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Session 1
• Introduction
Session 2
• How CBAHI Supports
Hospitals?
Session 3
• Survey Process
Session 4
• Hospital Survey Activities
Session 1
Introduction
3
Introduction
Accreditation
Accreditation Organizations
The CBAHI Accreditation Standards
The CBAHI Accreditation Purpose
Mission, Vision, & Values
CBAHI Theme
4
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 األداء بالمقارنة‬
‫مع معايير تلك الهيئة وبما يتطابق مع‬
‫احتياجات المرضى‬
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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 (Ministry of Health)
• 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
‫مساعدة المستشفيات‬
‫في تثبيت أسس‬
‫وقواعد العمل‬
‫سالمة‬
‫المريض‬
‫تحسين مستوى‬
‫الرعاية‬
‫الصحية‬
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
‫تحضير‬
ACCREDITATION
‫اعتماد‬
MONTIRING
‫مراقبة‬
Session 2
How CBAHI Supports Hospitals?
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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
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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
‫ ومن خالل استيفاءها يتم‬، ‫• هي جمل تفصل األداء المتوقع لكل معيار‬
‫التكامل مع المعيار و بها يكون المستشفى جاهز ألي نوع من التقييم‬
• 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
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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
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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
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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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50
Hospital Feedback Form
Hospitals are requested to complete
a Hospital Survey Feedback form
after the survey visit has been
completed
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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
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