Healthcare Leadership and CBAHI Standards
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Questions and Answers

What is one of the responsibilities of leaders in a healthcare center concerning telemedicine services?

  • To establish a social media presence
  • To create marketing strategies
  • To ensure integrity and security of telemedicine (correct)
  • To manage patient satisfaction surveys

    • Patients are registered at the center regardless of their health needs.

    False

    Which of the following is a focus of the indicators selected by leaders?

  • Financial profits
  • Structure, process, and outcome of services (correct)
  • Marketing effectiveness
  • Staff performance only

    • Match the standards to their descriptions:

    <p>Patients identification. = HCF must present an approved policy to Correctly identify patients Patients investigations. = Results provided to physicians and concerned personel on time. Care plan. = Concerned practitioner must specify in details what are going to be done and what to follow up for every patient. Patient Education. = Patient and family must be taught about patient's healthcare needs</p> Signup and view all the answers

    What is the main goal of the survey process in ambulatory healthcare facilities under CBAHI standards?

    <p>To integrate standards into daily practices</p> Signup and view all the answers

    Staff members do not assist families in making informed decisions about care and treatment.

    <p>False</p> Signup and view all the answers

    The center has a process for reporting __________ test results whether on-site or outsourced.

    <p>critical</p> Signup and view all the answers

    Compliance with CBAHI standards guarantees a completely safe patient environment.

    <p>False</p> Signup and view all the answers

    Which of the following is NOT a part of the evaluation process during a survey visit?

    <p>Interviews with patients</p> Signup and view all the answers

    Match the following CBAHI standards with their descriptions:

    <p>The governing body. = Defines healthcare facility structure, role, and responsibilities in a written document. The governing body should ensure patient, staff and visitor safety by: = Approving and evaluating quality and safety program Effective staff communication and clear reporting lines. = Approved and updated organizational chart identifies the relationship between the center’s governance, leadership, and other directors with names and titles. Responsible for HCF compliance with all applicable governmental laws and regulations. = Qualified director.</p> Signup and view all the answers

    Accreditation can be viewed as an endless journey towards quality improvement.

    <p>True</p> Signup and view all the answers

    What factors influence the survey scope of a healthcare facility by the CBAHI team?

    <p>The volume and complexity of services provided</p> Signup and view all the answers

    CBAHI surveys assess all types of services provided by a healthcare facility, including those not covered by their standards.

    <p>False</p> Signup and view all the answers

    Match the following chapters with their respective focus areas:

    <p>Leadership of the Organization (LD) = Governance and administrative control Radiology Services (RD) = Imaging services for diagnostics Medication Management (MM) = Oversight of medication-related policies Dermatology &amp; Aesthetics Medicine (DA) = Skin-related healthcare and cosmetic procedures</p> Signup and view all the answers

    What is the primary purpose of the electronic feedback form on the CBAHI website?

    <p>To gather stakeholder feedback on current standards</p> Signup and view all the answers

    The standards for ambulatory healthcare centers are intended to enhance safety and quality in patient care.

    <p>True</p> Signup and view all the answers

    What is the primary objective of the survey process in ambulatory healthcare facilities?

    <p>To ensure compliance with CBAHI standards</p> Signup and view all the answers

    What is a key focus of the indicators selected by leaders in a healthcare center?

    <p>Structure, process, and outcome of services</p> Signup and view all the answers

    Leaders are responsible only for the clinical services provided at the center.

    <p>False</p> Signup and view all the answers

    Compliance with CBAHI standards ensures a completely safe patient environment.

    <p>False</p> Signup and view all the answers

    The center develops and implements a process for reporting __________ test results.

    <p>critical</p> Signup and view all the answers

    What is one of the responsibilities of leaders regarding equipment procurement?

    <p>To guide the procurement in accordance with regulations</p> Signup and view all the answers

    Patients are clinically assessed through an established assessment policy.

    <p>True</p> Signup and view all the answers

    Accreditation is considered the start of a continuous improvement journey.

    <p>True</p> Signup and view all the answers

    Which chapter focuses on the management of medications in ambulatory healthcare centers?

    <p>Medication Management (MM)</p> Signup and view all the answers

    The CBAHI survey does not assess areas that are not covered by CBAHI standards.

