HCF CAP Preparation

1. Hospital CAP Preparation

2. Mr. Alan B. Mina
Senior Software Developer, CBAHI
amina@cbahi.gov.sa

3. CBAHI CAP request
The CAP package will be submitted to the hospital and an email notification will
be sent
1. Accredited: All or selected “Not Met” and “Partially Met” standards
2. Conditional: All
• “Significant Findings”
• “Not Met” and “Partially Met” ESR Standards
• All or Selected “Not Met” and “Partially Met” standards
After CBAHI Accreditation Decision, a CAP is required for:

4. HAD CAP submission to HCF Email Notification

5. Login to Hospital Portal
Click to confirm username and
password…
https://www.cbahi.gov.sa/hsa

6. CAP Notification in Home Page

7. CAP Guide

8. CAP action page
Standards that needs action
Save the action
Action form

9. CAP action page
Add a new Action
If all items has been completed,
click this button to finalize and
submit the CAP

10. HCF CAP Submission Form
Click to Finalize and
Submit CAP

11. HCF CAP Submission Email to CBAHI

12. CBAHI CAP Review of submitted CAP Actions
1. Upon receipt of the CAP action, CBAHI will then review the
actions then submits the cap actions to an STL
2. STL will then review the HCF’s actions then will decide:
a) Accept the action – The action is accepted and decide the final
score
b) Require a focus survey – the item will be included in a package of
standards that will be subjected to a focus survey
c) Require additional action – the standard will be re-submitted
back to the hospital for additional action
d) Follow-up on Midterm SA – The said item will be reviewed during
midterm self assessment of the hospital

13. HCF Additional Action Notification

14. HCF Additional Action Notification in Home Page

15. HCF Additional Action page
Click this to view standards that
requires additional action

16. HCF Additional Action page
Additional action
requirement
Add a new Action

17. HCF Additional Action action page
Click to save additional action

18. HCF Finalize and submit additional actions
Click to Finalize and Submit additional
actions

19. HCF additional action submission email to CBAHI

20. Questions???
For Inquiries, please email CBAHI Hospital Accreditation Department at
had@cbahi.gov.sa or send an email to ITSupport@cbahi.gov.sa to open
an IT service ticket.

21. Thank you…