Hospital accreditation guide october 2016

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Hospital Accreditation Guide Oct-2016
Hospital Accreditation Process Guide
October 2016

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Introduction
The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) Hospital Accreditation
Process Guide was developed to serve as a reference for hospitals during the preparation for
accreditation surveys as well as maintenance of accreditation. This guide is to be used in conjunction
with the third edition of CBAHI Hospital Accreditation Standards manual. It has been created to help
hospitals learn about the third edition of the national hospital accreditation standards’ survey process.
In addition, the guide has been designed to provide hospitals with an authoritative resource to use in
preparation for an accreditation survey. It addresses the activities required for conduction of a hospital
survey and form the basis for a successful accreditation survey. Additionally, it provides hospitals with
a means of ongoing self-assessment and continuous improvement.
CBAHI employs a dynamic development process to fulfill our mission as a driver for continuous
improvement. Any further modifications will be communicated to the hospitals through later editions
and amendments.
About CBAHI
What is CBAHI?
CBAHI, or the Central Board for Accreditation of Healthcare Institutions is a governmental organization
that promotes the quality, value, and optimal outcomes of health. CBAHI currently accredits in the
following areas:
 Hospitals
 Primary Healthcare Centers (PHC)
 Regional labs and blood banks
Mission
To promote quality and safety by supporting healthcare facilities to continuously comply with
accreditation standards.
Vision
To be the regional leader in improving the healthcare quality and safety.
Values
 Commitment to excellence
 Team spirit
 Integrity
 Professionalism

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Registration with CBAHI
All hospitals are required to register with CBAHI. To register, the following steps are followed:
1. Access www.cbahi.gov.sa in the address bar
2. Choose "Health Care Facility" and click register.
3. You will be directed to other web page.
4. Start entering your hospital information.
After completing all required information, you are required to:
1. Type the security numbers as they appear on the left bottom of the page.
2. A message about completion of registration will be displayed specifying the Username and
Password.
3. Use the specified Username and Password to access the hospital portal.
Scope of Accreditation Surveys
The scope of the CBAHI survey includes all standards-related functions of the surveyed hospital. Each
assessment survey is tailored to the type, size, and range of services offered by the hospital. Applicable
standards from the hospital standards manual are determined by Healthcare Accreditation Department
(HAD) staff based on the scope of the services provided by the hospital undergoing a survey.
Additionally, the on-site survey team will consider the specific applicability of individual standards. The
following chapters are considered mandatory for all hospitals:
1. Leadership (LD)
2. Human Resources (HR)
3. Management of Information (MOI)
4. Medical Records (MR)
5. Quality Management and Patient Safety (QM)
6. Social Care Services (SC)
7. Patient and Family Rights (PFR)
8. Medical Staff (MS)
9. Radiology Services (RD)
10. Physiotherapy Services (PT)
11. Respiratory Care Services (RS)
12. Dietary Services (DT)
13. Nursing Care (NR)
14. Patient and Family Education (PFE)
15. Provision of Care (PC)
16. Anesthesia Care (AN)
17. Emergency Care (ER)
18. Critical Care (ICU – CCU-PICU)
19. Operating Room (OR)
20. Medication Management (MM)
21. Infection Prevention and Control (IPC)
22. Laboratory (LB)
23. Facility Management and Safety (FMS)

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Goal of Accreditation Surveys
The goal of the survey is to determine if the hospital is in compliance with CBAHI Hospital
Accreditation Standards. Also where appropriate, CBAHI surveyors provide education and consultation
to the hospital’s staff throughout the survey to help them improve their clinical and administrative
processes.
Assessment of Compliance
The CBAHI expects substantial compliance with all applicable standards. The surveyors assess
compliance with standards through a combination of data sources that include at least one of the
following:
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 and
improvement activities.
Accreditation Decision Rules
Hospitals are expected to be in continuous compliance to CBAHI standards. Full compliance is expected
upon the effective date of the standards including the effective date of any revisions thereto. The hospital
must meet all applicable standards at a satisfactory level to become accredited. Hospitals undergoing
their first survey need to demonstrate a track record of four months of compliance, while hospitals
undergoing their triennial survey need to demonstrate twelve months of compliance prior to survey (or
from the effective date of the new standards if less than 12 months). The effective date of the new
requirements in this edition will be January 2016.
All standards have one or more sub-standard(s). 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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“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.
The overall score of the hospital is automatically calculated by the software application using the
average (arithmetic mean) score of all applicable sub-standards, i.e. as the sum of all values divided by
the number of values added.
When one or more chapters, standards, and/or sub-standards of the standards manual are not applicable
in a particular hospital, they are indicated by “N/A”. Non applicable chapters and standards are not
scored and are not included in either the numerator or denominator of the overall score.
Scoring guidelines apply a similar method to sub-standards requiring a sample for assessment of
compliance. For example, if observations are positive in ≥ 80 % of cases, if interviewees provide proper
answers in ≥ 80 % or if the average of positive findings in personnel records or medical records is ≥ 80
%, the score of the sub-standard will be fully met.
The Accreditation Decision Committee shall recommend one of the following accreditation decisions:
Accredited:
Accreditation will be awarded when the surveyed hospital demonstrates an overall acceptable
compliance with all applicable standards at the time of the initial (or reaccreditation) on-site survey, and
there are no issues of concern related to the safety of patients, staff or visitors.
Accreditation will also be recommended when the healthcare facility has successfully addressed all
requirements following a conditional accreditation and does not meet any rules for other accreditation
decisions. The decision to grant accreditation is not always straightforward. In some cases though, the
Accreditation Decision Committee
may consider the need for more clarification and/or a follow up focused survey of specific
standards/areas of concern or noncompliance before a consensus decision to grant accreditation can be
reached. This will also give the hospital a period of time to come into acceptable compliance.
Scoring Guidelines:
 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.
Conditional Accreditation:
Conditional Accreditation is granted when the hospital demonstrates a tangible compliance with all
applicable standards at the time of the on-site survey but still has not met requirements for accredited
status. The hospital is required then to develop a “Standards Compliance Progress Report”, followed by
a “follow up Focused Survey”
if required before changing the accreditation status. The non-compliant standards may include essential
safety requirements and/or other standards/issues of concern related to the safety of patients, staff or
visitors.
Scoring Guidelines:
 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.
Preliminary Denial of Accreditation (PDA):

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Preliminary Denial of Accreditation (PDA) is a stage -rather than a final accreditation decision- that
precedes denial of accreditation. The aim of allowing this stage is to give some additional time for
review and/or appeal before the determination to deny accreditation. It results when there is one or more
of the following reasons to
justify denying accreditation:
 Presence of an immediate threat to the safety of patients, visitors or staff that is observed by
CBAHI surveyors 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. Falsification is defined as the fabrication of any information (given by
verbal communication, or paper/electronic document) provided to CBAHI by an applicant or
accredited healthcare facility through redrafting, additions, or deletions of a document content
without proper attribution. Plagiarism is perceived by CBAHI as the deliberate use of other
healthcare facility original (not common-knowledge) material without acknowledging its source.
In this case, the hospital is required to respond to CBAHI by sending an official clarification
letter within five working days of the communication.
 Refusal by the hospital to receive the survey team and conduct a survey. In this case, the hospital
will receive upfront denial of accreditation and will be subject for exclusion from the national
accreditation program.
Denial of Accreditation:
Results when a health care facility shows a significant noncompliance with the accreditation standards
at the time of the on-site survey. It also results if one or more of the other reasons leading to preliminary
denial of accreditation have not been resolved. When the hospital is denied accreditation, it is prohibited
from participating in the accreditation program for a period of six months, unless the Director General
of CBAHI, for good reason, waives all or a portion of the waiting period.
Scoring Guidelines:
 Overall score less than 75% and/or
 More than 25% of the essential safety requirements are not in satisfactory compliance.
Special scoring considerations
 A selected group of standards have been assigned as Essential Safety Requirements (ESR)
indicated with a circular icon that contains the letters ESR in the standards manual. All ESRs
should be in full compliance for the hospital to be accredited. If more than 25% of ESRs are
partially or not met, the hospital will get Conditional Accreditation. The hospital is required then
to develop a “Standards Compliance Progress Report”, followed by a “follow up Focused
Survey” if required before changing the accreditation status.
 Criticality of the non-compliant standard(s) -i.e. the degree of severity and immediacy of risk to
patients, visitors or staff safety- has several levels. The most serious of which is when the
surveyor notices an immediate threat to safety or quality of care. Examples include:
o Healthcare provider is entering an isolation room without proper Personal Protective
Equipment (PPE).

