Healthcare Leadership and CBAHI Standards

The process by which CBAHI assesses healthcare facilities (HCFs) based on their services, size, and type of survey.

All standards-related functions within the HCF are assessed during a CBAHI survey.

CBAHI standards are chosen based on the services provided by the HCF and the on-site surveyors' judgment about which standards apply.

A concise statement that describes a standard's requirement, followed by sub-standards that provide more detailed information.

Each sub-standard is designed to act as evidence of compliance during the on-site survey, allowing for measurement and scoring.

Each standard includes an explanation to help ambulatory healthcare facilities (HCFs) understand the rationale behind it.

CBAHI welcomes feedback on its standards through an online form, allowing stakeholders to suggest improvements.

CBAHI continuously works to improve its processes, including standards development, to better meet the needs of its partners.

CBAHI standards ensure that healthcare facilities have well-qualified staff working in a well-organized environment to deliver effective and reliable services.

The governing body of a facility is responsible for defining its structure, operations, and the quality and patient safety program.

A comprehensive organizational chart helps understand the chain of command and how different departments collaborate.

The center must have a process to ensure patients are correctly identified before receiving care.

A qualified director is essential for managing the facility effectively and ensuring the smooth operation of services.

The center uses a formal, written policy to evaluate patients' health conditions.

The center follows a set system to inform doctors when tests are ready, with a stated deadline.

The center's scope of services should be tailored to the needs of the community, based on their health requirements.

The center uses a specific way to announce urgent test results, whether done in-house or at an external lab.

Leaders work collaboratively to develop a strategic plan that outlines long-term goals for the facility's success.

The doctor creates a care plan that considers the patient's individual needs and their cultural and religious beliefs.

The strategic plan is transformed into an operational plan that outlines practical steps to achieve the goals.

The center allows consultations with specialists when requested by the doctor or needed by the patient.

The leaders work together to create a budget that allocates resources and ensures the facility's financial stability.

Staff helps patients and their families understand treatment options and make informed choices about their care.

The center provides educational resources about health issues for patients and their families.

The leaders of the health center decide on and choose a set of indicators that focus on the structure, process, and outcomes of the services they provide.

Leaders establish a system to plan for and manage potential risks, ensuring the safety and well-being of patients and staff.

The center develops a formal written policy for reporting incidents or events that deviate from expected outcomes or affect patient safety.

Leaders carefully manage all contracts related to medical or operational services provided by external organizations.

The center ensures that telemedicine, remote diagnostic services, and other contracted services are secure and reliable.

The center follows clear policies and procedures to acquire essential medical equipment, medications, and consumables in accordance with national guidelines.

The center makes sure the facility is aesthetically pleasing and welcoming for patients.

The center has a system to check that patients are correctly identified, ensuring they receive the right care.

CBAHI uses a system to classify facilities based on their services, volume, complexity, and number of locations. This determines the type of survey (focused or full) conducted for each facility.

CBAHI standards are selected specifically based on the services provided by the facility and the on-site survey team's judgment regarding their relevance.

Each standard is a concise statement outlining a requirement, followed by sub-standards that provide more detailed information and act as evidence of compliance.

The National Standards for Ambulatory Care Centers include 11 chapters, each covering a specific service or function provided by ambulatory healthcare centers in Saudi Arabia.

The purpose of the standards is to ensure safety and quality patient care by providing clear requirements for each function and service.

Each chapter within the CBAHI standards provides a brief introduction explaining its relevance to patient safety and quality care.

The sub-standards within CBAHI standards are designed to be measurable and scored during the on-site survey, serving as evidence of compliance.

CBAHI encourages continuous improvement by providing an online platform for stakeholders to submit feedback on the national standards.

The healthcare facility's strategic plan outlines its long-term goals and objectives for success, developed collaboratively by leaders.

The healthcare facility's mission and vision guide the leaders in their work, ensuring quality care, patient satisfaction, and meeting community needs.

The healthcare facility must have a current organizational chart that accurately reflects its structure and reporting relationships.

