The document describes the process used by CBAHI surveyors to evaluate healthcare facilities for accreditation. Surveyors use various methods such as document reviews, staff and patient interviews, and facility tours. They assess areas like governance, patient care, safety, and quality assurance. Surveyors rate facilities on standards related to these areas using a scale of 0 to 2. Facilities must score over 75% overall and fully meet core standards to receive accreditation. Immediate threats to safety can result in accreditation being denied even if other standards are met.

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.

5. • Review of personnel files.
• Review of patients’ medical records.
• Evaluation of the facility’s achievement of specific outcome measures (e.g.,
acquired infection rates, patient satisfaction) through review and
discussion of monitoring and improvement activities.

6. Structure of the National Standards for
Ambulatory Care Centers
• The chapters are:
• Leadership of the Organization (LD)
• Provision of Care (PC)
• Laboratory Services (LB)
• Radiology Services (RD)
• Dental Services (DN)
• Medication Management (MM)
• Management of Information (MOI)
• Infection Prevention and Control (IPC)
• Facility Management and Safety (FMS)
• Day Procedure Unit (DPU)
• Dermatology & Aesthetics Medicine (DA)

7. Accreditation Decision Rules
• The most serious is when the surveyor notices an immediate threat to
safety or quality of care. Examples include:
• Expired material is being used.
• A bare electrical wire is hanging down without any protection.
• A patient is not properly identified.

8. Accreditation Decision Rules
• When a CBAHI surveyor notices an immediate threat, whether or not it is
directly linked to the standards, the survey team leader will notify the HCF
director and include the findings in the survey report.
• Each standard is composed of a stem statement and sub-standard(s). The
substandard is the evidence of compliance to be scored by the surveyor
during the on-site survey.
• Each substandard has an equal weight and is scored on a three-point scale
as follows:
• 0 = Insufficient Compliance (less than 50% compliance with the standard).
• 1 = Partial Compliance (from 50% to less than 85% compliance with the standard).
• 2 = Satisfactory Compliance (85% and more compliance with the standard).
• N/A = Not Applicable

9. Accredited
Accreditation will be awarded when the surveyed HCF demonstrates an overall acceptable
compliance with all applicable standards at the time of the initial (or re-accreditation) on-site
survey, and when there are no issues of concern related to the safety of patients, staff,
visitors or the facility itself. Accreditation will also be recommended when the HCF has
successfully addressed all post-survey requirements and does not meet any rules for denial.
Scoring Guidelines:
• Overall score 75% or above.
• All Core standards are fully met.
• All applicable standards score 50% and above.

10. Denial of Accreditation