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o Expired catheter is being used during central line insertion or other invasive procedure.
o Bare electrical wire is hanging down without any protection.
o Incompatible blood sample is sent from the operating room while the operation is in
progress.
o A new-born is not properly identified.
When CBAHI surveyor notices an immediate threat whether linked or not linked to the standards or
the ESRs, the survey team leader will notify the hospital director and will include the findings in the
survey report. Consequently, the hospital will receive a preliminary denial of accreditation until the
issue is resolved through a Corrective Action Plan, and possibly a follow up focused survey for
verification.
Hospital Responsibilities
Hospital’s survey coordinator
When the hospital completes its survey application, the hospital should select a person to serve as
hospital’s survey coordinator to handle the logistics of the survey visit. The hospital’s survey coordinator
designated by the hospital will serve as the liaison with the Healthcare Accreditation Department (HAD)
and the survey team leader about the survey visit arrangements.
Survey Team
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.
Note: CBAHI cannot honor requests for specific surveyors for the purpose of objectivity.
Travel Arrangements
The hotel and flight reservations will be arranged by CBAHI. All flights are booked to be the night
before the survey. A list of assigned surveyors together with their flights’ details and mobile numbers
will be sent to the hospital’s survey coordinator prior to the survey. The hospital should arrange ground
transportation from the airport to the hotel. The hospital should decide how to transport the team
members each day between their hotel and the hospital and to any remote sites they will visit as part of
the survey. The survey team leader and hospital’s survey coordinator should determine where and when
the team will be picked up or meet at the hotel. Additionally, the hospital should arrange transportation
from the hotel to the airport according to the departure time of surveyors.
Staff Involvement
A well-conducted survey requires important information from a broad range of staff for the deliberations
of the survey team. All survey team members interview different staff categories about a variety of
topics to ensure that the team has access to truly representative information related to implementation
of CBAHI standards from staff.
Conflict of Interest
CBAHI works to ensure the integrity and fairness of all businesses run by the employees working in the
central office as well as the surveyors. In addition, all healthcare facilities engaged in CBAHI

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accreditation process are required to refrain from any actual or potential act or behavior that might create
a conflict of interest including:
 Proposing any fee, remuneration, gift, or gratuity of any value to CBAHI employees or surveyors
for performance of their duties or survey-related activities.
 Employing or contracting or having any financial relationship with CBAHI employees or
surveyors for the purpose of the provision of consulting or related services in any capacity, either
directly or through another party. This includes services provides in preparation for the survey,
assisting in preparation of the self-assessment, conducting mock surveys, helping in the
interpretation of the standards, and alike. All requests for consulting services utilizing one of
CBAHI associates shall be directed to CBAHI central office.
 Not declaring to CBAHI any business (including consulting) or recruiting relationship with one
or more of CBAHI surveyors either directly or through another party with whom he or she is
affiliated, at any time during the preceding three (3) years.
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.
 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. Observers must not participate in the survey activities.
CBAHI observers/mentors
One or more observers or mentors may join the CBAHI survey team as part of the surveyors’ training
process. Observers and mentors from CBAHI side will be included in the list of the surveyors sent by
hospital accreditation department prior to the survey.

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CBAHI Survey Process
Overview
This section details the various activities of a hospital survey. For better understanding of the
accreditation survey process, the survey related activities are organized into the following three sections
in this guide:
 Pre-Survey Activities
 On-Site Survey Activities
 Post-Survey Activities
Pre-Survey Activities
Enrollment for Survey
The accreditation process begins with selection of the hospitals to be surveyed. Each year, CBAHI selects the
hospitals to be enrolled in the accreditation program. CBAHI sends a letter of enrollment to the selected hospitals
to start their application process.
Application for Survey
After completion of the enrollment process, hospitals selected for the accreditation process must
complete Survey Application Form available on the CBAHI website. The form contains information
regarding the organization and its facilities and services to enable establishment of a facility profile.
The form is divided into sections with guidelines to clarify the information required for every section.
The access to the e-App is provided by CBAHI to intended hospitals. The encoded data may be saved
in stages and updated as needed. 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”
o Select type of survey and the date
Not Applicable chapters
Update of Application Information
The hospitals are made aware that planning of the surveys is done according to the scope of services
they complete in the application form. If a hospital experiences significant changes after it submits its
application, the changes must be made in the application form within five (5) business days of this
change.
Note:
The requirement of updating the application information includes updates of the main contact persons
of the hospital to ensure an ongoing communication channel with the hospital and facilitate, when

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needed, timely communication of possible updates of CBAHI accreditation policies or standards to
concerned facilities.
Application for Reaccreditation Survey
The update for a re-accreditation survey should be completed by accredited hospitals. This update for
re-survey must be completed and submitted to CBAHI twelve weeks prior to the accreditation
expiration.
Resources to Assist Hospitals
CBAHI will assign each hospital enrolled for a survey a HAD’s accreditation coordinator, who will
serve as a primary contact between the hospital and Healthcare Accreditation Department (HAD). This
individual will coordinate survey planning and will be available to the hospital to answer questions and
clarify issues related to the survey process. In order to assist hospitals for preparation of surveys,
hospitals are offered the following resources:
1. CBAHI Standards Manual
All hospitals receive a copy of the standards manual upon registration with CBAHI. This will facilitate
for the hospital to gain better understanding of the standards’ requirements as well as the accreditation
policies. The standard manual is divided into three parts:
 Part I -- Introduction and explanatory notes
 Part II -- CBAHI accreditation policies
 Part III -- Accreditation standards for hospitals
2. Accreditation Process Guide
The Accreditation Process Guide provides additional useful information to assist hospitals prepare for
a survey. Additionally, it emphasizes self-assessment and ongoing standards compliance and continuous
quality improvement. The hospitals are provided with this guide upon successful registration with
CBAHI.
3. Self-Assessment Tool (SAT)
A successful self-assessment will provide valuable information that may be used for modification and
improvement of the performance of the hospital. Upon receipt and review of the hospital’s application,
the hospital will receive electronic access to a self-assessment tool (SAT). The SAT will facilitate for
the hospital its self-assessment and follow up of the progress of implementation. The SAT is fully
explained in the accreditation maintenance section of this document as part of the post-survey activities.
4. Hospital Orientation Programs (HOP)
CBAHI provides orientation programs in different regions of the Kingdom of Saudi Arabia. It offers
hospitals an introduction to the standards and their implementation, the accreditation policies, as well
as the survey process to make the survey preparation successful. Dates and venues of the orientation
programs are communicated to the hospitals in a timely manner.
5. Mock Survey

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Some hospitals will prefer to go for a Mock Survey but this is subject to the availability of adequate
resources at CBAHI and the requirement of its operational plans. CBAHI therefore is not obliged to
respond to all incoming mock survey requests.
6. Consultative Visit
CBAHI provides consultative visits upon request. These visits are optional and depend on the
availability of CBAHI resources. The consultative visits provide in-depth explanation of one or more
of the functions or areas covered by the standards.
7. Requests for Interpretation of Accreditation Standards and Policies
CBAHI responds to requested interpretation of an existing accreditation standard or policy. Requests
must be made in writing. Information on submitting a written request is available on the CBAHI website.
The requester can fill out a “contact us” form.
Survey Team Composition
Each accreditation survey is tailored to the type, size and range of services provided by the hospital. A
survey team is organized by CBAHI to conduct the on-site survey in order to determine the hospital’s
compliance with the standards’ requirements. 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 to be surveyed, based on average daily census;
 Complexity of services offered, including surgical and anesthesia services;
 Whether the facility has special care units or off-site clinics or locations.
Based on the above information, the CBAHI decides the length of the on-site survey and the number
and the disciplines of the surveyors. In a typical full survey of a hospital, the survey team would include
seven (7) surveyors who will be at the facility for three or more days. One of these surveyors will be
assigned as a team leader. Each hospital survey team is comprised of two teams as follows:
 The Core team, composed of three surveyors: administrator, nurse, and physician.
 The Specialty Team, composed of four surveyors: Pharmacist, Infection Control specialist,
Laboratory specialist, and facility management and safety specialist.
CBAHI may require a surveyor(s) to undergo a limited on-site survey when, in the judgment of CBAHI,
such an evaluation is warranted. This limited survey focuses on particular area(s) identified by CBAHI.
Examples may include, but not limited to, a specific issue such as a complaint or a sentinel event and
evaluating changes introduced by the hospital that were not available the time of a previous survey. The
survey team and the duration of the survey are determined by CBAHI on an individual bases. The scope
of the survey is limited to addressing the related issues. There is no set agenda.
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)

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 Offsite required documents
 Any other relevant documents as decided by CBAHI
These documents provide the surveyors an opportunity to verify whether the facts in the hospital
documents are consistent with the actual practice. These facts are taken into consideration while
evaluating the corresponding CBAHI standards.
Each member of the survey team is responsible about a set of chapters and occasionally with few
standards from other chapters in relation to his/her specialty. In general, the surveyors are allocated to
chapters as follow:
 Leadership & Quality Management Surveyor
o Leadership (LD)
o Human Resources (HR)
o Management of Information (MOI)
o Medical Records (MR)
o Quality Management and Patient Safety (QM)
o Social Care Services (SC)
o Patient and Family Rights (PFR)
 Medical Surveyor
o Medical Staff (MS)
o Radiology Services (RD)
o Physiotherapy Services (PT)
o Respiratory Care Services (RS)
o Dental Care (DN)
 Nursing surveyor
o Dietary Services (DT)
o Nursing Care (NR)
o Patient and Family Education (PFE)
 Chapters evaluated jointly by medical and nursing surveyors
o Provision of Care (PC)
o Anesthesia Care (AN)
o Burn Care (BC)
o Emergency Care (ER)
o Labor and Delivery (L&D)
o Hemodialysis (HM)
o Critical Care (ICU – NICU – PICU – CCU)
o Operating Room (OR)
o Oncology and Radiotherapy (ORT)

