PREPARED BY DR. MOHAMED RAMZY YOUSEF HOSPITAL QUALITY COORDINATOR QUALITY & PATIENT SAFETY DEPARTMENT

1. Central Board for Accreditation of Health care
Institutions CBAHI
‫الصحية‬ ‫المنشآت‬ ‫إلعتماد‬ ‫المركزي‬ ‫المجلس‬
STANDARDS & SURVEY PROCESS
ORIENTATION – SSPO
PREPARED BY
DR. MOHAMED RAMZY YOUSEF
HOSPITAL QUALITY COORDINATOR
QUALITY & PATIENT SAFETY
DEPARTMENT
4-10-2017

2. INTRUDUCTION
• The CBAHI precedes form the
Council of Health Services to
establish and pursue the applying of
the Quality Standards in all health
sectors all over the regions of the
Kingdom to improve the health
service provided to meet the
international patient safety goals
• The CBAHI was formed based on the
recommendation of the Council of
Health Services and the Council
formation was approved in the
meetings dated 1/3/1426 & 5/5/1426
chaired by the Minister of Health, as
Chairman of Council oF health
Services,
•‫الصحي‬ ‫المنشآت‬ ‫العتماد‬ ‫السعودي‬ ‫المركز‬‫ة‬
‫شهادات‬ ‫منح‬ ‫المخولة‬ ‫الرسمية‬ ‫الجهة‬ ‫هو‬
‫الصحية‬ ‫الرعاية‬ ‫منشآت‬ ‫لجميع‬ ‫االعتماد‬
‫والخاص‬ ‫العام‬ ‫القطاعين‬ ‫في‬ ‫العاملة‬
‫السعودية‬ ‫العربية‬ ‫بالمملكة‬.‫انبثق‬ ‫وقد‬
‫الصحي‬ ‫المنشآت‬ ‫العتماد‬ ‫السعودي‬ ‫المركز‬‫ة‬
‫غير‬ ‫كمنظمة‬ ‫السعودي‬ ‫الصحي‬ ‫المجلس‬ ‫من‬
‫للربح‬ ‫هادفة‬.‫الرئيسي‬ ‫المركز‬ ‫مهام‬ ‫وتكمن‬‫ة‬
‫الصحية‬ ‫الرعاية‬ ‫جودة‬ ‫معايير‬ ‫وضع‬ ‫في‬
‫تقي‬ ‫بموجبها‬ ‫يتم‬ ‫التي‬ ‫المرضى‬ ‫وسالمة‬‫يم‬
‫الدل‬ ‫إلقامة‬ ‫الصحية‬ ‫الرعاية‬ ‫منشآت‬ ‫جميع‬‫يل‬
‫المعايير‬ ‫بتلك‬ ‫التقيد‬ ‫على‬.‫المواف‬ ‫وتمت‬‫قة‬
‫مؤرخ‬ ‫اجتماعين‬ ‫في‬ ‫المجلس‬ ‫تشكيل‬ ‫على‬‫ين‬
1/3/1426‫و‬5/5/1426‫وزير‬ ‫برئاسة‬
‫الخدمات‬ ‫إدارة‬ ‫مجلس‬ ‫ورئيس‬ ‫الصحة‬
‫الصحية‬

