Hospital Orientation Program

Hospital Accreditation Guide (HAG)

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 Outline
Hospital Accreditation Guide (HAG)

• Registration with CBAHI

• Scoring Methodology

• Hospital Responsibilities

• Pre-Survey Activities

• Post-Survey Activities

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 Registration with CBAHI
All hospitals are required to register with CBAHI.

Use following link to register:

www.cbahi.gov.sa in the address bar

• Choose "Health Care Facility" and click register

• Complete the hospital information
A message about completion of registration will be
displayed specifying the Username and Password that is
to be used to access the hospital portal.

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 CBAHI Surveyors Assessment Methods
1. Interviews with hospital Leadership, clinical and support staff,
patient and family. Observation of patient care and services
provided.
2. Building tour and observation of patient care areas, building
facilities, equipment management, and diagnostic testing services.
3. Review of written documents such as policies and procedures,
orientation and training plans and documents, budgets, and quality
assurance plans.
4. Review of personnel files.
5. Review of patients’ medical records.
6. Evaluation of the hospital’s achievement of specific outcome
measures (e.g., hospital-acquired infection rates, patient
satisfaction) through a review and discussion of monitoring

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 Accreditation Decision Rules
First survey: track record of four months of compliance

Triennial survey: twelve months of compliance prior to survey (or from the
effective date of the new standards if less than 12 months).
The sub-standards are the elements of the standards that are reviewed and
scored by the surveyor on site.
Each sub-standard is scored on a three-point scale based on the degree of
compliance with the sub-standard’s requirements:

• “0” = Insufficient compliance when < 50 % compliance with the sub-standard

and/or compliance is less than two months to the initial survey or less than six
months for the triennial survey.

• “1” = Partial compliance when ≥ 50 to < 80 % compliance with the sub-

standard and/or compliance is for two to less than four months only prior to
the initial survey or six to less than twelve months for the triennial survey.

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 Accreditation Decision Rules

• “2” = Satisfactory compliance when ≥ 80 % compliance with the sub-standard

or compliance is for four months prior to the initial survey or twelve months
for the triennial survey.
•
• “NA” = Not Applicable indicates that the standard/sub-standard does not
apply to the hospital.

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 Accreditation Decision Rules
The Accreditation Decision Committee shall recommend one of the following
accreditation decisions:
Accredited:
• Overall score 85% or above
• All essential safety requirements are in satisfactory compliance
• No other issues of concern related to the safety of patients, visitors or staff.
Conditional Accreditation:
• Overall score 75% or above and less than 85%
• Some of the essential safety requirements (but not exceeding 25% of them) are
not in satisfactory compliance.
Denial of Accreditation:
• Overall score less than 75% and/or
• More than 25% of the essential safety requirements are not in satisfactory
compliance

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 Hospitals Responsibilities
Hospital’s survey coordinator:
• Serve as hospital’s survey coordinator to handle the logistics of
the survey visit.

• Liaison with the Healthcare Accreditation Department (HAD) and

the survey team leader about the survey visit arrangements.

• A list of survey team members, with their biographies, will be

sent to the hospital prior to the survey visit.

• The hospital should contact the Healthcare Accreditation

Department (HAD) promptly if any surveyor is deemed to be
inappropriate due to conflict of interest or other valid reasons. N
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 Hospitals Responsibilities

Survey Logistics Hospitals should provide appropriate logistics that

include the following:

• A workroom that is large enough for the survey team members

to review documents and leave computers and binders. The
workroom needs to be furnished with a desk or table, access to
electrical outlets, and internet access.

• A workroom(s) for group meetings and interviews with staff as

specified in the survey agenda.

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 Hospitals Responsibilities
Survey Logistics Hospitals should provide appropriate logistics that
include the following:
• Assigning a counterpart for each surveyor who is a responsible
person for the same specialty during the survey.

• Hospital Observers When the hospital’s team includes an

observer, who may represent a consulting firm or staff from other
hospitals, the hospital must inform CBAHI and obtain its official
approval at least one week prior to the survey.