The leaders of the healthcare facility work together to develop a staffing plan that meets the service needs and ensures sufficient qualified personnel are available.

This document outlines the center's mission (purpose), vision (future goal), and values (guiding principles).

The governing body approves the center's budget, which covers operational expenses like staff salaries and equipment, as well as major investments (capital budget).

The governing body appoints a qualified director responsible for managing the day-to-day operations of the center.

The governing body defines the scope of services offered by the center, and outlines its plans and programs to meet the needs of the community.

The leaders develop and implement a plan for continuous improvement in the quality and safety of patient care.

Leaders identify key indicators (measures) to track how well the center is performing, focusing on the structure (resources), process (workflow), and outcomes (results) of care.

Leaders develop a program to identify, assess, and manage potential risks to the center, patients, and staff.

Leaders ensure staff are trained and competent in specific procedures, including medical devices and equipment, to provide safe and effective care.

The healthcare center develops a comprehensive program to protect staff health and safety, addressing potential risks and ensuring a safe work environment for all employees.

Leaders ensure that patients and their families have the right to be involved in their own care and treatment, promoting patient-centered decision-making and empowering individuals in their healthcare journey.

The center develops a documented process for disclosing incidents or events affecting patient safety, that deviate from expected outcomes.

Leaders make certain that telemedicine, remote medical services, and any external service contracts are safe and trustworthy.

The center follows a consistent policy and procedure to purchase or donate medical equipment, medications, and essential supplies, complying with national laws.

Contracts for services provided by external organizations require careful oversight and management by the facility's leadership.

Leaders communicate the center's mission, values, and goals to all staff and customers.

Leaders use research-backed practices and evidence-based information to improve services.

The staffing plan outlines the number, type, and qualifications of required staff.

The staffing plan ensures there are enough qualified staff to provide safe and effective care.

The center recruits and hires staff based on the staffing plan's requirements.

Job descriptions clearly outline the knowledge, skills, and attitudes required for a role.

A written policy outlines the process for receiving, reviewing, and interviewing job candidates.

Leaders collaborate to develop a budget that allocates resources to all patient care units.

Leaders regularly review key performance indicators, surveys, and feedback to improve operations.

The governing body of a healthcare center is responsible for approving and overseeing the quality and patient safety program, including risk management. They review reports regularly and ensure corrective actions are implemented.

The center's organizational chart demonstrates the hierarchical structure, showing the relationships between the governing body, leadership, and directors. It helps everyone understand who reports to whom.

A qualified director is crucial for managing the center effectively. They ensure compliance with regulations, develop policies, and oversee resource allocation. They're responsible for creating a safe environment for everyone.

The center's scope of services should be tailored to the needs of the community they serve. Leaders and the governing body work together to define the services offered, based on community health needs.

The center has a written quality and patient safety program that outlines how they ensure safe and effective care. This program includes policies and procedures to address risks and improve quality.

The governing body receives regular reports on the center's quality and patient safety program, including risk management. They evaluate these reports to identify areas for improvement and ensure actions are taken.

The center director recommends new policies to the governing body for approval and ensures compliance with existing policies. This helps maintain consistent standards and operations.

The center director ensures the center has the resources it needs to provide planned services, including staff, equipment, and funding. They work with the governing body to manage the budget effectively.

The center director is responsible for creating a safe and functional environment for patients, visitors, and staff. This includes ensuring a clean and well-maintained facility.

The center has a written job description for the center director, and their qualifications match the requirements outlined in the description. This helps ensure they have the necessary skills and experience.

A healthcare facility that meets all licensing requirements, provides services covered by CBAHI standards, and has been operating for at least 12 months is eligible to apply for accreditation.

CBAHI accreditation is granted to healthcare facilities that meet specific standards related to patient care, safety, and organizational structure.

The facility must maintain a current organizational chart that accurately reflects its structure and reporting relationships.

A qualified director is crucial for managing the center effectively. They are responsible for compliance with regulations, policy development, and resource allocation.

This document outlines the healthcare facility's mission, values, and long-term goals.