3. • ‫التأسيس‬
•‫الص‬ ‫المنشآت‬ ‫العتماد‬ ‫السعودي‬ ‫للمركز‬ ‫األولى‬ ‫البدايات‬ ‫ترجع‬‫إلى‬ ‫حية‬
‫عام‬2001‫مك‬ ‫في‬ ‫الشاملة‬ ‫الجودة‬ ‫برنامج‬ ‫في‬ ً‫ال‬‫متمث‬ ‫كان‬ ‫حيث‬ ‫م‬‫ة‬
‫الر‬ ‫تقديم‬ ‫جودة‬ ‫تحسين‬ ‫إلى‬ ‫تهدف‬ ‫كانت‬ ‫التي‬ ‫المبادرة‬ ،‫المكرمة‬‫عاية‬
‫المكرمة‬ ‫مكة‬ ‫منطقة‬ ‫في‬ ‫الصحية‬.
•‫عام‬ ‫في‬2005‫تطبيق‬ ‫برنامج‬ ‫تطوير‬ ‫جرى‬ ‫وزاري‬ ‫أمر‬ ‫وبموجب‬ ‫م‬
‫المركزي‬ ‫المجلس‬ ‫اسم‬ ‫عليه‬ ‫وأطلق‬ ‫المكرمة‬ ‫مكة‬ ‫في‬ ‫الشاملة‬ ‫الجودة‬
‫لت‬ ‫صالحياته‬ ‫حدود‬ ‫توسيع‬ ‫تم‬ ‫الذي‬ ‫الصحية‬ ‫المنشآت‬ ‫العتماد‬‫شمل‬
‫السعودية‬ ‫العربية‬ ‫المملكة‬ ‫مناطق‬ ‫جميع‬.

4. •‫في‬‫عام‬2006‫من‬ ‫الصحية‬ ‫الرعاية‬ ‫جودة‬ ‫في‬ ‫خبراء‬ ‫وبمساعدة‬ ‫م‬
‫المنشآت‬ ‫العتماد‬ ‫السعودي‬ ‫المركز‬ ‫وضع‬ ، ‫والخاص‬ ‫العام‬ ‫القطاعين‬
‫للمستشفيات‬ ‫الوطنية‬ ‫للمعايير‬ ‫مجموعة‬ ‫أول‬ ‫الصحية‬.

5. •‫الص‬ ‫المنشآت‬ ‫العتماد‬ ‫السعودي‬ ‫المركز‬ ‫العتماد‬ ‫اإللزامية‬ ‫الصفة‬‫حية‬
•‫عام‬ ‫أواخر‬ ‫في‬2013‫اإلسم‬ ‫بتغيير‬ ‫الوزراء‬ ‫مجلس‬ ‫قرار‬ ‫صدر‬ ‫م‬
‫إلى‬ ‫الرسمي‬"‫الصحية‬ ‫المنشآت‬ ‫العتماد‬ ‫السعودي‬ ‫المركز‬"‫وشم‬ ،‫ل‬
‫منشآت‬ ‫لجميع‬ ‫الوطني‬ ‫باالعتماد‬ ‫المركز‬ ‫تكليف‬ ً‫ا‬‫أيض‬ ‫القرار‬‫الرعاية‬
‫الصحية‬.‫االعتم‬ ‫باعتبار‬ ‫الصحة‬ ‫وزارة‬ ‫تعميم‬ ‫إلى‬ ‫باإلضافة‬ ‫هذا‬‫اد‬
‫مس‬ ً‫ا‬‫شرط‬ ‫الصحية‬ ‫المنشآت‬ ‫العتماد‬ ‫السعودي‬ ‫المركز‬ ‫من‬ ‫الصادر‬ً‫ا‬‫بق‬
‫التشغيل‬ ‫رخصة‬ ‫لتجديد‬–‫المشار‬ ‫من‬ ‫المزيد‬ ‫تشجيع‬ ‫نحو‬ ‫خطوة‬‫في‬ ‫كة‬
‫الطموحة‬ ‫الوطنية‬ ‫المبادرة‬ ‫هذه‬.

6. Mission
•“To promote quality
and safety by
supporting healthcare
facilities to continuously
comply with
accreditation standards
•‫من‬ ‫والسالمة‬ ‫الجودة‬ ‫تعزيز‬
‫الرعاية‬ ‫مرافق‬ ‫دعم‬ ‫خالل‬
‫المست‬ ‫االمتثال‬ ‫على‬ ‫الصحية‬‫مر‬
‫االعتماد‬ ‫لمعايير‬

7. The CBAHI Goals
Ultimate Goal:
1. To establish and pursue the applying of the
Quality Standards to improve the health
service provided to meet the international
patient safety goals in
• All health Care Sector
• All over the regions of the Kingdom