• CBAHI observers/mentors One or more observers or mentors

may join the CBAHI survey team as part of the surveyors’ training
process.

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 Hospitals Responsibilities
Survey Logistics Hospitals should provide appropriate logistics that
include the following:
• Assigning a counterpart for each surveyor who is a responsible
person for the same specialty during the survey.

• Hospital Observers When the hospital’s team includes an

observer, who may represent a consulting firm or staff from other
hospitals, the hospital must inform CBAHI and obtain its official
approval at least one week prior to the survey.

• CBAHI observers/mentors One or more observers or mentors

may join the CBAHI survey team as part of the surveyors’ training
process.

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Pre-Survey Activities

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 Pre Survey Activities
Each year, CBAHI selects the hospitals to be enrolled in the
accreditation program.
• CBAHI sends a letter of enrollment to the selected hospitals.
• Hospitals selected must complete Survey Application Form.
• The access to the e-App is provided by CBAHI to intended
hospitals.
The Survey Application Form is completed as follows:
• Visit www.cbahi.gov.sa/hsa
• Enter your user name and password
• Complete and submit the hospital demographic questionnaire
• Under the “Survey Process” menu, select “Apply for a new Survey”
• Select type of survey and the date

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 Pre- Survey Activities
Resources to Assist Hospitals
The update for re-accreditation survey must be completed and
submitted to CBAHI twelve weeks prior to the accreditation
expiration.
• HAD’s accreditation coordinator - a primary contact between the
hospital and Healthcare Accreditation Department (HAD)
• CBAHI Standards Manual
• Accreditation Process Guide
• Self-Assessment Tool (SAT)
• Hospital Orientation Programs (HOP)
• Mock Survey
• Consultative Visit
• Requests for Interpretation of Accreditation Standards and Policies

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 Pre Survey Activities
Each year, CBAHI selects the hospitals to be enrolled in the
accreditation program.
• CBAHI sends a letter of enrollment to the selected hospitals.
• Hospitals selected must complete Survey Application Form.
• The access to the e-App is provided by CBAHI to intended
hospitals.
The Survey Application Form is completed as follows:
• Visit www.cbahi.gov.sa/hsa
• Enter your user name and password
• Complete and submit the hospital demographic questionnaire
• Under the “Survey Process” menu, select “Apply for a new Survey”
• Select type of survey and the date

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 Pre- Survey Activities
Resources to Assist Hospitals
Survey Team Composition
The survey team size and composition is based on a careful review of the
following factors as provided in the application for survey:
• Size of the facility (average daily census).
• Complexity of services offer (surgical and anesthesia services).
• Presence of special care units or off-site clinics.

• Typical Survey team (Seven and Visit Team Leader):

• Core team (three): administrator, nurse, and physician.

• The Specialty Team (four) : Pharmacist, Infection Control specialist,

Laboratory specialist, and facility management and safety specialist.

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 Pre Survey Activities
• Survey Team Members
• The survey team members are experienced health professionals, who have
been trained as surveyors. Prior to the survey, the surveyors review
information related to the hospital from the following:
• Application information
• Mid-term self-assessment and related corrective action plan(s)
• Offsite required documents

• Off-Site Survey Activities

• The hospital scheduled for the onsite survey shall send a list of the off-site
required documents for the off-site review by the surveyors at least two (2)
weeks prior to the date of the onsite survey. The list shall be communicated,
as a signed and scanned PDF document, with the Healthcare Accreditation
Department (HAD).

