PowerPoint Presentation

[Virtual Presenter] Welcome to Saudi Central Board for Accreditation of Healthcare Institutions Awareness Session in preparation for un-announced re-accreditation survey visit expected during the fourth quarter of 2021. The duration of this session will be for 90 minutes to the basic required information and useful readiness tips prior to C-B-A-H-I survey visit, orient you on some of common and general question might be asked and share with you what the survey activities and expectations.

[Audio] The International Society for Quality in Health Care (ISQua) CBAHI At A Glance The Saudi Central Board for Accreditation of Healthcare Institutions (C-B-A-H-I) is the official agency authorized to grant accreditation certificates to all governmental and private healthcare facilities operating today in Saudi Arabia. C-B-A-H-I has emerged from the Saudi Health Council as a non-profit organization. The principal function of C-B-A-H-I is to set the healthcare quality and patient safety standards against which all healthcare facilities are evaluated for evidence of compliance. Evolution of CBAHI: Foundation The foundation of C-B-A-H-I dates back to 2001 as Makkah Region Quality Program (M-R-Q-P-), an initiative aimed at improving quality of healthcare delivery in the Makkah region of Saudi Arabia. Expansion In 2005, by a Ministerial Order, M-R-Q-P was advanced and named as Central Board for Accreditation of Healthcare Institutions (C-B-A-H-I) and its jurisdiction was expanded to the whole country. National Standards In 2006, with the help of healthcare quality experts from the public and private sectors of Saudi Arabia, C-B-A-H-I developed the first set of national standards for hospitals. ISQua accreditation In 2012, CBAHI's 2nd edition of national standards for hospitals was certified by the International Society for Quality in Healthcare (ISQua). C-B-A-H-I accreditation becomes compulsory In late 2013, when a Cabinet of Ministers Decree called for changing CBAHI's official name to the "Saudi Central Board for Accreditation of Healthcare Institutions", it also mandated the national accreditation by C-B-A-H-I on all healthcare facilities. In addition, the Ministry of Health is mandating C-B-A-H-I accreditation as a prerequisite for renewal of the operating license – a step towards encouraging more participation in this ambitious national initiative. Mandatory status of C-B-A-H-I accreditation: It is mandatory for all public and private healthcare delivery facilities (hospitals, polyclinics, blood banks and medical laboratories) in Saudi Arabia to comply with national standards set by C-B-A-H-I and obtain its accreditation through a survey process set forth by it. Vision, Mission and Values Our Vision To become the regional leader in improving healthcare quality and safety. Our Mission To promote quality and safety by supporting healthcare facilities to continuously comply with accreditation standards. Our Values Excellence: We do not accept anything below excellence in the work that we do. This entails a tireless commitment to conceptualizing and applying creativity, innovation, modern technology, and attracting highly-qualified and talented individuals to work with us. Team Spirit: Our associates work with each other as well as with the healthcare facilities as a single harmonious, coherent, and collaborative team that has the shared goal of improving healthcare as stipulated in our vision and mission. Integrity: We are committed to honesty, transparency, and admission of any mistakes without equivocation. We strive to conduct our work in accordance with defined laws and regulations, avoiding conflict of interest or concealment of the truth, whether being in direct attendance or not. Professionalism: We see professional behavior as a synonym to courteousness and respect for our partners, whether they be individuals or organizations. This professionalism encompasses data and information confidentiality, doing the right thing right from the first time, and ensuring maximum accuracy and objectivity during assessment visits..

[Audio] In late 2013, Resolution No. (371) of the Council of Ministers was issued, changing the name to the "Saudi Central Board for Accreditation of Healthcare Institutions"; and under this resolution, national accreditation has become mandatory. In addition, a previous circular of the Ministry of Health was issued considering national accreditation by C-B-A-H-I a precondition to renew the operating license for all private medical facilities, a step towards encouraging more participation in such an determined national initiative..

[Audio] CBAHI is reporting to Saudi Health Council..

[Audio] Researches show that receiving accreditation leads to higher operational efficiency and Significantly helps to build an effective system to support patient safety and minimize risks. CBAHI is recognized by the international Society for Quality in Health Care (ISQua) , the entity supervising all healthcare accreditation bodies all over the ward, meaning that C-B-A-H-I standards are in line with international best practices. National standards by C-B-A-H-I are clear, detailed and descriptive. They are designed to match the work environment in the Kingdom..

