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  1. 1. CBAHI Standards and Survey Process Orientation – SSPO October, 2015
  2. 2. Outline • Introduction to CBAHI • NHS 3rd Edition Standards Structure • Essential Safety Requirements (ESRs) • Survey Process Changes • CBAHI scoring system • Accreditation polices and decision rules • Appeal policy • Accreditation Maintenance 2
  3. 3. CBAHI 3
  4. 4. . Mission “To promote quality and safety by supporting healthcare facilities to continuously comply with accreditation standards.” 4
  5. 5. Vision “To become the regional leader in improving healthcare quality and safety.” 5
  6. 6. Values Commitment To Excellence Team Spirit Integrity Professionalism TIPE 6
  7. 7. The Logo 7
  8. 8. The Main Pillars of CBAHI Standards Surveyors Survey Process 8
  9. 9. NHS 3rd Edition Standards & Survey Process 9
  10. 10. 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 CBAHI –NHS 3rd Edition Chapters
  11. 11. • Standards related to HR in the former “LD” chapter have been moved to a new separate chapter “HR”. • “Medical Staff and Provision of Care” has been divided into two chapters: – Medical Staff: describes structure and organization of the medical staff. – Provision of Care: addresses the quality and safety of the actual clinical care processes. CBAHI –NHS 3rd Edition Major Changes
  12. 12. • Ambulatory Care” and the “Psychiatry” chapters have been merged with the “Provision of Care” chapter to emphasize the continuum of care. CBAHI –NHS 3rd Edition Major Changes
  13. 13. • The CBAHI accreditation standards for hospitals underwent an extensive review based on the past experience. • The changes in this new edition include: – Chapters, – Standards, – Survey process, – Essential Safety Requirements (ESRs), – Scoring Guidelines, – Accreditation Decision Rules, and – Introduction of Tracers CBAHI –NHS 3rd Edition Major Changes
  14. 14. 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
  15. 15. Examples Essential Safety Requirements (ESRs) • HR.5 The hospital has a process for proper credentialing of staff members licensed to provide patient care. • MS.6 The hospital has clearly defined and documented processes used to credential, appoint, and grant clinical privileges to medical staff. • MS.9 Medical staff leaders make use of the data and information resulting from the medical staff performance review. • PC.26 Patients at risk for developing venous thromboembolism are identified and managed. • PC.28 Policies and procedures guide the care of psychiatric patients.
  16. 16. Survey Process Changes 16
  17. 17. • 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. 17 Hospital Accreditation Guide - HAG
  18. 18. Hospital Accreditation Guide - HAG All the resources that hospitals need for preparing for Accreditation are available online. SUPPORT: hospital preparation for accreditation surveys 18
  19. 19. New Survey Process Design 19
  20. 20. On-Site Survey Activities Opening Conference Closed Medical Record Review Personnel File Review Formal/committee Interviews Medical Exec P&T Infection Control Safety Quality & Data session Contracted Services Building tour Unit visit Staff interview Observation Open medical record Documented Evidence Exit Conference Leadership Interview Document Review 20
  21. 21. New Survey Process Statistics 21 21% 5% 10% 59% 5% 0% Document Review Closed Medical Record Review Personnel File Review Unit Visit Formal/Committees Interviews Leadership Interview
  22. 22. CBAHI scoring system 22
  23. 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 23
  24. 24. Accreditation Polices and Decision Rules 24
  25. 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). 25
  26. 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). 26
  27. 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. 27
  28. 28. Accreditation Decision Rules • 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. 28
  29. 29. Accreditation Decision Rules • Preliminary Denial 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. 29
  30. 30. Accreditation Decision Rules • Denial of Accreditation: • Overall score less than 75% and/or • More than 25% of the essential safety requirements are not in satisfactory compliance. 30
  31. 31. Appeal against Accreditation Decision • 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 31
  32. 32. Appeal against Accreditation Decision • 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. 32
  33. 33. 33 Accreditation Maintenance
  34. 34. Standing Requirements for 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 • 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. • 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. 34
  35. 35. Questions? Thank you 35