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 Pre Survey Activities
List of policies to be sent prior to the survey
Document Name Related Standards
1. Policy for Development and Maintenance of Policies LD.20
2. Medical Records Documentation Policy MR.5
3. Information confidentiality, security, and integrity PFR.7, MOI.6
4. Committee Management Policy LD.9
5. Policy for Delegation of Authority LD.17
Strategic Plan LD.11.2, LD.11.3, LD.12.1,
6. LD.12.2, LD.12.3, LD.12.4,
LD.12.5, LD.12.6, LD.12.7,
LD.15.1, LD.15.2, LD.15.3,
LD.15.4, LD.15.5, LD.15.6,
LD.15.11
7. Policy for Contracted Services LD.21, IPC.1
8. Job Description Policy HR.3
9. Policy for Management of Personnel Files HR.4
10. Probationary Period Evaluation Policy HR.8
11. Regular Performance Evaluation Policy HR.9
12. Safe Disposal of Medical Wastes Policy LD.23, IPC.26
13. Medical staff bylaws MS.1.1, MS.1.2, MS.1.3, MS.1.4,
MS.1.5, MS.1.6
14. Multidisciplinary Medication Management Plan MM.4.1
15. Hospital Drug Formulary MM.8.1
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 Pre Survey Activities
List of policies to be sent prior to the survey
Document Name Related Standards
15. Hospital Drug Formulary MM.8.1
16. Pharmacy Organization Structure MM.2.1
17. Pharmacy Scope of Services LD.28.2
18. Safety of the Building Management Plan FMS.1.1.1
19. Security Management Plan FMS.1.1.2
20. Life/Fire Safety Management Plan FMS.1.1.6
21. Internal Disaster Management Plan FMS.1.1.5
22. External Disaster Management Plan FMS.1.1.4
23. Hazardous Materials and Waste Management Plan FMS.1.1.3

24. Medical Equipment Management Plan. FMS.1.1.7

25. Utility Management Plan. FMS.1.1.8
26. Civil Defense License/Assessment Report along with corrective action FMS.4.1, FMS.4.2
plan.
27. Safety Committee Terms of Reference FMS.3.1, FMS.3.2,
FMS.3.3
Running construction/Renovation/Demolition works (if applicable) FMS
28.

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Survey Activities

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 On-Site Survey Activities
Opening Conference Objectives:
• To explain the scope of survey and what is expected from
the hospital during the survey.
• To orient the surveyors about the hospital’s structure, scope
of services, staffing, mission, and vision.
• To officially start the on-site survey.

Review of Documents Objectives:

• To evaluate compliance with standards that should be evidenced
in written documents.

Records and additional documents:

• Selected sample of closed medical records as well as personnel
files will be reviewed.

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 On-Site Survey Activities
Surveyors Business Lunch:
• Only surveyors attend this meeting.

Surveyors End of the Day Meeting:

Only surveyors attend this meeting which will include the following
activities:
• Team members to present items for presentation at the debriefing
session.
• Team members to present items for possible discussion during the
upcoming committees meetings.
• Team members present their next day survey activities

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 On-Site Survey Activities
Executive Leadership Interview (3rd day)
To discuss significant issues encountered during the survey.

Attendees:
The entire CBAHI survey team.
Hospital team:
• Governing Body representative
• Hospital Director
• Medical Director 4. Nursing Director
• Administrative Director
• Operations Director
• Quality Improvement Director
• Others to be determined by the CBAHI survey team

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 On-Site Survey Activities
Executive Leadership Interview (3rd day)
Agenda:
• Introduction

• Discussion on the management survey findings that are

related to leadership standards such as organizational
structure, and staffing issues (if any).

• Explore the leadership’s support for different functions such

as patient and family rights

• Clarify and discuss significant findings during the survey such

as issues related to patients, staff, facilities or visitors’ safety.
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 On-Site Survey Activities
Quality and Patient Safety Committee and Data Management Session (2 nd day)
To have an overview on the hospital-wide quality improvement and patient
safety program, including how data and information are managed and
communicated to end users to better hospital services.
Attendees:
• Current members of the committee with a minimum number to meet the
quorum as per terms of reference. According to the available specialties in the
hospital, the following are the least number required to attend:
• Chairman of the committee
• Quality Director
• Medical Director
• Nursing Director
• Risk Manager
• Medical Records Manager
• Healthcare Information System Manager
• Other specialties QI designees as per hospital 3 – 5 main services
• Operations/Logistic representative
• One project team (team leader and a team member)