    <p>True</p> Signup and view all the answers

    Match the following chapters with their focus areas:

    <p>LD = Leadership of the Organization LB = Laboratory Services DA = Dermatology &amp; Aesthetics Medicine DPU = Day Procedure Unit</p> Signup and view all the answers

    What is one of the methods used by CBAHI to improve the standards?

    <p>Feedback collection through an electronic form</p> Signup and view all the answers

    The National Standards for Ambulatory Care Centers consist of ten chapters.

    <p>False</p> Signup and view all the answers

    What policy must leaders develop to ensure patient complaints and concerns are addressed?

    <p>Patient rights policy</p> Signup and view all the answers

    The center's leaders are responsible for ensuring accurate billing for provided services.

    <p>True</p> Signup and view all the answers

    What is one of the ethical standards that leaders develop to guide in patient care?

    <p>A code of conduct for employees</p> Signup and view all the answers

    Match the following leadership responsibilities with their descriptions:

    <p>Develop risk management program = Identify potential risks and implement mitigation strategies Implement incident reporting policy = Facilitate the reporting of adverse events and near misses Oversee contracts for services = Manage agreements with clinical or operational partners Ensure telemedicine security = Protect the integrity and security of remote healthcare services</p> Signup and view all the answers

    Leaders must prioritize and select indicators that focus on which of the following?

    <p>Structure, process, and outcome of services</p> Signup and view all the answers

    Leaders are responsible for ensuring an aesthetic appeal for the center.

    <p>True</p> Signup and view all the answers

    What is one requirement for contracted entities according to the leaders?

    <p>They should be based on evidence-based criteria developed by the relevant department.</p> Signup and view all the answers

    Leaders are responsible for ensuring that contract services are compliant with applicable laws and regulations.

    <p>True</p> Signup and view all the answers

    What is the role of the governing body in relation to the quality and patient safety program?

    <p>They approve and evaluate the program annually.</p> Signup and view all the answers

    The center's organizational chart does not need to be updated regularly.

    <p>False</p> Signup and view all the answers

    Match the following roles of the center director with their corresponding responsibilities:

    <ol> <li>Ensures compliance = A. Legal adherence</li> <li>Communicates organizational chart = B. Staff awareness</li> <li>Develops mission statement = C. Strategic leadership</li> <li>Oversees resources availability = D. Budget management</li> </ol> Signup and view all the answers

    When must the governing body evaluate reports on the quality and patient safety program?

    <p>Quarterly</p> Signup and view all the answers

    All staff must be unaware of the organizational chart.

    <p>False</p> Signup and view all the answers

    The director ensures the availability of __________ resources for planned services.

    <p>adequate and proper</p> Signup and view all the answers

    Which of the following is NOT a responsibility of the center director?

    <p>Implementing all corrective actions</p> Signup and view all the answers

    What is the primary focus of the budget process in a healthcare center?

    <p>To allocate resources based on patient care needs and complexity</p> Signup and view all the answers

    Leaders are responsible for communicating the mission, vision, and values only to the staff.

    <p>False</p> Signup and view all the answers

    Match the following policies to their related descriptions:

    <p>Staffing Plan = Defines staff requirements to meet safe patient care Recruitment Policy = Outlines the process for evaluating job applicants Job Descriptions = Specifies roles and responsibilities for each position Performance Review = Regular evaluation of staff performance based on credentials</p> Signup and view all the answers

    Which responsibility does the staffing plan NOT include?

    <p>Setting the facility operating hours</p> Signup and view all the answers

    Evidence-based and best practice information is essential for developing and improving the center's services.

    <p>True</p> Signup and view all the answers

    All categories of staff must have clearly written __________.

    <p>job descriptions</p> Signup and view all the answers

    What is a key element in the performance review meetings held by leaders?

    <p>Review key performance indicators and feedback</p> Signup and view all the answers

    Which of the following is a responsibility of the governing body according to the standards?

    <p>Approving the quality and patient safety program</p> Signup and view all the answers

    The organizational chart must be current and clearly define the center's management structure.

    <p>True</p> Signup and view all the answers

    Leaders must ensure all medical staff members have current delineated __________.