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 Medication Management Surveyor
o Medication Management (MM)
 Infection Control surveyor
o Infection Prevention and Control (IPC)
 Laboratory surveyor
o Laboratory (LB)
 Facility Management and Safety surveyor
o Facility Management and Safety (FMS)
Survey Scheduling and Survey Agenda
The Healthcare Accreditation Department (HAD) handles all scheduling and survey agenda
arrangements for surveys in cooperation with the relevant hospital representative(s). Information
received from the hospital through the completion of the survey application form will guide the flow of
the survey. The agenda of the visit reflects the activities to take place during the survey. CBAHI
surveyors and hospital’s staff will participate in those activities. A survey agenda has been developed
for a survey that reflects a 3 days survey, which is the duration of most surveys carried out by CBAHI.
Hospitals with wider scope of services and larger bed capacity (such as tertiary care hospitals and
physically large facilities with multiple buildings and locations) may have a survey for 4 or 5 days with
a corresponding agenda of the same duration. The Healthcare Accreditation Department (HAD) will
communicate the survey agenda to the hospital at least three weeks (3) prior to the survey. For more
details on standard agenda items, please refer to Annex A. Please note that the prayer time difference in
the various regions of the Kingdom may affect the survey agenda for the business lunch time. For more
details on the hospital representatives and agenda item requirements, please refer to each activity
detailed in this guide. Scheduling and postponement of surveys are detailed in the accreditation policies
section of the standards manual.
The Self-Assessment Tool (SAT)
The self-assessment tool (SAT) has been developed to assist hospitals measure their compliance with
CBAHI standards, maintain a status of accreditation readiness, and oversee the quality and safety of
patient care. The tool is aimed at leadership working in a hospital. It is intended for use by the hospital
leadership, planners, hospital committees’ team members, and other personnel with a responsibility for
their facility’s plans, policies, and procedures. It has been designed to encourage participants to meet
together and discuss issues relating to compliance as well as non-compliance with CBAHI standards.
The tool is expected to provide hospitals with means of evaluating their plans, policies, procedures and
capabilities against current CBAHI standards. Additionally, it provides an opportunity for members of
the management team to reflect on their progress, think about areas for improvement and focus their
improvement activities on areas that are relevant to CBAHI standards. The CBAHI hopes that this tool
will enable the hospital to:
 Identify its own strengths and weaknesses
 Identify and take forward areas for improvement

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 Understand more clearly the issues that are of interest to CBAHI
 Export the data for analysis and evaluation by CBAHI
How this self-assessment tool is constructed
The SAT is designed to walk the user through all the CBAHI hospital accreditation standards. The tool
is designed to include all standards arranged per chapters that parallel the CBAHI standards manual.
The tool allows the users to keep track of the specific planning and response considerations their hospital
has addressed. This SAT contains a number of sections under each chapter:
 A standard section that contains a standard with its related sub-standards drawn from current
CBAHI standards manual.
 An activity section that contains the activity (and related activities, if applicable) that will be
used to assess this sub-standard.
 A document description section that contains the name and the description of the document
required in this sub-standard (if applicable).
 A scoring section contains scoring points which you consider when reflecting on a sub-standard
statement.
 A comments box gives you space to record the assessment findings of your compliance, highlight
strengths and weaknesses and document your improvement plan.
How frequently should the self-assessment be performed?
CBAHI accreditation policies require hospitals to conduct self-assessment during preparation for an
initial survey and at the middle of an accreditation cycle of an accredited hospital, i.e., eighteen months
after awarding accreditation.
 During preparation for an initial survey, the SAT facilitates the process of evaluation of the
hospital’s readiness for an accreditation survey in addition to helping the hospital in preparation
for the survey.
o All registered hospitals with CBAHI should do self-assessment and submit to CBAHI
within 3 months of notification of their enrollment in CBAHI visit plan per that year.
o To be eligible for CBAHI visit you should have a SAT score of 70% or more and all
ESRs are in full compliance.
o If SAT score below 70% and/or ESRs are not in full compliance, the hospital will be not
eligible for CBAHI visit temporarily till re-submission of SAT again after more 3 months
to re-evaluate their readiness and hospital visit will be decided thereafter.
 Three months before the middle of an accreditation cycle (fifteen months after the accreditation
award), each accredited hospital will be notified regarding its due time for submission of its
SAT. The hospital has three months to conduct and submit its self-assessment. The hospital is
required to send CBAHI its self-assessment together with an action plan for standards that are
not in full compliance. The CBAHI requirements related to the mid-term self-assessment are
detailed in the accreditation policies section of the standard manual.
CBAHI considers that the self-assessment is an important part of the process of hospital improvement,
and is recommended to be an ongoing activity within the hospital. Hospitals are recommended to
perform the self-assessment more frequently (e.g., quarterly) to ensure ongoing compliance, look at
progress overtime, and consequently improve the quality and safety of services provided.
How to use this tool
There are three point rating scales which ask you where the hospital is with respect to the issues
underlying the sub-standards. The hospital staff record which standards the hospital has insufficient
compliance, partial compliance or satisfactory compliance. Each sub-standard is scored from 0–2 where

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0 = insufficient compliance, 1 = partial compliance, and 2 = satisfactory compliance. Some standards
may not be applicable to your hospital. These standards should be marked as “NA” = Not Applicable.
The rating scales are expected to help you determine where to focus your improvement efforts. When
you repeat the self-assessment, the rating scales may also help you to monitor the progress you have
made over time.
The self-assessment results in the compilation of compliance reports. These reports are then used to
identify non-compliance areas as well as other opportunities for improvement. Initiating and maintaining
improvement steps are most effective when they are planned and implemented organization-wide. The
hospital leaders collaborate with relevant staff members to prioritize, plan and implement corrective
action plans that address all identified noncompliant areas. The action plan should identify all non-
compliant standards, the required interventions with defined dates, the responsible staff members, and
as applicable, monitoring measures that ensure sustainability of the implemented interventions. These
plans, when implemented and routinely monitored, contribute to the proper compliance with standards
and consequent provision of quality care.
How the hospitals can access the self-assessment tool
The SAT is freely available on the hospital portal to use. Upon registration, the hospital receives a user
name and password that are used to download the tool. This section is designed for users responsible for
self-assessment administration and completion of the online self-assessment. It provides step-by-step
instructions on how to complete a task.
The self-assessment is an internet based program that provides features for:
• Entering self-assessment findings
• Sending surveys to respondents for completion
Appearance may differ in other environments. If you require further assistance, contact the System
Administrator at had@cbahi.gov.sa
System requirements
The online self-assessment is best viewed in the latest Internet Explorer or Google Chrome. Minimal
system requirements include:
How to login and use
• visit http://www.cbahi.gov.sa/hsa
o Enter your user name number and password
• Select “Self-Assessment Tool” from the main menu.
 Fill the Self-assessment application form
 CBAHI will then approve your self-assessment application form and an email will be
sent to your facility informing you about the approved Self-assessment record
• Set your N/A chapters
• Click the transaction name link under “Transaction” column to begin your self-assessment.
 You will be required to specify an SAT surveyor for each of the specialties.
 Upon submitting the surveyor details for each of the specialty, an email will be sent to
the email you specified – informing them about their username and password - for each
of the specialty

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 The assigned surveyor can now start scoring his own domain by logging in to:
http://www.cbahi.gov.sa/hsa by using the username and password in the email.
 After each of the surveyors for each specialty has finished scoring all their scorable items,
the “FINALIZE & SUBMIT” button on the same row with the same transaction will be
enabled – this means that all scorable items have been scored and can now be submitted
to CBAHI
 Click “FINALIZE & SUBMIT” and click “OK” to submit your “Self-Assessment”
 An email will be received by CBAHI about your SAT submission.

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Off-Site Survey Activities
The hospital scheduled for the onsite survey shall send a list of the off-site required documents, listed
below, 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).
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
6.
Strategic Plan
LD.11.2, LD.11.3, LD.12.1,
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
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 plan.
FMS.4.1, FMS.4.2
27. Safety Committee Terms of Reference FMS.3.1, FMS.3.2, FMS.3.3
28.
Running construction/Renovation/Demolition works (if
applicable)
FMS.5.1

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Role of the Visit Team Leader:
Responsibilities of the team leader include but not limited to:
 Review the uploaded hospital profile.
 Review hospital website (if any) for any additional information related to the survey.
 Ensure all logistical arrangements for survey visit via communication with HAD’s accreditation
coordinator.
 Coordinating with hospital visit coordinator to finalize the hospital chapter applicability.
 Coordinating with hospital visit coordinator to finalize the survey agenda.
 Clarify the purpose of the survey visit for the health care facility leaders.
 Ensure abidance by the agenda according to the allocated activities.
 Deal with any conflicts arising between surveyors and/or with the hospital.
 Communicate with hospital visit coordinator the required medical records and personnel files
prior to review sessions.
 Coordinate and arrange a new session “if needed”.

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On-Site Survey Activities
Understanding the organization and assessing compliance is accomplished through a number of
activities specified in the survey agenda. The survey commences with an opening conference followed
by a review of documents’ session. A facility tour and departments/units’ visits are also conducted
during the on-site survey where the surveyors observe compliance with standards, interview staff, and
examine open patient medical records and additional documents. This is followed by reviewing a
selected sample of closed medical records as well as personnel files
Survey Team Arrival
 The surveyors arrive at the hospital early enough for a timely start to the survey activities as per
the survey agenda. Upon arrival, surveyors will present their CBAHI identification.
 The surveyors will meet in the designated room provided by the hospital.
Surveyor Planning Session:
 Only surveyors attend this meeting which will include the following activities:
 Discuss the aim of this meeting & the survey.
 Introduce team members.
 Discuss survey schedule.
 Review list of departments/units/areas/programs/services within the organization (scope of
services).
 Review the organization chart and map of the organization including items in the hospital
demographic date and hospital website (if any).
 Review list of discharged patients (with diagnosis).
 Prepare for the opening conference.
 Review the roles of hospital observers (if any).
 Liaise with hospital leaders to take permission for FMS chapter photos (if required).
 Review the non-applicable chapters/standards issues (if any).
 Team leader should address the following with colleagues:
o Hospital counterparts & interaction with them.
o Required documents, personnel files & medical records.
o Report significant issues or adverse events to Visit Team Leader (VTL).
o Scoring guideline.
o Keeping their laptops’ information safe.
o The importance of communication among team members.
o Time management.
o Be thorough in examination of the information provided and keep an open mind.