8. Additional Goals:
1. Create an “army” of Quality oriented and
committed personnel through widening the
involvement in the process.
2. Create a healthcare information data base for the
Kingdom of Saudi Arabia Hospital activities and
performance.
3. Enhancing the communication between all
sectors in healthcare ( MOH, Private, Military ,
Specialist , Armed forces , others and ARAMCO)
The CBAHI Goals

9. what CBAHI stand for ?
‫؟‬ CBAHI‫باالختصار‬ ‫المقصود‬ ‫ما‬

10. The Main Pillars of CBAHI
•Standards
•Surveyors
•Survey Process

11. CBAHI –NHS 3rd Edition Chapters
1. Leadership
2. Human Resources
3. Medical Staff
4. Provision of Care
5. Nursing
6. Quality Management and Patient
safety
7. Critical Care Services
8. Labor and Delivery
9. Emergency Care
10. Hemodialysis
11. Anesthesia
12. Patient and Family Rights
13. Operating Room
14. Radiology Services
15. Burn Care
16. Oncology and Radiotherapy
17. Specialized Care Services
18. Management of Information
19. Medical Records
20. Infection Prevention and Control
21. Medication Management
22. Laboratory
23. Facility Management and Safety

12. CBAHI –NHS 3rd Edition
Major Changes
The changes in this new edition include:
– Chapters,
– Standards,
– Survey process,
– Essential Safety Requirements (ESRs),
– Scoring Guidelines,
– Accreditation Decision Rules, and
– Introduction of Tracers

13. Essential Safety Requirements
(ESRs)
Selected standards have been assigned as Essential
Safety Requirements. ESR
• ESRs are selected based on:
– Proximity of risk,
– Probability of harm,
– Severity of harm, and
– Number of patients at risk.
Score will be the same as the other sub-standards

14. Shared/hospital-wide standards
• TOTAL NUMBER OF SHARED SUB STANDARDS: 91
• LD shared sub-standards: 38
• HR shared sub-standards: 30
• QM shared sub-standards: 3
• PFR shared sub-standards: 8
• MOI shared sub-standards: 9
• MR shared sub-standards: 1
• FMS shared sub-standards: 2

15. Scoring of shared standards
• The score will be averaged from all shared surveyors.
• All surveyors will review and discuss
comments/findings as a team or with concerned
specialty surveyor

16. •What is CBAHI main pillars ?
•‫لالعتماد‬ ‫السعودي‬ ‫للمركز‬ ‫الثالثة‬ ‫الركائز‬ ‫هي‬ ‫ما‬...‫؟‬
•What ESR stand for ?
•‫االختصار‬ ‫يعني‬ ‫ماذا‬? ESR
•How many chapters in 3rd eddition ?
•‫؟‬ ‫سباهي‬ ‫معايير‬ ‫من‬ ‫الثالث‬ ‫االصدار‬ ‫فصول‬ ‫عدد‬ ‫كم‬

17. Survey Process Changes

18. Hospital Accreditation Guide - HAG
Support CBAHI Surveyors in the accreditation process .
• It is the operational manual for the CBAHI surveyors
• It covers the technical protocols, sample agenda,
activity
requirements as well as the forms used during the
execution of surveys.

19. NEW SURVEY PROCESS DESIGN

20. On-Site Survey Activities

21. Survey Team Composition
• A typical full survey of a hospital, the survey team would
include seven (7) surveyors who will be at the facility for three
(3) or more days:
• MAIN (CORE) TEAM
• Leadership & Quality Management
Surveyor
• Medical Surveyor
• Nursing Surveyor
• SPECIALTY TEAM
• Medication Management Surveyor
• Infection Control Surveyor
• Laboratory Surveyor
• Facility Management and Safety
Surveyor

22. CBAHI scoring system

23. Scoring Guidelines
• Each sub-standard has equal weight and is
scored on a three point scale as follows:
0 = < 50% Compliance
1 = >= 50% - < 80% Compliance
2 = >= 80% Compliance
N/A = Not Applicable
3,588 scorable sub-standards

24. Accreditation Polices and
Decision Rules

25. Accreditation Policies
• Accreditation decisions are communicated
to the hospital within (30) days after the
conclusion of the survey visit.
• Accreditation decision making process is basically based on:
• The findings of the survey team members as recorded
in the survey report.
• Discussions regarding the survey findings between the
surveyor and the specialty team leader (STL).
• Review of the draft report by the participating hospital
for feedback.
• Review/discussion during the meeting of the
Accreditation Decision Committee (ADC).

