1. Central Board of Accreditation for Healthcare Institutions المجلس المركزي لاعتماد المنشآت الصحية
CBAHI SURVEY PROCESS

2. Introduction form CBAHI chairman

3. Session 1
Introduction
Session 2
How CBAHI Supports Hospitals?
Session 3
Survey Process
Session 4
Hospital Survey Activities

4. Session 1
Introduction

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

6. 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.
المستشفيات تقيم بواسطة مؤسسة وهيئة خارجية من أجل تحديد مستوى الأداء بالمقارنة مع معايير تلك الهيئة وبما يتطابق مع احتياجات المرضى

7. International Accreditation Body
Accreditation Organizations
National Accreditation Body
International Accreditation Body
J.C.A.H.O. (Joint 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)
CCHSA Canadian Healthcare Accreditation Body
CBAHI:
Central Board for Accreditation
of Health care Institutions

8. The CBAHI Accreditation Standards
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 May 2006.

9. مساعدة المستشفيات في تثبيت أسس وقواعد العمل تحسين مستوى الرعاية الصحية
CBAHI Accreditation Purpose
ensure the safety of our patients and establishing hospital infra structure
The purpose of the accreditation process is to improve the services of healthcare sector in SAUDI ARABIA,
مساعدة المستشفيات في تثبيت أسس وقواعد العمل
سلامة
المريض
تحسين مستوى الرعاية الصحية

10. 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.

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

12. CBAHI Theme
PREPARATION
تحضير
ACCREDITATION
اعتماد
MONTIRING
مراقبة

13. How CBAHI Supports Hospitals?
Session 2
How CBAHI Supports Hospitals?

14. 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

15.
cbahi

16. Std. Statement
Std. Intent
Preparation Tool (PT)
Teaching tools
Sample

17. SELF ASSESSMENT
The process starts with the Hospital completing the self assessment

18. Hospital Accreditation Guide
The hospital can download the HAG from this site

19. Hospital Accreditation Guide

20. Hospital Accreditation Guide

21. Hospital Reporting Site
Preparation Tools (PT) are statements that detail the specific performance expectations and/or structure or process that must be in place
هي جمل تفصل الأداء المتوقع لكل معيار ، ومن خلال استيفاءها يتم التكامل مع المعيار و بها يكون المستشفى جاهز لأي نوع من التقييم
PT are evaluated by the following scale:
0 = insufficient compliance
1 = minimal compliance
2 = partial compliance
3 = satisfactory compliance

22. 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
MS.23.PT1
Evidence of communication between the head of department and medical director
Interview
MS.23.PT2
Sampling of quality improvement project in the medical departments ref;etc. sharing findings
Observation
MS.23.PT3
The meeting minutes contain evidence that the department head shares his/her findings with the Medical Director
Document Review

23. 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
PSOI
PH.2.PT1
Pharmacy mission, vision, and values are clearly written
Document Review
PH.2.PT2
Pharmacy mission, vision, and values are posted
Observation
PH.2.PT3
Pharmacy mission, vision, and values are verbalized
Interview

24. 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
IC.16.PT1
Written Policies and procedures on standard and isolation precautions.
Document Review
IC.16.PT2
Evidence of staff awareness of standards and isolation precautions (Interview)
Interview
IC.16.PT3
Evidence of compliance with standard and isolation precautions
Observation

25. Session 3
Survey Process

26. Survey Process Applicability of Chapters and Standards
CBAHI Surveyor Team
CBAHI Survey Process
Applicability of Chapters and Standards
Scoring Method
Accreditation Decision Rules

27. CBAHI Surveyor Team (1) or two (2) days) (3) or four (4) days
All seven will go together first day during accreditation surveys and may be on different day during mocks.

28. CBAHI Survey Process
Hospital accreditation Result has to be approved by the Central Board before it is given to the hospital.
The surveyors are not permitted to provide hints to the hospital regarding the accreditation status .

29. 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.

30. Applicability of Chapters and Standards
Chapter specialty
Applicability
Chapter VII
Intensive Care Unit (ICU)
1. Adult, Pediatric (ICU/PICU
2. Coronary Care Unit (CCU)
3. Neonate (NICU)
ICU All hospitals - Pediatric ICU based on scope of services
CCU applies for hospitals providing invasive cardiac procedures
NICU for hospitals providing obstetric care
Chapter IX
Labor & Delivery (L&D)
For hospitals providing obstetric care
Chapter X
Haemodialysis (HM)
For hospitals providing renal dialysis
Chapter XIII
Burn Care (BC)
Based on Scope of Services
Chapter XIV
Medical & Radiation Oncology (MRO)
Chapter XV
Psychiatry (PS)
For hospitals providing in-patient psychiatry services
Chapter XVI
Specialized Areas (SA) Rehabilitation (RH)
Based on Scope
Chapter XVII
2. Dental Services (DN)

31. 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.

32. Accreditation Decision Rules
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.

33. Accreditation Decision Rules
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.

34. 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%

35. Accreditation Decision Rules:
We were asked:
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.

36. 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 %

37. 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

38. HOSPITAL SURVEY ACTIVITIES
Session 4
HOSPITAL SURVEY ACTIVITIES

39. Survey Activities Agenda Documents review
Medical record review (closed, open)
Personnel record review
Unit Visit (observation , Interview)
Interview
Agenda

40. 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

41. 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.

42. 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.

43. 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.

44. 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.

45. 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

46. Personnel File Review General Guideline
The scope of the personnel file review is the completeness of documentation of the recruitment, orientation, evaluation, continuing education, privileges and competencies process and monitoring.
Hospitals are encouraged to present the needed documentation in one location to ensure comprehensiveness of personnel data and history during his/her employment in the organization.

47. 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

48. 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,

49. 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
The survey team may spend as much as half its time visiting places where patients receive care and services.
These visits show the surveyors how the your hospital cares for its patients.
Surveyors will also examine how hospital has implemented and improved the planning and design processes.
Visits to patient care settings include:  

50. Hospital Survey Report
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.

52. Hospital Feedback Form
Hospitals are requested to complete a Hospital Survey Feedback form after the survey visit has been completed

53. 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

54. شكــراً
لـكــم..
Thank
You.