    <p>clinical privileges</p> Signup and view all the answers

    What is one of the key responsibilities of leaders in a healthcare center?

    <p>Developing an operational budget</p> Signup and view all the answers

    All staff must be trained in cardiopulmonary resuscitation as per the standards.

    <p>True</p> Signup and view all the answers

    Which of the following is NOT a requirement for a healthcare facility to be eligible for CBAHI accreditation?

    <p>Maintaining a social media presence</p> Signup and view all the answers

    Healthcare facilities must send back an application form to become eligible for a CBAHI survey visit.

    <p>True</p> Signup and view all the answers

    What does HCF stand for in the context of healthcare accreditation?

    <p>Healthcare Facility</p> Signup and view all the answers

    Match the following requirements with their descriptions for healthcare facility accreditation:

    <p>Valid License = Indicates legal permission to operate Organized Medical Staff = Necessary for patient care services Operational for 12 Months = Assures establishment of facility National Standards Compliance = Ensures adherence to CBAHI guidelines</p> Signup and view all the answers

    Which of the following authorities may set additional licensing requirements for healthcare facilities?

    <p>Saudi Commission for Health Specialties</p> Signup and view all the answers

    All healthcare facilities in Saudi Arabia automatically qualify for CBAHI accreditation.

    <p>False</p> Signup and view all the answers

    What is a main activity that healthcare facilities must complete to achieve CBAHI accreditation?

    <p>Conduct a self-assessment using the Self-Assessment Tool</p> Signup and view all the answers

    CBAHI provides ongoing orientation programs that any healthcare facility can attend regardless of accreditation status.

    <p>False</p> Signup and view all the answers

    Match the following components with their descriptions:

    <p>National Standards = Guidelines for accreditation Orientation Programs = Training sessions for HCF representatives Self-Assessment Tool = Internal evaluation tool for compliance Accreditation Guide = Resource for survey preparation</p> Signup and view all the answers

    How does CBAHI select healthcare facilities for its accreditation program each year?

    <p>First-come, first-served</p> Signup and view all the answers

    CBAHI requires all healthcare facilities to complete the Self-Assessment Tool before the accreditation survey.

    <p>False</p> Signup and view all the answers

    What role does the self-assessment play in the accreditation process?

    <p>It helps determine the facility's preparedness for a survey</p> Signup and view all the answers

    What is a primary purpose of the Mock Survey Visit offered by CBAHI?

    <p>To clarify accreditation policies and standards</p> Signup and view all the answers

    A Mock Survey Visit is mandatory for all healthcare facilities seeking accreditation.

    <p>False</p> Signup and view all the answers

    Match the following requirements with their corresponding actions:

    <p>Submit Survey Application Form = Initiate the survey process Acknowledge Service Agreement = Return signed copy to CBAHI Pay accreditation fees = Ensure financial obligations are met Notify HCF of survey date = Inform about the upcoming survey</p> Signup and view all the answers

    What will happen if the facility leadership fails to accommodate the survey team during a short-notice survey?

    <p>The facility will be denied accreditation</p> Signup and view all the answers

    Healthcare facilities may be temporarily or permanently excluded from the national accreditation program if they cannot achieve accreditation.

    <p>True</p> Signup and view all the answers

    How long does it typically take for a healthcare facility to achieve accreditation after registration?

    <p>6 to 18 months</p> Signup and view all the answers

    What overall score must a healthcare facility achieve for accreditation?

    <p>75% or above</p> Signup and view all the answers

    Healthcare facilities are denied accreditation if they successfully resolve all post-survey requirements.

    <p>False</p> Signup and view all the answers

    Which of the following is NOT a reason for the denial of accreditation?

    <p>Accidental submission of incomplete documents</p> Signup and view all the answers

    Plagiarism in the accreditation process is considered a severe issue.

    <p>True</p> Signup and view all the answers

    Match the following reasons for denial of accreditation with their descriptions:

    <p>Immediate threat = A situation that endangers safety Fraud = Deliberate deception in information Noncompliance = Failure to meet required standards Focused survey = Failure to meet specific accreditation criteria</p> Signup and view all the answers

    What is one requirement for all applicable standards for accreditation?