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o Treat all information provided by other team members with confidence during the
review.
o Timely data entry.
o Daily team meetings (time & venue).
o Strengths & areas for improvement.
o Required materials for exit conference.
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.
Participants
 From CBAHI: The entire survey team
 From Hospital: it may include
o Hospital Director
o Medical Director
o Nursing Director
o Administrative Director
o Operations Director
o Quality Improvement Director
o Surveyors' counterpart
Logistics
 A workroom that is large enough to hold all participants with data show facility.
Agenda:
 The team leader will introduce survey team members.
 The hospital leadership will introduce:
o The hospital scope of services
o Highlight the hospital improvement initiatives.
o The surveyors' counterpart to facilitate the smooth flow of the survey process.
Team leader may:
 Discuss any modification in the agenda with the hospital leaders.

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 Request a short meeting with hospital director or medical director for further clarification of the
scope of activities that were doubted.
 Clarify any confusion regarding certain applicability and scope of services with the hospital
leaders.
Review of Documents
Objectives
 To evaluate compliance with standards that should be evidenced in written documents.
Participants
 From Hospital: Staff who are familiar with the hospital’s documents
Logistics
 A workroom that accommodates the surveyors together with staff familiar with the hospital’s
documents.
Procedures
 Documents required to be reviewed include, but not limited to, policies and procedures manuals,
plans, meeting minutes, and quality indicators. The required documents for review must be
current and approved by relevant leaders.
 To facilitate the review of documents, the documents required for review during the document
review session of the on-site survey must be available at the time of the survey. The hospital is
expected to organize the required documents in binders for easy access. The hospital is required
to organize the documents required for review for each surveyor in a separate binder. The binders
should be arranged according to the list provided in this guide in Annex B. At the discretion of
the survey team, surveyors may request additional documents for review during the survey.
 It shall be noted, by the hospital, that whenever a standard or a substandard listed in the CBAHI
Standards Manual requires a policy and procedure, the hospital shall prepare the required policy
and procedure for the document review session of the on-site survey listed below, whether or
not it is specified in the list of required documents.
 When the hospital elects to present the required documents in an electronic format, the hospital
should provide a printer to be used in case a surveyor requires a hard copy of any document.
 It is very much encouraged that the staff accompanying the surveyor (i.e., the surveyor
counterpart) are oriented to the document arrangement.
Surveyors Business Lunch:
o Survey team present their findings with special emphasis to cross-linked items.
o Team members may request colleagues from other chapters to assess/check doubtful
issue/s related to their specialty.

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o Team members to present any major/significant issue encounter during the survey.
o Team members to report encountered difficulties in time management.
o Team members to clarify any activity-overlap issue.
o Team members present their next survey activities.
Surveyors End of the Day Meeting:
o Team members to present items for presentation at the debriefing session.
o Team members to present items for possible discussion during the upcoming
committees meetings.
o Team members present their next day survey activities.
Surveyors Debriefing
There should be no surprises in the survey report, because the surveyors will have already raised any
issues and the hospital is kept abreast of findings. During the survey, the surveyors maintain ongoing
communication with their counterparts from the hospital. This occurs informally as questions arise. The
surveyors present their findings to their counterparts for discussion and clarification. This allows for
direct face-to-face interaction with the surveyors, 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.
Medical Records Review (Closed and Open)
Objectives
 To gather information about compliance with the standards that require documentation in the
medical records.
 To assess the care processes provided to the patients.
Participants
 From CBAHI: The entire survey team with the exception of the FMS & LD Surveyors.
 From Hospital: At the discretion of the hospital, staff familiar with the contents of the medical
records.
Logistics
 Closed medical records are reviewed in the same workroom utilized during the documents
review session.
 Open medical records are reviewed during unit visits.
Procedures

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 Surveyors will use both closed and open medical records. While closed records determine the
past practice and the frequency of a deficient practice, open patient records reflect services
provided at the time of the survey. See Annex C for standards requiring documentation in the
medical records.
 The selection of closed medical records for review is guided by the services provided by the
hospital and any available source of information during the period prior to the survey such as the
top diagnoses and procedures and patient discharge lists. The open medical records for review
are selected from a list of active records provided by the hospital.
Selection Criteria
 Physician Closed Medical Record Review
o A sample of medical records will be requested within the look-back period for the
survey (4 months prior to the 1st cycle of accreditation and 1 year for subsequent
accreditation cycles).and it will include –but not limited to- the following:
1. Dental case with high risk procedure
2. Day surgery patient
3. Two patients transferred to other hospital
4. Two major surgery patient
5. Two emergency patients with multiple consultations
6. ICU patient
7. NICU patient
8. CCU patient
9. Two hemodialysis patients
10. Two patients with outpatient visits
11. Two physiotherapy patients referred from inpatient
12. Patients involved in major incident
13. Two Interventional radiology procedure to check both RD and sedation standards.
If interventional RD is not applicable, ask for sedation files
 The laboratory surveyor will review (20) Closed MR;
o Five with a history of therapeutic phlebotomy/apheresis
o Five with a history of blood transfusion
o Five with a history of adverse transfusion event
o Five with a history of surgical pathology studies
 Nursing Closed Medical Record Review
o A sample of medical records will be requested within the look-back period for the
survey (4 months prior to the 1st cycle of accreditation and 1 year for subsequent
accreditation cycles).and it will include –but not limited to- the following:
1. Two terminally ill patient referred to home care (if applicable) or referred to any
other service
2. Two patient transferred to other organizations
3. Two surgical patient
4. Two Sedation patient discharge directly to home after the procedure
5. Two patient refused treatment

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6. Two ICU patient
7. Two CCU patient
8. Two delivery patient
9. Two patient with nutritional risk
10. Two patient receiving therapeutic diet
Personnel Files Review
Objectives
 To evaluate standards related to human resources such as staffing, recruitment, staff
qualifications, job descriptions, orientation and education, and staff evaluation.
Participants
 From CBAHI: The entire survey team.
 From Hospital: At the discretion of the hospital, staff familiar with the contents of personnel
files.
Logistics
 Personnel files are reviewed in the same workroom utilized during the documents review
session.
Procedures
 Hospitals are required to have the requested personnel files (mentioned below as well as files
randomly selected during the survey) ready prior to the personnel files review session.
 The surveyors will provide the hospital with the randomly selected personnel files list required
to be reviewed during the session. The selection may include, but not limited to, medical and
administrative staff, new hires, nurses, technicians, and contractors. See Annex D for standards
requiring personnel files review.
 As the hospital may have more than one location for the filling of the processes under
assessment, the hospital should guide the surveyors about the different ways for their
documentation. Hospitals are encouraged to present the needed documentation in one location
to ensure comprehensiveness of personnel data and the employment history in the hospital.
These issues should be clarified prior to starting of the session.
 To facilitate the personnel files review, hospitals are required to ensure availability of the
following elements, as applicable, in the personnel files:
- Educational certificates
- Orientation and education
- License and registration
- Job Description
- Performance evaluation
- Credentialing of clinical staff
- Privileging of medical staff

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Required Personnel Files
LD & QM Surveyor
 Hospital Director
 Head of Medical Department
 Finance Director
 Quality Director
 HR Director
 Medical Records Director
 Medical Records Staff
 Clinical Coder
 Part Time Department Head
 Duty Manager
 Head of Social Services
 Social Workers
 Patient Safety Officer
 Randomly selected files:
o Contracted Worker
o New Hire
o Admin Staff
o Medical Staff
o Nursing Staff
MD Surveyor
 Medical Director
 Head of OB/GYN
 Head of Anesthesia
 Head of OR
 Head of ICU
 Head of PICU
 Head of NICU
 Head of CCU
 Head of Hemodialysis
 Head of ER
 Head of Radiology
 Head of Burn Unit
 Head of Oncology & Radiotherapy
 Head of Respiratory Therapy
 Head of Physiotherapy
 Head of Dental
o Physician who perform sedation
o Anesthesiologist
o Psychiatrist
o Hemodialysis physician
o Hemodialysis nurse
o ER physician
o ER Nurse
o ICU physician
o PICU physician

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o NICU physician
o CCU physician
o OB/GYN physician
o Burn Unit physician
o Oncology physician
o Respiratory Therapist
o Physiotherapist
o Dentist
o Dental Technician
o New hire
NR Surveyor
 Nursing Director
 Deputy nursing director
 Nurse involved in restraint
 Nursing assistant
 OR nurse manager
 ICU nurse manager
 PICU nurse manager
 NICU nurse manager
 CCU nurse manager
 OB/GYN nurse manager
 ORT nurse manager
 Hemodialysis nurse manager
 ER nurse manager
 Burn unit nurse manager
o Nurse involved in sedation
o ICU nurse
o PICU nurse
o NICU nurse
o CCU nurse
o OB/GYN nurse
o Midwifes
o Newborn nurse
o Hemodialysis nurse
o ER nurse
o Burn unit nurse
o ORT nurse
o Dietary supervisor
o Dietitian
o New hire
MM Surveyor
 Pharmacy Director
 Pharmacy Quality coordinator
 IV pharmacist
 IV technician
 TPN pharmacist
 TPN technician

