hospital CBAHI Survey accreditation Guide.

1. Accreditation Survey

2. • CBAHI surveyors typically employ a variety of evaluation techniques
and strategies to objectively decide whether the facility meets
standards related to key systems and functions, such as governance
and leadership, patient care processes, medication management,
infection control, management and safety of the facility environment
and quality assurance.
• For example, the survey team may review written documents (e.g.,
strategic and operational plans and budgets, and clinical policies and
procedures). In addition to reviewing documents, surveyors will
interview facility leaders, physicians, nurses, employees and patients
to determine the facility’s performance and compliance with
standards.
• For example, the surveyor might interview a staff member to check
on the process he or she would complete to report a medical error,
that caused harm to one of the patients receiving care in that facility.
Similarly, a surveyor might interview a patient about his or her level of
satisfaction with the care the HCF provides.

3. • HCF leaders, including members of the governing body, may be interviewed regarding
facility processes and how they are designed to meet standards related to planning,
budgeting, quality assurance activities and human resources management. Surveyors
tour the facility’s buildings and patient care areas to evaluate standards related to
overall cleanliness, building safety, fire safety, waste management, equipment and
supply management, infection control and emergency preparedness. Other diagnostic
and support services such as the laboratory, radiology, pharmacy, central sterile services
and day procedure unit are also assessed for safety, effectiveness, quality control and
equipment management.

4. • In summary, during an on-site survey, surveyors use a variety of evaluation
approaches to determine the facility’s compliance or performance
regarding applicable structure, process and outcome standards.
These methods might include any combination of the following:
• Interviews with facility leadership, clinical and support staff, patients and
family.
• Observation of patient care and services.
• Facility tour and observation of patient care areas, building facilities,
equipment management and diagnostic testing services.
• Review of written documents such as policies and procedures, orientation
and training plans, budgets and quality improvement plans.