    <p>At least 50% compliance</p> Signup and view all the answers

    What is the maximum number of calendar days allowed to submit an appeal against an accreditation decision?

    <p>15 days</p> Signup and view all the answers

    CBAHI will consider appeals that do not result in a change of accreditation status.

    <p>False</p> Signup and view all the answers

    Match the accreditation appeal outcomes with their implications:

    <p>Adverse decision upheld = No change in accreditation status Appeal is upheld = Denial of accreditation is reversed Full re-survey decided = New evaluation of the HCF’s compliance</p> Signup and view all the answers

    Which of the following is NOT a valid ground for an appeal?

    <p>Consistent information not presented to the survey team</p> Signup and view all the answers

    Appeals must be sent via electronic mail to be considered by CBAHI.

    <p>False</p> Signup and view all the answers

    What happens to the healthcare facility’s status upon initial acceptance of the appeal request?

    <p>Prior accreditation status is restored.</p> Signup and view all the answers

    What is the time frame for reporting a sentinel event to CBAHI after internal notification?

    <p>Five working days</p> Signup and view all the answers

    A healthcare facility can delay notifying CBAHI about significant changes for up to ninety days without justification before facing penalties.

    <p>True</p> Signup and view all the answers

    What must be submitted to CBAHI within thirty working days after reporting a sentinel event?

    <p>Root Cause Analysis with a risk reduction action plan</p> Signup and view all the answers

    The HCF must notify CBAHI in writing about any significant changes no later than __________ days after their occurrence.

    <p>thirty</p> Signup and view all the answers

    Match the following actions with their corresponding time frames:

    <p>Report a sentinel event = 5 working days Submit a Root Cause Analysis = 30 working days Notify significant changes = 30 days Submit mid-cycle survey plan = 60 days</p> Signup and view all the answers

    What may happen if an HCF delays submission of the midterm assessment for over sixty days without justification?

    <p>Temporary suspension of accreditation</p> Signup and view all the answers

    CBAHI requires accredited healthcare facilities to report any changes to governance or ownership only if they deem it significant.

    <p>False</p> Signup and view all the answers

    Failure to provide an acceptable justification for a delay exceeding __________ days in notifying changes could result in revocation of accreditation.

    <p>ninety</p> Signup and view all the answers

    Which of the following is included in the significant changes that need to be reported to CBAHI?

    <p>A significant change in volume of services</p> Signup and view all the answers

    What is the purpose of a Corrective Action Plan (CAP) when accreditation is awarded to a healthcare facility?

    <p>To address non-compliant standards identified during the evaluation</p> Signup and view all the answers

    A midterm self-assessment must be completed 12 months after the accreditation decision.

    <p>False</p> Signup and view all the answers

    What is the maximum number of days within which a Corrective Action Plan (CAP) must be submitted for review to CBAHI after accreditation?

    <p>120 days</p> Signup and view all the answers

    If a healthcare facility delays the submission of the CAP for more than _____ days without justification, it may face temporary suspension of its accreditation certificate.

    <p>30</p> Signup and view all the answers

    Match the following CBAHI requirements with their purpose:

    <p>Corrective Action Plan = Addressing non-compliant standards Midterm Self-Assessment = Self-evaluation of standards compliance Submission of evidence = Demonstrating compliance to CBAHI Review by CBAHI = Accepting or denying CAP based on evidence</p> Signup and view all the answers

    What is the main focus of the midterm self-assessment for accredited healthcare facilities?

    <p>To identify areas of non-compliance with standards</p> Signup and view all the answers

    Completion of the midterm assessment allows a healthcare facility to create a plan to correct deficient areas before the next on-site survey.

    <p>True</p> Signup and view all the answers

    The maximum time allowed for a healthcare facility to complete a midterm self-assessment is _____ months.

    <p>3</p> Signup and view all the answers

    What happens if a healthcare facility submits a Corrective Action Plan (CAP) after the given due date without justification?

    <p>It faces a temporary suspension of accreditation</p> Signup and view all the answers

    Which of the following is NOT a sentinel event that must be reported to CBAHI?