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 On-Site Survey Activities
Quality and Patient Safety Committee and Data Management
Session (2nd day)
Agenda:
• Introduction
• Hospital presentation on the quality improvement and patient
safety program to include:
• QI program structure
• QI program flow (how it is integrated with other hospital-wide
programs)
• Highlight on an improvement project
• Performance indicators’ monitoring process
• Key performance indicators’ reports submitted to the governing
body
• Risk management initiatives and data trends

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 On-Site Survey Activities
Quality and Patient Safety Committee and Data Management
Session (2nd day)
Agenda:
• Hospital presentation on the quality improvement and patient
safety program to include:
• Management of data and information processes
• Information needs assessment process
• Information management structure
• Data management education and training
• Data and report flow and management
• Open discussion between surveyor and hospital representative.
• Other topics may be raised and discussed based on the surveyor
findings during the hospital visit.

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 On-Site Survey Activities
Quality and Patient Safety Committee and Data Management Session
(2nd day)
Required Documents:
The hospital is requested to have documentations related to its quality
improvement program, patient safety initiatives, risk management
program and activities, data and information
These may include, but not limited to:
1. Terms of reference of the quality improvement committee, patient
safety team or equivalent.
2. Committee membership list.
3. Minutes of meetings for the tracking period.
4. Managerial and clinical performance monitoring indicators
5. Patient safety indicators.
6. Improvement projects or programs (may include list of projects and
teams if available)

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 On-Site Survey Activities
Quality and Patient Safety Committee and Data Management
Session (2nd day)
Required Documents:
1. Improvement activities based on information resulting from
data analysis 8. Risk management program
2. Patient safety program
3. Key performance indicators’ reports submitted to the governing
body
4. Incidents reporting system and data trends
5. Annual review of committee performance
6. Information needs assessment process and report
7. Information management related activities, education and
reports

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 On-Site Survey Activities
Surveyors Debriefing
• There should be no surprises in the survey report.

• Ongoing communication with the counterparts from the hospital.

• Allows the hospital to clarify or explain possible discrepancies or

compliance issues, and allows for consultation and education.

• Additionally, the daily debriefing and the closing conference, at

the end of the survey, allow hospitals to challenge cited
deficiencies.

• Finally, the hospital will review a draft exit report for feedback or
correction of any issues of fact as a step before making the
accreditation decision.

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 On-Site Survey Activities
Surveyors Debriefing
Closing Conference Objectives:
• To provide the hospital with an initial overview on the
outcome of the survey.
• To allow the hospital to clarify or explain possible
discrepancies or compliance issues.
• To provide the leaders with the hospital’s strengths and
areas for improvements. Participants

At the conclusion of the on-site survey, after collection of final

data, the surveyors hold a closing conference at which they
present key findings and the hospital’s areas for improvement.

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 On-Site Survey Activities
Exit Report
• Exit report will be provided to the hospital director
including the draft of major findings in ESRs and other
standards in all specialties. Other information provided
may include how the hospital could have access to the
detailed report and possible follow-up decisions or
activities.
• As the surveyors are “fact finders” for the CBAHI, they
do not render the final accreditation decision, but
instead they report findings to the CBAHI.
• Therefore, during the exit conference, the surveyors will
not state whether the hospital will be awarded an
accreditation.
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Post-Survey Activities

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 Post- Survey Activities
Survey Report

. The surveyed hospital receives official documents detailing the

accreditation decision and any required follow-up activities within thirty
days after the conclusion of the survey.

Hospitals will be able to access the survey report through the use of their
username and password through the hospital portal.

Survey Report Contents :

• Dates of the survey
• Names of the surveyors
• The services and sites assessed
• The scope of the survey and the standards used
• The findings of the survey team for all sub-standards that had
insufficient or partial compliance.
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 Post- Survey Activities
Hospital Feedback

• CBAHI appreciates each surveyed hospital’s feedback.

• The feedback is very beneficial in ensuring the continuing growth

and improvement of CBAHI’s accreditation program.

• An email is sent to the hospital’s survey coordinator after the

survey visit has been completed requesting their feedback about
CBAHI standards, survey process and surveyors’ performance .

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THANK YOU

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