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 Chemotherapy pharmacist
 Chemotherapy technician
 Drug Information pharmacist
o Nurse compounding sterile products
o Medication administration nurse
o Selected pharmacy staff
o New hire
IC Surveyor
 IC Director
 IC Practitioners
 CSSD Supervisor
 CSSD staff
o Contracted worker
o Sample From Hospital
o New hire
LB Surveyor
 Lab director
 Lab supervisor
 Lab sections heads
 Lab technicians
 Blood bank technicians
 POCT technician
o POCT staff
o Contracted worker
o New hire
FMS Surveyor
 FMS Director
 Safety Officer
 Staff Handling Nuclear Material
 Security Staff
 House Keeper
 Store Keeper
 Biomedical Engineer
 Electrical Engineer
 Maintenance Engineer
 SFDA Liaison Officer
 HVAC System Maintenance Engineer
 Water System Maintenance Engineer/Technician
 PMG System Maintenance Engineer/Technician
o Maintenance staff

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o Nursing Staff
o Contracted Worker
o New Hire

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Facility Tour and Unit Visits
Objectives
 To interview staff to evaluate their education about the standards.
 To observe the implementation of standards and ensure that they are in place, e.g., condition of
the hospital (FMS chapter) and infection control practices (IPC chapter).
 To examine open medical records in patient care areas.
 To review additional documents in respective departments/services, e.g., pharmacy, laboratory,
infection control, and facility management and safety.
 To interview patients.
Participants
 From Hospital: Staff and management involved in the patient’s care or other services in the area
visited.
Logistics
 Hospitals should assign a counterpart for each surveyor to guide the surveyor to the various
survey sites.
Procedures
 During this activity, the surveyor moves through the hospital and visits all areas of the hospital
that affect the delivery of care and services. The From Hospital are interviewed, facilities are
observed, and records are checked to ensure compliance with certain standards’ requirements.
This activity also includes a facility tour conducted for review of infection control and facility
management and safety standards.
 The surveyors determine the units, departments, and other areas to be visited during the survey
process.
 At all times during the unit visits, the surveyors gather information with minimal disruption of
the daily activities of the hospital being surveyed.
 Hospitals are expected to have their key personnel present during their respective area visit. In
addition, the surveyors may request a particular staff category, when needed.
 Specialty-specific visits and a facility tour are also included in this activity. Surveyors will
interview individuals responsible for managing the following departments / committee(s) in
addition to review of related documents in their respective departments. Areas/departments
visited by surveyors during the specialty-specific visits include:
 Laboratory (LB chapter): laboratory department.
 Pharmacy (MM chapter): pharmacy, outpatient clinics, and any other area where a
medication may exist.
 Facility Management and Safety (FMS chapter): roof, kitchen, laundry, generator, electrical
room, medical gases room, workshops, main store, reverse osmosis plant, biomedical
workshop, procedures room, central sterilization, patient care rooms, bathrooms, waste

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collection rooms, staircases, corridors, main entrances, emergency exits, isolation room,
ambulances, and nurse stations.
 Infection Control (IPC chapter): operating rooms, central sterilization, kitchen, infection
control unit, isolation rooms, staff health clinic, laundry, dental clinic, and any other areas
that may be used by patients.

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CBAHI SURVEY / MEETINGS AND COMMITTEES:
No
.
Activity Venue/ Room Set-
up
Day Duration Chairperson
1. 1st
Day Surveyor planning
session
Conference Style
Room
1st
Day 30 minutes VTL
2. Opening Conference Hospital Auditorium 1st
Day 30 minutes VTL
3. Surveyors’ Business Lunch U Shape 1st
Day 60 minutes VTL
4. 1st
Day Surveyors End of the
Day Meeting
Conference Style
Room
1st
Day 60 minutes VTL
5. 2nd
session
Conference Style
Room
2nd
Day 30 minutes VTL
6. 2nd
Day Surveyors Debriefing Hospital Auditorium 2nd
Day 30 minutes VTL
7. 2nd
Day Surveyors’ Business
Lunch
U Shape8 2nd
Day 60 minutes VTL
8. 2nd
Day Surveyors End of the
Day Meeting
Conference Style
Room
2nd
Day 60 minutes VTL
9. Planning for Quality Interview Conference Style
Room
2nd
Day 30 minutes LD
10. Quality Management Interview
(Data Management Session)
Conference Style
Room
2nd
Day 90 minutes LD
11. Planning for Pharmacy and
Therapeutics Committee
Interview
Conference Style
Room
2nd
Day 15 minutes MM
12. Pharmacy and Therapeutics
Committee Interview
Conference Style
Room
2nd
Day 45 minutes MM
13. Planning for Environmental
Safety Committee Interview
Conference Style
Room
2nd
Day 15 minutes FMS
14. Environmental Safety
Committee Interview
Conference Style
Room
2nd
Day 45 minutes FMS
15. Planning for Infection Control
Committee Interview
Conference Style
Room
2nd
Day 15 minutes IPC
16. Infection Control Committee
Interview
Conference Style
Room
2nd
Day 45 minutes IPC
17. Planning for Contracts Review Conference Style
Room
2nd
Day 15 minutes IPC or FMS
18. Contracts Review Conference Style
Room
2nd
Day 45 minutes IPC or FMS
19. 3rd
session
Conference Style
Room
3rd
Day 30 minutes VTL
20. 3rd
Day Surveyors’ Business
Lunch
U Shape 3rd
Day 60 minutes VTL
21. Planning for Executive
Leadership Interview
Conference Style
Room
3rd
Day 30 minutes VTL

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22. Executive Leadership
Interview
Conference Style
Room
3rd
Day 60 minutes VTL
23. Exit Conference Hospital Auditorium 3rd
Day 30 minutes VTL

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Executive Leadership Interview Session
Aim:
 To clarify and discuss findings encounter during the survey.
 The survey team may also explore the leadership’s support for different functions within the
organization by forwarding, to the Executive Interview Session, survey activities related to
patient and family rights, outcomes of hospital committees, and departmental improvement
projects.
Attendees:
CBAHI:
 The entire survey team.
Hospital:
1. Governing Body representative
2. Hospital Director
3. Medical Director
4. Operations Director
5. Nursing Director
6. Quality Improvement Director
7. Others may be invited based on need (VTL will ifor the hpspita; QM
Duration: 60 minutes
Schedule: To be held on the 3rd
day of the survey, before compiling the Exit Report”.
Surveyor Planning for the interview:
The survey team must hold a planning session prior to the interview to arrange the questions
and/or clarification in a logical sequence. The VTL should alert the team to:
1. Link their questions to the survey activities
2. Have clear and specific questions without any unnecessary/lengthy introduction.
3. Not to be drifted toward presenting their final findings.
4. As needed, address their question to specific member of the panel
5. Manage the time properly and use polite gestures to stop the counterparts from dilatation.
Interview Session Agenda:
1. Introduction; the VTL shall iterate the aims of the interview session and introduce the survey
team.

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2. Discussion; Survey team members who have forwarded survey activity(ies) to the session
will take turns in presenting their questions/inquiries as per the agreed upon sequence.
3. Closing; the VTL shall bring the meeting to closure by identifying the remaining activity in
the survey agenda, convening the projected time for the “Exit Conference”

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Quality and Patient Safety Committee and Data Management Session
Aim: 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:
1. Chairman of the committee
2. Quality Director
3. Medical Director
4. Nursing Director
5. Risk Manager
6. Medical Records Manager
7. Healthcare Information System Manager
8. Other specialties QI designees as per hospital 3 – 5 main services
9. Operations/Logistic representative
10. One project team (team leader and a team member)
Duration: 90 minutes (30 minutes for review of related documents + 60 minutes Interactive discussion)
Schedule: To be held on the 2nd
day of the survey. Avoid overlap with any other meetings to augment
membership attendance.
Agenda:
1. Introduction
2. Hospital presentation on the quality improvement and patient safety program to include:
a. QI program structure
b. QI program flow (how it is integrated with other hospital-wide programs)
c. Highlight on an improvement project
d. Performance indicators’ monitoring process
e. Key performance indicators’ reports submitted to the governing body
f. Risk management initiatives and data trends
g. Management of data and information processes
i. Information needs assessment process
ii. Information management structure
iii. Data management education and training
iv. Data and report flow and management
3. Open discussion between surveyor and hospital representative.
4. Other topics may be raised and discussed based on the surveyor findings during the hospital visit.
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 management process, and
improvement projects present during this session. 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.

