Work
functions are applicable to all hospitals.

Applicability of Chapters and Standards

Chapter #
Chapter VII

Chapter specialty
Intensive Care Unit (ICU)
1. Adult, Pediatric (ICU/PICU
2. Coronary Care Unit (CCU)
3. Neonate (NICU)

Chapter IX
Chapter X
Chapter XIII
Chapter XIV
Chapter XV
Chapter XVI
Chapter XVII

Labor & Delivery (L&D)

Haemodialysis (HM)
Burn Care (BC)
Medical & Radiation Oncology
(MRO)
Psychiatry (PS)
Specialized Areas (SA)
Rehabilitation (RH)
2. Dental Services (DN)

Applicability
ICU All hospitals - Pediatric ICU based
on scope of services

CCU applies for hospitals providing

invasive cardiac procedures
NICU for hospitals providing obstetric care
For hospitals providing obstetric care
For hospitals providing renal dialysis
Based on Scope of Services
Based on Scope of Services
For hospitals providing
psychiatry services
Based on Scope
Based on Scope

in-patient

Scoring Method
The hospital must meet all the applicable standards elements
at a satisfactory level to become accredited. Each standard
element is scored on a four-point scale:
Initial Survey
3 = Fully Met when 75 % compliance with the standards
elements.
2 = Partially Met when 50 to < 75 % compliance with the
standards elements.
1 = Minimally Met when 25 to < 50 % compliance with
the standards elements.
0 = Not Met when < 25 % compliance with the standards
elements.

General Principles
All CBAHI chapters have equal weight regardless of the
standard contents. Additionally, all standards within a

chapter weigh equally.

Each standard is assigned ONE point. The ONE point

is divided equally among the elements when more than

one required element exists.

The score of each standard represents the mean score

of the included elements.
Each chapter score is calculated as the mean of
standards scores. The overall hospital score is calculated
as the mean of the scores of all chapters. All scores are
presented as percentage.

Accreditation Decision Rules:

Accredited The hospital is awarded accreditation if:

the overall compliance score equals to or more than 80 %

No more than 2 chapters score less than 50%

Accreditation Decision Rules:

We were asked:
1.

Why the passing mark is 80%?

And the answer is:

We do not have bold standards

More than 70% of our standards are essential structural
standards.

Accreditation Decision Rules:

Accreditation Denied The hospital will be denied
accreditation if:
the overall score is less 70 % or
more than 2 chapters score less than 50 %

Accreditation Decision Rules:

70 to 79%
Hospitals scoring from 70 to 79% is required to be
resurveyed within 90 days of the result for chapters that
score less than 50%

Validity of accreditation: every 3 years

Session 4

HOSPITAL SURVEY ACTIVITIES

38

Survey Activities
Agenda

Documents review
Medical record
review (closed, open)
Personnel record
review
Unit Visit (observation
, Interview)
Interview

Hospital Survey Activities

Document Review
Medical Records Guidelines
Personnel File Review General Guidelines

Leadership Interview
Staff Interview and Observations
Visit to Patient Care Settings
Hospital Survey Report
40

Documents Review
The hospital is expected to prepare binders to facilitate
the review of their documents in relation to compliance

to the CBAHI National Hospital Standards.

The binders to be organized according to the list
provided in this guide.
The list reflects the arrangements based on the surveyor
conducting review (not based on the chapters).

It is very much encouraged that the surveyor counter-part is

oriented to the document arrangement.

Document Review General Guidelines

The scope of this activity is to ensure hospital adherence to the
CBAHI requirements, especially that most standards main

requirements are the presence of policies and/or completion of

certain records
The 1st document surveyors need to review and clarify as a team
is the hospitals' policy management system (policy on policies),
which is addressed in LD.28. The hospital should introduce

their system in the opening conference.

Document Review General Guidelines

If a needed document is not available the surveyor will ask the

hospital representative to present it preferably within the survey
day. The hospital will be given chance to present any missing
evidence within the survey period.

Document Review General Guidelines

(PH-IC-FMS-LAB): for specialty area, evidence of compliance

must be presented within the specialty survey day (by the end of
day 1)
Hospitals will be considered in compliance with the standards
requirements if a track record of the past four (4) months of the
survey date was presented, such as meeting minutes and data

trends or 4 meeting minutes.

Medical Records Review General Guidelines

Hospitals are requested to have the list of the last
month discharge patients ready by the Surveyors
Planning Session on day 1.
Required medical record list will be requested
after the Opening Conference based on the month
discharged cases
Hospitals to clarify their documentation
guidelines prior to the medical records review
session to smooth the process

Personnel File Review General Guideline

The scope of the personnel file review is the completeness

of

documentation of

evaluation,

continuing

the recruitment, orientation,

education,

privileges

and

competencies process and monitoring.

Hospitals

are

documentation

encouraged
in

one

to

present
location

the

needed

to

ensure

comprehensiveness of personnel data and history during

his/her employment in the organization.

Leadership Interview
Decision making process based on data,
Participation in quality improvement activities
Understanding of patient safety concept and
goals,
Understanding of hospital mission,
Sentinel events and OVR reporting, Root Cause
Analysis
Patient and family right

Staff Interview and Observations

Unit rounds for Staff Interview and Observations
posting and knowledge of hospital mission,
OVR reporting,

understanding of assigned jobs,

Understanding of infection control guidelines,

Understanding of safety and security codes,

Visits to Patient Care settings

During these visits the survey team may talk with
managers, direct care providers, and patients. The
team also observe:
Reviews open medical records
Environment of care
Infection control
Patient care
Staff communications
Patient rights issues

Hospitals will be able to access their survey report through their "hospital
portal". The report face-sheet will show the overall final score and the scores
of each chapter.

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51

Hospital Feedback Form

Hospitals are requested to complete

a Hospital Survey Feedback form
after the survey visit has been
completed

52

CD Content
HAS visit Agenda
Hospital Accreditation Guide
Application form (demographic
questionnaire)
Survey tools packages
Hospital self assessment Application
HAS presentation
HAS visit report
Acknowledgment letter
53