26. Accreditation Policies
•Other factors are:
• Criticality of the non-
compliant standard(s),
i.e. the degree of
severity and immediacy
of risk to patients,
visitors or staff safety.
•Any concerns regarding
the compliance of the
hospital with the
Essential Safety
Requirements (ESRs).

27. Accreditation Decision Rules
•Accredited:
• Overall score 85% or above and
• All essential safety requirements are in
satisfactory compliance and
• No other issues of concern related to the
safety of patients, visitors or staff.

28. • Conditional Accreditation:
• Overall score 75% or above and less than 85%
and/or
• Some of the essential safety requirements
(but not exceeding 25% of them) are not in
satisfactory compliance.
Accreditation Decision Rules

29. • Preliminary ‫مبدئي‬Denial of
Accreditation (PDA):
• Presence of an immediate threat to
the safety that is observed during the
on-site survey.
• Significant noncompliance with the
accreditation standards at the time of
the on-site survey.
• Failure of timely submission of the
post survey requirements after
conditional accreditation.
• The hospital has received
conditional accreditation and was
subjected to a follow up focused
survey but still could not meet the
requirements for accreditation.
• Reasonable evidence exists of
fraud, plagiarism, or falsified
information related to the
accreditation process
• Refusal by the hospital to receive
the survey team and conduct a
survey.
Accreditation Decision Rules

30. • Denial ‫رفض‬ of Accreditation:
• Overall score less than 75% and/or
• More than 25% of the essential safety requirements are
not in satisfactory compliance.
Accreditation Decision Rules

31. •‫؟‬ ‫المعيار‬ ‫لقياس‬ ‫الثالثة‬ ‫الدرجات‬ ‫هي‬ ‫ما‬
•WHAT ARE THE THREE POINT
SCALE FOR STANDARED ?

32. Appeal against Accreditation
Decision

33. • A surveyed healthcare
facility can appeal against
the following accreditation
outcomes:
• Preliminary Denial of
Accreditation (provided it is not due
to failure of timely submission of the
post survey requirements after
granting accreditation or after
conditional accreditation, or due to
the facility remains conditionally
accredited after a follow up focused
survey).
• Suspension/Revocation of
Accreditation.
All appeals shall be made within
maximum of (15) calendar days
from receiving the official survey
report

34. Grounds for appeals
• Relevant and significant
information which was
available to the survey team
was not considered in the
making of the accreditation
decision.
• The report of the
surveyors(s) was inconsistent
with the information
presented to the survey
team.
• Perceived bias of a
surveyor(s).
• Information provided by the
survey team was not duly
considered in the survey
report.
• The outcome of the appeal
–if comes in favor of the
appealer- will result in
changing the accreditation
status.
• Appeals that will not result
in changing the status of
accreditation will not be
considered by CBAHI.

35. Standing Requirements
Accreditation Maintenance
• Corrective Action Plan (CAP)
• When accreditation is awarded, a (CAP) addressing all
standards that were not in satisfactory compliance should
be received within (120) days from the date of the
accreditation decision

36. Standards Compliance Progress Report (SPR)
• When a hospital is conditionally accredited, an (SPR) should
be received within (60) days from the date of the accreditation
decision.
• The hospital compliance is going to be validated through a
follow up focused survey within (30) days from the date of
receiving the SPR.
Standing Requirements
Accreditation Maintenance

37. Midterm Self-Assessment
• Accredited hospitals are required to participate in a mid-
cycle self-evaluation of standards compliance, Fifteen
months from the date of accreditation awarding.
Standing Requirements
Accreditation Maintenance

39. ‫المرضى‬‫وسالمة‬ ‫الجودة‬‫ادارة‬
‫العام‬‫ات‬‫الميق‬‫مستشفى‬