    <p>Low patient satisfaction score</p> Signup and view all the answers

    CBAHI has a zero tolerance policy for disciplinary actions against staff who report sentinel events.

    <p>True</p> Signup and view all the answers

    What must healthcare facilities accredited by CBAHI report within five working days following the internal notification of a sentinel event?

    <p>Sentinel Event Reporting Form (SERF)</p> Signup and view all the answers

    Match the following sentinel events with their descriptions:

    <p>Unexpected death = Death that was not anticipated due to the patient's underlying condition Retained instrument or sponge = Accidental leaving of medical equipment in a patient after surgery Infant or child abduction = Unauthorized removal of a child from a healthcare facility Unexpected loss of a limb or function = Loss occurring unexpectedly due to medical intervention</p> Signup and view all the answers

    Which of the following describes the primary intent of reporting sentinel events?

    <p>Identify deficiencies in healthcare systems</p> Signup and view all the answers

    Healthcare facilities not accredited by CBAHI are required to report sentinel events.

    <p>False</p> Signup and view all the answers

    What is one consequence for a healthcare facility if disciplinary action is taken against a staff member for reporting a sentinel event?

    <p>Negative impact on accreditation status</p> Signup and view all the answers

    What is the primary objective of a Root Cause Analysis (RCA)?

    <p>To identify the root causes of adverse events</p> Signup and view all the answers

    CBAHI will allow a healthcare facility to maintain its accreditation only if it demonstrates commitment to addressing root causes.

    <p>True</p> Signup and view all the answers

    Match the following actions with their descriptions related to sentinel events:

    <p>Root Cause Analysis = Identifies underlying reasons for adverse events Progress Report = Shows implementation progress of the risk reduction plan Focused Survey = Evaluates adherence to corrective actions Accreditation = Maintained through commitment to correction processes</p> Signup and view all the answers

    What determines the outcome of a reported sentinel event?

    <p>The level of commitment the HCF demonstrates</p> Signup and view all the answers

    CBAHI can decide on a healthcare facility's eligibility for accreditation without reviewing sentinel event reports.

    <p>False</p> Signup and view all the answers

    The submission of a progress report shows the progress made in implementing the __________ plan.

    <p>risk reduction</p> Signup and view all the answers

    What is included in the risk reduction plan following a sentinel event?

    <p>Review and redesign of processes</p> Signup and view all the answers

    What action may be taken if a healthcare facility does not allow CBAHI surveyors to conduct a survey?

    <p>Revocation of accreditation</p> Signup and view all the answers

    Accreditation suspension can only be lifted after a period of six months.

    <p>False</p> Signup and view all the answers

    What is the minimum duration of prohibition for revocation of accreditation?

    <p>eighteen months</p> Signup and view all the answers

    CBAHI conducts surveys that can be either unscheduled or __________.

    <p>unannounced</p> Signup and view all the answers

    Match the actions CBAHI can take with their corresponding descriptions:

    <p>At Risk of Suspension = A warning indicating potential suspension Suspension of Accreditation = A temporary halt in accreditation status Revocation of Accreditation = Permanent removal from accreditation participation Focused Survey = Assessment aimed at specific concerns</p> Signup and view all the answers

    What factors does CBAHI consider when determining the level of response to a violation?

    <p>Frequency of the violation and previous history</p> Signup and view all the answers

    An accredited healthcare facility must undergo a survey at least once every six months.

    <p>False</p> Signup and view all the answers

    How much notice is given before an unscheduled CBAHI survey?

    <p>48 hours</p> Signup and view all the answers

    If a violation is identified, CBAHI can issue a letter of __________ to the healthcare facility.

    <p>At Risk of Suspension of Accreditation</p> Signup and view all the answers

    What happens to the accreditation status of a facility if it rectifies the causative violation after a suspension?

    <p>Accreditation can only be regained after the prohibition period</p> Signup and view all the answers

    What is a key requirement for healthcare facilities (HCF) to maintain their accreditation according to CBAHI?

    <p>They must ensure truthfulness in all dealings.</p> Signup and view all the answers

    Accredited healthcare facilities can relax their compliance with standards after receiving accreditation.