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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)
7. Improvement activities based on information resulting from data analysis
8. Risk management program
9. Patient safety program
10. Key performance indicators’ reports submitted to the governing body
11. Incidents reporting system and data trends
12. Annual review of committee performance
13. Information needs assessment process and report
14. Information management related activities, education and reports

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Infection Prevention and Control Committee Interview
Aim:
 To have an overview about the infection prevention and control program and to ensure it is implemented
in the hospital as a multidisciplinary process.
 To discuss the role of the committee in monitoring and supporting the IPC program.
Attendees:
 CBAHI: Infection Control Surveyor.
 Hospital: 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:
2. Infection Control Director
3. Infection Control Practitioner
4. Nursing Director
5. Infectious Disease Consultant
6. Other specialties as per hospital main services
Duration: 60 minutes (15 Min. for review of related documents + 45 Min. Interactive discussion)
Schedule: To be held on the late afternoon of the 2nd
day of the survey. Avoid overlap with quality and data
session or any other meetings to augment membership attendance.
Agenda:
1. Introduction
2. Discussion about the essential role of the committee and its outcome
3. Review of the required documents
Required Documents:
The hospital is requested to have documentations present at the IC review session
1. Terms of reference of the IC committee.
3. Meeting minutes.
4. Committee annual report
5. Surveillance report

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Pharmacy and Therapeutics Committee Interview
Aim:
 To have an overview about the medication management program and to ensure it is implemented in the
hospital as a multidisciplinary process.
 To discuss the role of the committee in monitoring and supporting the medication management program.
Attendees:
 CBAHI: Medication Management Surveyor.
of reference.
According to the available specialties in the hospital, the following are the least number required to
attend:
2. Pharmacy Director
3. Nursing Director
4. Infectious Disease Consultant
5. Internal Medicine consultant
6. Surgery Consultant
7. Pediatrics Consultant
8. Ob/Gyn Consultant
9. Other specialties as per hospital main services
10. Logistic Representative
Duration: 60 minutes (15 Min. for Review of related documents + 45 Min. Interactive discussion)
Schedule: To be held on the afternoon of the 2nd
day of the survey. Avoid overlap with quality and data session
or any other meetings to augment membership attendance.
Agenda:
1. Introduction
2. Discussion about the essential role of the committee and its outcome
3. Review of the required documents
Required Documents:
The hospital is requested to have documentations present at the P&T review session
1. Terms of reference of the P&T committee.
3. Meeting minutes for the last twelve months.
4. Drug Formulary.
5. Relevant indicators (e.g. drug utilization review reports)

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Environmental Safety Committee Interview
Aim:
 To have an overview on how the hospital manages its facilities and ensures safety of its employees,
patients, and visitors at all times.
 To discuss the activities of the safety committee and the optimal utilization of its functions in improving
a safe work and care environment at the hospital.
Attendees:
 CBAHI: Facility Management and Safety (FMS) Surveyor.
of reference and according to the available specialties in the hospital, it should include at least twelve
(12) members:
1. Biomedical Engineering director
2. Housekeeping manager
3. Infection Control representative
4. Laboratory representative
5. Medical staff (E.R)
6. Non-medical maintenance director
7. Nursing director
8. Quality director
9. Radiation safety officer
10. Risk manager
11. Safety Officer
12. Security officer
Duration: 60 minutes (15 Min. for Review of related documents + 45 minutes interactive discussion)
day of the survey. Avoid overlap with other meetings to
augment membership attendance.
Agenda:
1. Introduction
2. Discussion on the committee role and its outcome
3. Discussion on the required programs
4. Discussion on risk management process related to hospital and environmental hazards
Required Documents:
The hospital is requested to have documentations related to safety committee. These may include, but not
limited to:
1. Terms of reference of the Safety Committee.
3. Agenda and meeting minutes approved by the hospital director.
4. Attendance sheet.
5. Facility safety tour reports.
6. Corrective and preventive action plans and budgeting of long-term upgrading and replacement
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7. Occurrence Variance Reports (OVRs) related to the FMS program with proper action plan to
avoid reoccurrences.
Contracted Services Interview Session
Aim:
 To have an overview on how outsourced and contracted services are planned, monitored, managed, and
improved in the hospital.
 To discuss the role of hospital stakeholders in ensuring the level of safety and quality of outsourced and
contracted services.
Attendees:
 CBAHI: Facility Management and Safety (FMS) and Infection Control Surveyors.
 Hospital: Hospital entity in charge of establishing and monitoring outsourced and contracted services
leaders, including:
1. Hospital director or his/her designee
2. Manager of hospital operations or equivalent
3. Manager of administrative and financial division or equivalent
4. Infection control representative
5. Laboratory representative
6. Manager of non-medical maintenance or equivalent
7. Manager of bio-medical engineering or equivalent
8. Manager of support services (housekeeping, laundry, and pest control – if outsourced)
9. Food services manager (if outsourced)
10. Nursing administration representative
11. Risk manager
Duration: 60 minutes (15 Min. for Review of related documents + 45 minutes interactive discussion)
day of the survey. Avoid overlap with other meetings to
augment membership attendance.
Agenda:
1. Introduction
2. Hospital presentation to address the following outline within the scope of the related standards
requirements:
h. Number of outsourced services/ contracts
i. List of contracted companies (within the hospital premises and off-site)
j. Company selection processes
k. Outsourced and contracted services performance monitoring tools and process
l. Roles and responsibilities in monitoring contracted services
m. Outsourced/contracted services’ performance monitoring reports and flow processes
n. Sample of outsourced/contracted services performance monitoring reports content
o. Sample of actions taken by hospital leadership based on contract monitoring reports
p. Risk management process related to a company with unsatisfactory compliance
q. New employees screening and immunization process for contracted workers
r. Contract renewal process

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s. Contracts to manage constructions and renovation works
t. Open discussion
Required Documents:
The hospital is requested to have documentations related to safety committee. These may include, but not
limited to:
1. Policies and procedures to ensure the quality and safety of all contracted services, including
company/service selection criteria.
2. Policies and procedures indicating how to track and monitor all contracted services
3. Sample contract
4. List of laws and regulations relevant to the scope of contracted services (e.g. medical waste
disposal laws).
5. Number of renewed contracts and contracts that were aborted.
6. New employees screening and immunization process for contracted workers.
7. Laboratory services contract (if outsourced).
8. Contracts to manage constructions and renovation works.
9. Policy to address agent or contractor repairs.
10. Evidence for reporting medical supplies adverse effects.
11. Corrective and preventive action plans and budgeting of long-term upgrading and
replacement resulted from contracted services monitoring outcome.
12. Occurrence Variance Reports (OVRs) related to the contracted services program with proper
action plan to avoid reoccurrence.

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Report Preparation session (before exit conference)
Objectives
 To prepare an initial exit report that can be shared with the hospital at the end of the on-site
survey
 To provide the hospital with the possible challenges and areas for improvement
 Provide the hospital with the list of non-compliant “ESR’s” that need immediate leadership
attention.
Participants
 From CBAHI: The entire survey team.
Logistics
 A workroom that can accommodate all the surveyors together
Procedures
 After each surveyor has completed scoring all the sub-standards under his scope of on-site
assessment, the whole team has to integrate their findings into one report that will be shared with
the hospital at the end of the on-site survey.
 The Visit Team Leader (VTL) shall be responsible to ensure integration of the findings and
recommendations for the sub-standards that are scored by more than one surveyor to ensure
accuracy and reliability of the initial report.
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
 From Hospital: Chief medical and administrative staff of the hospital. It is encouraged that
various From Hospital (especially those at supervisory levels) attend this session.
Logistics
 A workroom that is large enough to hold all participants.
Procedures
 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. Exit
report will be provided to the hospital director including the draft of major findings in ESRs and

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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.
 Members of the leadership group are encouraged to take this opportunity to comment and
provide feedback on the findings for which there are issues of interpretation, as well as express
their perceptions of the survey.

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Post Survey Activities
Accreditation Decision and plan for correcting ESR’s
Following completion of the survey, CBAHI renders an accreditation decision and delivers a report.
Types of possible accreditation decisions, follow up activities, required accreditation maintenance
activities are fully explained in part two of the standards manual. The surveyed hospital receives official
documents from CBAHI 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
CBAHI provides a survey report to the hospital for on-site visits. The first page of the report contains
items such as the dates of the survey, the names of the surveyors, the services and sites assessed, and
the scope of the survey and the standards used. The main part of the report contains the findings of the
survey team for all sub-standards that had insufficient or partial compliance.
Survey Feedback
In order to evaluate and improve its performance, CBAHI appreciates each surveyed hospital’s
feedback. This 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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Terms of Accreditation
The CBAHI accreditation is granted for a three years period. CBAHI will send a renewal letter to
accredited hospitals describing how to begin the renewal process before the accreditation expires.
Accreditation Maintenance
The maintenance of the accreditation process pertains only to hospitals already accredited. When a
hospital receives accreditation, the hospital is responsible for maintaining compliance with the CBAHI
standards for the full duration of the accreditation term. CBAHI reserves the right to review the
accreditation status where there is substantial evidence to suggest that accreditation standards are not
being met. CBAHI adopted procedures that facilitate maintenance of accreditation. These procedures
are intended to create an ongoing “maintenance of accreditation” signaling that once a hospital has
achieved accreditation, a process of continuous improvement maintains the accreditation status. The
maintenance of accreditation procedures are fully described in the accreditation policies part of the third
edition of the CBAHI standards manual. As part of accreditation maintenance procedures, the mid-term
self-assessment serves as an opportunity for a hospital to engage in a process of rigorous self-review
and improvement against CBAHI standards.
.