[Audio] The process of standards development can last up to 18 months or more before an initial draft is produced. The draft standards are then distributed nationally for review and made available for comment on the standards Field Review page of the C-B-A-H-I website. Based on the feedback received from the field review, the draft standards may be revised and again reviewed by the relevant experts and technical committees. The 2nd reviewed draft standards are pilot-tested in a well selected hospitals sample, representing public and private sectors. Feedback from pilot testing are considered in the final draft and survey process design. Finally, the draft is approved by the Standards Development Committee and provided to the Board for initial approval before submission to the Saudi Health Council for approval. Once the standards are in effect, ongoing feedback is sought for the purpose of continuous improvement. C-B-A-H-I surveyors are then trained on how to assess compliance with the standards.

[Audio] King Faisal Specialist Hospital and Research Center – Riyadh will be surveyed on the 3rd National Hospital Standards edition which includes 23 chapters coving clinical and non clinical services. The new 4th edition standards not released yet..

[Audio] Around 3200 elements need to be assessed during the survey visit accordingly Sub-standards were grouped to be checked by seven surveyors with different specialties: Leadership surveyor will assess 489 elements from different chapters Medical surveyor has 645 Element to be scored Nursing Surveyor will assess 494 elements.

1. Leadership. 2. Human Resources. 3. Medical Staff. 4. Provision of Care. 5. Quality Management. 6. Operation Room. 7. Management of Information. 8. Laboratory. 9. FMS. 654 Element to be scored Laboratory Surveyor.

usa. https://portal.cbahi.gov.sa/english/patient-safety/essential-safety-requirements.

[Audio] They are estimated to be basic conditions that must be fully observed to and monitored annually to ensure patient safety and protection against healthcare related errors..

[Audio] They are estimated to be basic conditions that must be fully observed to and monitored annually to ensure patient safety and protection against healthcare related errors..

[Audio] Midterm Self Assessment will be after 15 months the Accreditation..

Survey visit predicted on the 4th Quarter of 2024.

[Audio] Based on C-B-A-H-I re-accreditation process policy, unannounced survey visit can be conducted two months before or after the re-accreditation date, accordingly we are predicating the visit to be during the 4th quarter 2021 or during the 1st quarter 2022..

[Audio] After Covid -19 Pandemic issue, the survey process was changed radically, the duration of site visit will be one instead of four days, accordingly C-B-A-H-I system will randomly select only 30% out of 3200 substandard to be evaluated and scored .The selected package will not be shared with the hospital. Notification about the visit will be 5 working days before the visit day and all Essential Safety Requirements standards will be included. ..

Yes, it does, CBAHI accreditation is a national mandate according to Ministerial Cabinet decree number 371..

[Audio] The most dominant activity during one day survey will be visiting of different clinical and non clinical areas , so surveyor will interact with frontlines asking question , request for demonstrating of certain practices and check the policies and document evidences for implementation of policies and procedures..

Organization chart. Scope of Service Department chairman/director CV Departmental Staffing plan Department minutes of meeting List of internal and external customers On call list Examples of departmental relevant policies Example of requests for resources by area’ leaders Quality Indicators Quality Projects Training record for new instrument(s) – If applicable.

Leadership Surveyor.

Readiness for Leadership Surveyor Activities. Areas will be visited: Social Services Patient Relations Admission Office Financial Department Supply Chain Management Medical Records Health Information Technology Affairs Human Resources Quality Management Division Training and Development Department Inpatient Units Outpatient Clinics.

Data Management Session. Surveyor will visit units/clinics and ask about the selected Quality Indicators. the indicator(s) were selected? the selected indicators are monitored? were the corrective actions taken ? WHY HOW WHAT.

[Audio] The contents of the administrative P&P manual are communicated with and made accessible to the hospital staff. Hospital-wide policies are properly communicated to all relevant staff. Policies are communicated to staff and are always accessible. P&P that ensures the confidentiality of information related to the patient's health and how to protect it from loss or misuse..

[Audio] With your commitment and support, we will achieve quality of care and patient safety.