    <p>False</p> Signup and view all the answers

    CBAHI takes action if it becomes aware of an immediate threat to the __________ of patients or staff in an accredited HCF.

    <p>safety</p> Signup and view all the answers

    Match the following types of violations to their descriptions:

    <p>Immediate threat = Present danger to patients or staff Failure to report sentinel event = Not reporting an incident without justification Discouraging communication = Taking action against whistleblower concerns Lack of continuous compliance = Not adhering to standards post-accreditation</p> Signup and view all the answers

    Which of the following is a consequence of not adhering to specified timeframes for accreditation?

    <p>Possible suspension or revocation of accreditation</p> Signup and view all the answers

    CBAHI may act upon information received from the media regarding potential accreditation violations.

    <p>True</p> Signup and view all the answers

    Match the following actions to their potential consequences:

    <p>Discouraging staff communication = Loss of trust and potential revocation Failure to submit a corrective action plan = Suspension of accreditation Deliberate misrepresentation = Immediate threat to accreditation Ignoring sentinel event reporting = Serious violation of standards</p> Signup and view all the answers

    What is the purpose of random surveys conducted by CBAHI?

    <p>To evaluate consistency and quality of the accreditation program</p> Signup and view all the answers

    A healthcare facility will incur charges when a random survey is conducted.

    <p>False</p> Signup and view all the answers

    Random surveys are unannounced and may occur between __________ months after an accreditation survey.

    <p>9 to 30</p> Signup and view all the answers

    Match the following concepts related to CBAHI surveys with their descriptions:

    <p>Random Surveys = Unannounced evaluations of accredited healthcare facilities Validation Surveys = Assessing inter-rater reliability among surveyors Accreditation Decision Report = Outcome of the main accreditation survey CBAHI Standards = Requirements that healthcare facilities must meet for accreditation</p> Signup and view all the answers

    What type of information is CBAHI required to keep confidential during the accreditation process?

    <p>Mock and final accreditation survey reports</p> Signup and view all the answers

    CBAHI makes the results of investigations involving falsified information available to the public.

    <p>False</p> Signup and view all the answers

    Match the following types of information with their classification regarding public release:

    <p>Accreditation status = Publicly available Survey report's contents = Confidential Survey areas = Publicly available Post-survey requirements = Confidential</p> Signup and view all the answers

    What is the primary function of CBAHI regarding complaints against accredited healthcare facilities?

    <p>To assess compliance with accreditation standards.</p> Signup and view all the answers

    CBAHI can follow up on complaints related to healthcare facilities that are not accredited.

    <p>False</p> Signup and view all the answers

    Match the responses CBAHI may take regarding a complaint with their descriptions:

    <p>Write to the HCF = Request records related to the complaint Conduct a visit = Verify compliance with standards</p> Signup and view all the answers

    What happens if a complaint does not relate to CBAHI standards?

    <p>The complainant is advised to contact the HCF or regional health authority.</p> Signup and view all the answers

    CBAHI will disclose information related to complainants to the public if requested.

    <p>False</p> Signup and view all the answers

    What kind of information will a complainant receive from CBAHI regarding the course of action taken?

    <p>the actions CBAHI took regarding the complaint.</p> Signup and view all the answers

    Study Notes

    National Ambulatory Care Standards

    • The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) is the official agency authorized to grant healthcare accreditation to all governmental and private healthcare facilities operating in Saudi Arabia.
    • CBAHI's mission is to support all healthcare facilities, through accreditation, to continuously comply with quality and patient safety standards.
    • Its vision is to be the leading healthcare accreditation agency in the region.
    • CBAHI has several accreditation programs, including Ambulatory Healthcare, Primary Healthcare, Hospital Healthcare, and Clinical Laboratories and Blood Banks, with those related to other areas under development.
    • Healthcare accreditation is a rigorous, independent assessment process by an external accreditation body of systems, processes, and performance of healthcare facilities to ensure compliance with predetermined national standards.
    • Accreditation benefits include enhancing organizational structure and management, improving patient safety, and increasing public confidence in service quality and safety.
    • Accreditation enhances efficiency and lean practices, leading to reduced waste and optimized resource use.
    • It boosts competitiveness via increased public confidence and higher market share, and is increasingly linked to reimbursement.
    • It supports continuous quality improvement initiatives in healthcare facilities.