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Annex A
Standard Survey Agenda

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Note 1:
For the Medical and Nursing Surveyors’ Units Visit, please select the units from the following list and
specify it in the particular slot in the schedule, taking in consideration that both surveyors shall not be
visiting the same area at the same time. The sequence of units shall be determined based on the physical
layout of the organization that will allow a smooth flow and ideal utilization of the surveyor time. Please
note that this is a standard agenda so according to the hospital scope of services you may add or eliminate
some units.
Units to be visited by the medical surveyor:
1. ER;
2. OR;
3. Surgical Ward;
4. Medical Ward;
5. Pediatrics Ward;
6. ICU;
7. PICU;
8. NICU;
9. CCU;
10. OPD;
11. Physiotherapy;
12. Radiology;
13. Oncology;
14. Dental;
15. Hemodialysis;
16. L&D;
17. Burn Unit; and
18. Day Surgery.
Units to be visited by the nursing surveyor:
1. ER;
2. OR;
3. L&D;
4. Surgical Ward;
5. Medical Ward;
6. Pediatrics Ward;
7. ICU;
8. PICU;
Standard Survey Agenda

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9. NICU;
10. CCU;
11. OPD;
12. Oncology;
13. Nursery; and
14. Burn Unit.
The information verification session at the third day of the survey is a specially designed session to
allow more flexibility for the surveyor if he/she wants to verify any of the information collected over
the three survey days
Note 2:
For the FMS Surveyors’ Units Visit, please select the units from the following two lists (external and
internal locations) and specify it in the particular slot in the schedule, surveyors shall not be visiting the
same area at the same time. The sequence of units shall be determined based on the physical layout of
the organization that will allow a smooth flow and ideal utilization of the surveyor time. Please note that
this is a standard agenda so according to the hospital scope of services you may add or eliminate some
units.
Exterior locations to be visited by the FMS surveyor:
1. Construction, renovation or demolition project;
2. Medical Waste Store Room;
3. Hospital roof;
4. Elevator Service Room;
5. Hospital gates/ Entrances / Handicap access;
6. Kitchen;
7. Laundry;
8. Ambulances;
9. Holding Areas;
10. Technical Rooms;
11. Electrical Rooms;
12. Central store;
13. Biomedical Engineering Workshop;
14. Generators;
15. Chillers;
16. Central Medical Gas Station;
17. RO Plant,
18. Fire Pumps;
19. Boilers;
20. Septic Tank; and
21. Parking area/ Handicap slots.

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Interior locations to be visited by the FMS surveyor:
1. Hospital Lobby and gates;
2. Corridors/ Staircases/ Assembly Points;
3. Elevators;
4. MRI;
5. ICU/NICU/ isolation rooms;
6. Operating Rooms;
7. Emergency Room/ Triage Areas;
8. In-Patient Rooms/Bathrooms/ Special Needs Bathrooms;
9. Children Playroom;
10. Laboratory;
11. Radiology Department;
12. Nuclear Medicine;
13. Dermatology Clinic/ Laser room(s);
14. Delivery room;
15. Nursery;
16. Female wards;
17. Central sterilization service department;
18. Medical records;
19. Emergencies Command Center;
20. Nursing Stations;
21. Safety Department;
22. Sub-stores/ Pharmacy store;
23. Pantries and staff lounges;
24. Cardiology Units;
25. Dialysis Unit;
26. Dental Unit;
27. Data Center (servers room);
28. Clean utility;
29. Dirty utility; and
30. Janitorial closet.

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TYPE OF SURVEY – FACILITY NAME
DAY 1, Day of the week, DD MMM, YYYY (Morning)
Time/Activity LD MD NR IC MM LB FMS
08:00
To
08:30
Activity Surveyor Planning Session
Location
08:30
To
09:00
Activity Opening Conference
Location
09:00
To
12:00
Activity Document Review Document Review Document Review Document Review Document Review Document Review Document Review
Location
Counterpart(s)
12:00
To
13:00
Activity Surveyors' Business Lunch
Location

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DAY 1, Day of the week, DD MMM, YYYY (Afternoon)
13:00
To
14:00
Activity Unit Visit Unit Visit Unit Visit Documents Review Unit Visit Documents Review Documents Review
Location(s) (Social Services) (Inpatient
Pharmacy)
Counterparts
14:00
To
15:00
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit
Lab Leadership
Interview
Facility Tour
Location(s) (Patient Affairs) (CSSD / Endoscopy
/ Laundry)
(ER /
Ambulance)
Counterparts
15:00
To
16:00
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Location(s) (Medical Supply /
Admission
Office/ Duty
Manager Office)
(Utility Rooms /
Waste Segregation
Areas / Morgue)
(OPD /
Outpatient
Pharmacy)
Counterparts
16:00
to
17:00
Activity Data Entry / Surveyor Meeting
Location Quality meeting room

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08:00
To
08:30
Activity Surveyor Planning Session (list of “Closed Medical Records” should be provided at the end of session)
Location
08:30
To
09:00
Activity Day One Debriefing
Location
09:00
To
10:00
Activity
QM Department
Visit
Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Location(s) (NICU / PICU /
ICU/CCU)
(Pharmacy
Warehouse
/Narcotics)
Counterparts
10:00
To
11:00
Activity
QM Committee
Interview
Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Location(s) (Burn Unit / Regular
Ward/Staff Health
Clinic)
(IV Clean Room)
(TPN /)
Counterparts
11:00
To
Activity
Data Management
Session
Unit Visit Unit Visit
IC Committee
Unit Visit Unit Visit Facility Tour

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12:00 Interview
Location(s) 11:00 to 11:30
(Chemotherapy)
Counterparts:
11:30 to 12:00
Pharmacy
Admin/QI Meeting
Counterparts
12:00
To
13:00
Activity Surveyors' Business Lunch
Location

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13:00
To
14:00
Activity Unit Visit Unit Visit Unit Visit Unit Visit
P and T Committee
Interview
Unit Visit Facility Tour
Location(s) (Medical Records (OR)
Counterparts
14:00
To
15:00
Activity Unit Visit
Closed Medical Records
Review
Review
Unit Visit
Unit Visit
Review
Environmental Safety
Committee Interview
Location(s) (Inpatient Unit/ OPD/
Hospital Tour)
(ER)
(Dental / Kitchen)
(ICU / NICU)
Counterparts
15:00
To
16:00
Activity Unit Visit
Review
Review Contract Review Unit Visit
Review
Contract Review
Location(s) (Finance / Purchasing /
Academic Affairs / IT)
( Medical /Surgical)
Counterparts
16:00
To
17:00
Activity Data Entry / Surveyor Meeting
Location

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08:00
To
08:30
Activity Surveyor Planning Session (list of “Personnel Files” should be provided at the end of session)
Location
08:30
To
10:00
Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour
Location(s) HR Department (Dialysis /
Water Plants)
(L&D, OR,
Radiology,
Conscious Sedation
Area and
extemporaneous
preparations)
Counterparts
10:00
To
11:00
Activity
Personnel Files
Review
Personnel Files
Review
Personnel Files
Review
Personnel Files
Review and
Closed Medical
Records Review
Personnel Files
Review
Personnel Files
Review
Personnel Files
Review
Location
Counterparts
11:00
To
12:00
Activity Information Verification
Information Verification
Location(s)
12:00
To
13:30
Activity Business Lunch and Preparation for the Executive Leadership Interview
Location

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13:30
To
14:30
Activity Executive Leadership Interview
Location
14:30
To
16:00
Activity Data Entry and Preparation of the Exit Report
Location
16:00
To
16:30
Activity Pre-Exit Conference Meeting with Hospital Leadership (Optional Session)
Location
Counterparts
16:30
To
17:00
Activity Exit Conference (Optional session if the facility opt to have “Pre-Exit Conference”)
Location

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Annex B
Required Survey Documents

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1. Leadership & Quality Management Surveyor (Closed Session)
Required Documents Related Standards
Policy on Policy
1. Policy for Development and Maintenance of Policies LD.20.1
Laws and Regulations
2. Laws and Regulations Worksheet e.g. HR.5.5, ORT.2.1,
FMS.4.1, etc.)
LD.3.1
3. Evidence of Hospital Compliance with Relevant Laws and
Regulations
LD.3.2, LD.2.3
Hospital Leadership /Governing Body
4. governing body formation document LD.1.1
5. Governing Body Bylaws or Similar Document LD.1.2
6. Administrative Policies and Procedures Manual LD.6.3, LD.6.1
7. Policy for Delegation of Authority LD.1.3
8. Governing Body Meeting Minutes LD.1.4
9. Reports from Hospital Director to Governing Body LD.2.5
10. Evidence that the Leadership Supporting Hospital Safety LD.2.7
11. Hospital Executive Committee LD.2.8, LD.5.1, LD.5.4, LD.5.5, LD.5.6,
LD.14.2, LD.14.3, LD.24.2
12. Evidence of Hospital Director Response to the Authorities LD.2.9
13. Reports and Communications about Performance Quality LD.10.3
14. Evidence of Community Leaders Participation in Planning LD.11.2
15. Key Performance Indicator Report LD.15.8
16. Policy for Vertical and Horizontal Communication LD.18.1
17. Policy for Handling Incoming External Requests LD.18.5
18. Evidence on Response to any Incoming Requests LD.18.6
19. Contracts Oversight Process LB.1.4
Hospital Scope of Services
20. Hospital Scope of Services LD.4.1, LD.4.2, LD.4.3, LD.4.4, LD.4.5,
LD.4.6
Hospital Strategic Plan
21. Mission Statement LD.7.1, LD.7.4, LD.7.5
22. Hospital Code of Conduct LD.8.1, LD.8.2, LD.8.3, LD.8.4
23. Document Identifying Relevant Community Leaders LD.11.1
24. Hospital Strategic Plan LD.11.2, LD.11.3, LD.12.1, 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
Hospital Budgeting Process
25. Hospital Budgeting Process LD.13.2, LD.13.3, LD.13.4, LD.13.5
Hospital Staffing Plan
26. Hospital Staffing Plan LD.16.1, LD.16.2, LD.16.3, LD.16.4,
LD.16.5
Hospital Committees
27. Policy for Committee Management LD.9.1, LD.9.2, LD.9.3
28. Committee Terms of Reference (Sample) LD.9.3