    Scope of Accreditation Surveys

    • CBAHI surveys are comprehensive evaluations of healthcare facilities focusing on standards related to governance, leadership, patient care, processes, medication management, infection control, facility safety, and quality assurance.
    • Survey methods involve document reviews, staff and patient interviews, and facility tours.
    • The range of services provided by the healthcare center may influence the applicability of particular standards.
    • CBAHI standards cover structure, process, and outcome aspects of healthcare facilities.
    • Structure standards include facility design, manpower, and equipment availability.
    • Process standards address clinical and administrative activities.
    • Outcome standards are focused on the benefits and effectiveness of interventions.

    Standards Development Process

    • Standards are statements of excellence that outline essential functions and expectations for providing safe and quality healthcare.
    • Standards are developed by experts in the field and reflect currently accepted standards of care.
    • Standards development involves multiple stages, including a public review period and approval by the CBAHI board to ensure alignment with stakeholders' needs.
    • Standards are available on the CBAHI website's Field Review page and are open to public comments.
    • Standards development is an ongoing process, always open to update and revision to meet best practices.

    Accreditation Survey Process

    • CBAHI surveyors utilize a variety of methods (e.g., interviews, observations, document reviews, and patient interviews) during an on-site visit to evaluate if a facility meets the applicable standards related to structure, process, and outcome.
    • HCFs are expected to conduct a comprehensive self-assessment prior to the survey visit, to identify any areas of potential non-compliance with standards.
    • Survey processes are tailored to specific facility needs and are conducted by external surveyors.
    • CBAHI standards address a range of systems and functions, including governance, leadership, patient care processes, medication management, infection control, facility environment, equipment, and quality assurance aspects.

    Accreditation Policies

    • All licensed healthcare facilities in Saudi Arabia are eligible for CBAHI accreditation.
    • Eligibility criteria include a valid license from MOH and possible additional licenses from other relevant authorities, confirmed functioning for at least 12 months prior to the survey.
    • Registration is the first step toward accreditation, accomplished through a registration form on CBAHI's portal.
    • The accreditation process includes orientation for facilities - facilities must attend at least one orientation session.
    • A Mock Survey, optional to aid in understanding, can be arranged with prior notice.
    • Dates and logistics for accreditation surveys are communicated to facilities prior to a visit.
    • The Service Agreement must be signed by the facility at least 45 days before the survey.
    • HCFs can appeal CBAHI decisions/outcomes (excluding those related to submitting post-survey requirements) within 15 days (provided there is a valid reason/evidence to justify the appeal).

    Accreditation Decision Rules

    • Accreditation is granted when the facility consistently demonstrates satisfactory compliance (minimum 75% overall score), adheres to core standards (at least 50% compliance rate), and addresses any concerns raised during the survey.
    • Denial of accreditation can result from serious non-compliance (e.g., clear safety violations, adverse events, significant non-compliance, failure to address issues/concerns), and appeals must be submitted within 30 days of receiving the decision.

    Accreditation Maintenance

    • HCFs must maintain ongoing compliance (through activities like Corrective Action Plans (CAPs) and periodic or mid-cycle self-assessments, with ongoing monitoring and periodic surveys if required) - delays in submitting corrective action plans can lead to temporary or permanent suspension of accreditation.

    Sentinel Events

    • Serious patient adverse events (e.g., unexpected deaths, wrong procedure/site/patient, retained foreign objects, severe medication errors, etc.) are immediately reported to CBAHI within five days, and Root Cause Analysis (RCA) completed within 30 days, as required by policy.

    Glossary

    • The document provides glossary definitions for terms related to CBAHI and healthcare, found on pages approximately 106–123.
    • A list of abbreviations is available on pages approximately 123–124.

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    Related Documents

    National Ambulatory Care Standards PDF
    Ambulatory Health Care Standards Saudi PDF

    Description

    This quiz explores the responsibilities of leaders in healthcare centers, particularly concerning telemedicine services and compliance with CBAHI standards. Participants will assess their understanding of policies, procedures, and the standard requirements that ensure efficient patient care and safety.

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