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29. Terms of Reference of Patient Rights/Patient Advocacy
Committee
PFR.1.1
30. Terms of Reference of Research Committee PFR.16.3
31. Medical Records/Forms Committee MR.16.2
Leadership & Quality Management Surveyor (Units Documents)
Human Resources
1. Human Resources Manual HR.1.3
2. Laboratory/facility policy on job description and samples
of job descriptions (lab staff)
HR.3.1
3. Policy for Delegation of Authority LD.17.1, LD.17.2
4. Policy for Management of Personnel Files HR.4.1
5. Policy for Credentialing and Privileging HR.5.1
6. Departmental and Job Orientation Program HR.7.1
7. Policy for Probationary Period Evaluation HR.8.1
8. Policy for Regular Performance Evaluation HR.9.1
9. Policy for Staff Complaint HR.14.1
10. Evidence of Staff Complaints Management HR.14.3
11. Evidence for Exit Interview HR.15.4
12. General Hospital Orientation Program / Employee
Handbook
PFR.2.1
Education and Training Department
13. Training Needs Assessment HR.10.1, HR.10.2
14. Policy for Continuing Education HR.11.1
15. Evidences of support of Staff Education HR.11.2
16. Continuing Education Program HR.11.3
Quality Management Department
17. Hospital Organization Chart QM.3.4
18. Departmental Scope of Services QM.1.1
19. Quality Improvement Plan/Program QM.4.1, QM.4.2, QM.4.3, QM.4.4,
QM.2.1, QM.2.2
20. Risk Management Program QM.13.1, QM.13.2, QM.13.4, QM.13.5,
QM.13.9, QM.13.10, QM.13.11,
QM.13.13
21. Terms of Reference of Patient Safety Committee QM.16.4, QM.16.9
22. Patient Safety Culture Assessment Report and Actions QM.16.5
23. Leadership Patient Safety Rounds QM.16.6
24. Policy for Incidents Reporting QM.14.1, QM.14.2
25. Terms of Reference for Quality Improvement
Committee/Council
QM.14.4, QM.14.6
26. Policy for Sentinel Events QM.15.1, QM.15.2
27. Reports of Sentinel Events QM.15.3, QM.15.4, QM.15.5, QM.15.6
28. Data Management Education/Training Program MOI.5.1, MOI.5.2, MOI.5.3
29. Performance Improvement Projects/Reports QM.12.1, QM.12.2, QM.12.3
30. Hospital Indicators Reports MOI.4.2, QM.10.1, QM.10.2, QM.10.3

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31. Evidence on Systematic Approach of New or Modified
Processes
LD.19.1
32. List of Identified Customers and their Needs LD.19.2
33. Risk Assessment LD.19.4
34. Pilot Testing Report LD.19.5
35. New Process Indicators LD.19.6
36. Staff Training Records for New Processes LD.19.7
Patient Affairs
37. Patient and Family Rights Statement PFR.1.3, PFR.4.2, PFR.8.1, PFR.8.2,
PFR.8.3
38. Policy for Patient and Family Rights PFR.1.4, PFR.8.1, PFR.8.2, PFR.8.3,
PFR.8.4, PFR.17.5
39. General Hospital Orientation Program / Employee
Handbook
PFR.2.1
40. Policy for the Protection of Patient Belongings PFR.4.1, PFR.4.3
41. Policy for Information Confidentiality, Security and
Integrity
PFR.7.1, PFR.7.2
42. Terms of Reference of Research Committee PFR.7.2
43. Patient's Booklet/Handbook PFR.8.6
44. Policy for Patient Complaint PFR.14.1
45. Evidence of Patient Complaints Management PFR.14.3
46. Patient Satisfaction Program PFR.15.1, PFR.15.2
Social Services
47.
Policy For Refusal of Treatment PFR.11.1, PFR.11.2, PFR.11.3 PFR.11.4,
PFR.11.5
48. Policy on "No Code" PFR.12.1
49. Policy for Experimental Research PFR.16.1, PFR.16.2,
50.
Sample of patient's informed consent for participating in
research. PFR.16.4, PFR.16.5
Medical Records
51. Departmental Staffing Plan MR.1.3
52. Policy for Medical Records Documentation MR.5.1, MR.5.6
53. Policy for Medical Records Protection MR.6.3, MR.13.1, MR.13.3
54. Policy for Access to Medical Records MR.9.1
55. Medical Records Management Process MR.11.3, MR.15.1, MR.15.2
56. Policy for Medical Records Retention MR.12.1, MR.12.2
57. Policy for Release of Medical Records MR.14.1, MR.14.2, MR.14.3
58. Medical Records Review Reports MR.17.1, MR.17.2, MR.17.3, MR.17.4,
MR.17.5
IT
59. Policy for Data and Information Retention MOI.2.5, MOI.8.1, MOI.8.2, MOI.8.3
60. Policy for Information Confidentiality, Security and
Integrity
MOI.6.1, MOI.6.2, MOI.6.3, MOI.6.4,
MOI.6.9
Property Control
61. Evidence for Qualification of Medical Suppliers LD.23.2
62. Documents Reflecting Implementation of Safe
Management of Medical Supplies and Devices Process
LD.23.4, LD.23.9
63. Medical Supplies and Devices Inspection Reports LD.23.5
64. Evidence for Reporting Medical Supplies Adverse Effects LD.23.6

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65. Risk Assessment QM.24.6
Hospital-wide
66. Departmental Organization Chart LD.26.1, LD.26.2
67. Departmental Mission Statement LD.27.1, LD.28.2
68. Departmental Scope of Services LD.28. 2
69. Annual Departmental Plan LD.15.9
70. Departmental Staffing Plan LD.30.2, LD.30.3, HR.2.1, HR.2.3, HR.2.4
71. Departmental Meeting Minutes LD.18.2
72. Policy for Development and Maintenance of Policies LD.20.1, LD.20.2
73. Policies and Procedures LD.20.3, LD.20.4
74. Interdepartmental Agreement LD.27.2
75. Departmental Manual LD.29.1
76. Multidisciplinary Policies and Procedures (Sample) LD.29.2
77. Departmental Request for Resources and Staffing LD.30.1
78. Performance Improvement Projects/Reports LD.31.1, LD.31.2, LD.31.4
79. Departmental Indicators Report LD.31.3
80. Evidences of rewarding recognized staff HR.15.1
81. Information System Downtime Procedures and Forms MOI.9.1

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2. Medical Surveyor (Closed Session)
Medical Staff Bylaws
1. Medical Staff Bylaws MS.1.1, MS.1.2, MS.1.3, MS.1.4, MS.1.5,
MS.1.6
Medical Committees
2. Medical Executive Committee MS.3.1, MS.3.2, MS.3.3, MS.3.4, MS.10.3
3. Cardiopulmonary Resuscitation Committee PC.32.7, MS.18.1, MS.18.2, MS.18.4,
MS.18.5
4. RRT Committee Meeting Minutes PC.33.4
5. Credentialing and Privileging Committee MS.5.1, MS.5.2
6. Policy for Credentialing and Privileging MS.6.2, MS.6.6, MS.7.3, MS.7.4
7. Hospital Mortality and Morbidity Committee MS.12.1, MS.12.2, MS.12.3, MS.12.4,
MS.12.5, MS.12.6
8. Medical Records/Forms Committee MS.13.1, MS.13.2, MS.13.3, MS.13.4
9. Utilization Review Committee MS.14.1, MS.14.2, MS.14.3
10. Operating Room Committee MS.17.1, MS.17.2, MS.17.3, MS.17.4
11. Oncology and Radiotherapy Committee/Tumor Board ORT.5.1, ORT.5.2, ORT.5.3, ORT.5.4
12. Committee Terms of Reference (Sample) LD.9.3
Medical Staff Performance Evaluation
13. Documented Evidence of Peer Review MS.4.4
14. Policy for Unplanned Review of Medical Staff
Performance
MS.8.2
15. Credentialing and Privileging Committee MS.10.2
a.
Policies for Patient Care Hospital-wide
16. Policy for Patient Assessment and Re-assessment PC.6.1
17. Policy for Care of Psychiatric Patient PC.27.3, PC.28.1, PC.28.2
18. Policy for Cardio-pulmonary Resuscitation PC.32.1, PC.32.2
19. Cardio-pulmonary Resuscitation (CPR) Form PC.32.3
20. Policy for Rapid Response Team PC.33.1
21. Policy for Care of Vulnerable Patient PC.34.1, PC.34.2
22. Policy for Patient Transfer PC.38.9, PC.39.1, PC.39.4
23. Policy for Informed Consent PFR.10.1, PFR.10.4
24. Policy for Moderate and Deep Sedation/Analgesia AN.13.1, AN.14.1, AN.14.2
a.
Policies for Organ Donation
25. Policy for Organ Donation ICU.12.5, PC.43.1, PC.43.3, PC.43.4,
PFR.18.1, PFR.18.3, PFR.18.4, ICU.12.1,
ICU.12.2, PICU.13.2, CCU.13.1, CCU.13.2,
CCU.13.5
26. Policy for Organ Transplantation PC.43.2, PC.43.3

Hospital accreditation guide october 2016

Hospital accreditation guide october 2016

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Hospital accreditation guide october 2016