The organizational chart clearly shows the lines of authority and reporting relationships within the healthcare facility.

This individual manages the day-to-day operations of the healthcare facility, ensuring compliance with regulations and policies.

Leaders carefully manage all contracts related to medical or operational services provided by external organizations.

This involves purchasing or donating medical equipment, medications, and essential supplies, following national guidelines.

The center develops a documented process for disclosing incidents or events affecting patient safety that deviate from expected outcomes.

A CBAHI mock survey allows facilities to review their practices and standards, receiving feedback from experienced surveyors before a real survey.

A real CBAHI survey assesses a facility's compliance with accreditation standards to determine accreditation eligibility.

The facility is required to acknowledge and sign the Service Agreement 45 days before a survey.

Evidence of completed accreditation fees needs to be provided to CBAHI before a survey.

There is a minimum of six months between two consecutive real surveys at the same facility.

A short-notice survey means the facility must receive the survey team and facilitate their work. Failure to do so may lead to accreditation denial.

The facility needs to submit a completed Survey Application Form to CBAHI before a survey.

The number of mock surveys a facility can participate in is limited based on factors like CBAHI resources and the facility's commitment to improvement.

Facilities that fail to meet accreditation standards may be excluded from the national accreditation program temporarily or permanently.

The facility must demonstrate a strong commitment to achieving compliance with accreditation standards to participate in a mock survey.

A healthcare facility can challenge a CBAHI accreditation decision if they believe it was based on inadequate information, inconsistent reports, surveyor bias, or a failure to consider relevant information.

The healthcare facility must provide documented evidence supporting their appeal, including a completed Appeal Request Form, within 15 calendar days of receiving the official survey report.

To be eligible for appeal, the facility must demonstrate one or more specific grounds, such as inaccurate information used during the accreditation process or bias among surveyors.

CBAHI will only consider appeals that have the potential to change the accreditation status, meaning they are not reviewing appeals that won't result in a different outcome.

If the appeal request is accepted, the facility's prior accreditation status is reinstated while the appeal is being reviewed.

The appeal request must clearly state the grounds for appeal, including specific reasons and evidence supporting each claim.

A healthcare facility must clearly identify any alleged procedural errors or inconsistencies between the accreditation decision and CBAHI standards.

CBAHI will review the appeal request, considering all available evidence. They may uphold the initial decision or modify or reverse it, potentially leading to a re-survey.

A mock survey allows healthcare facilities to practice for a real accreditation survey, receiving feedback from experienced surveyors before a real evaluation.

A real CBAHI survey assesses a facility's compliance with healthcare standards to determine if it meets accreditation criteria.

The facility needs to submit a completed Survey Application Form to CBAHI before a survey.

The facility must maintain a current organizational chart that accurately reflects its structure and reporting relationships.

The facility is required to acknowledge and sign the Service Agreement 45 days before a survey.

CBAHI accreditation maintenance focuses on ongoing compliance with standards, requiring activities like submitting a Corrective Action Plan (CAP) and completing a Midterm Self-Assessment.

When a facility doesn't fully comply with CBAHI standards during a survey, they must create a plan to address the issues and show improvement.

This plan should include a clear description of the corrective actions and a timeline for implementation, with assigned responsibilities.

A CAP that is submitted late or without a valid reason may result in temporary suspension of accreditation.

A self-assessment conducted by the facility 15 months after initial accreditation to review their compliance with standards.

If non-compliance with standards is found during the Midterm Self-Assessment, a Corrective Action Plan (CAP) is typically required.

Facilities must complete their Self-Assessment within three months of the 15-month mark from their accreditation date.

CBAHI reviews each facility’s action plan, often through a telephone interview, to determine if the plan and timelines are acceptable.

A mock survey allows facilities to practice for a real CBAHI accreditation survey, receiving feedback from experienced surveyors.

A real CBAHI survey assesses a facility's compliance with accreditation standards to determine their accreditation eligibility.

CBAHI requires healthcare facilities (HCFs) to submit a plan of action for areas of non-compliance identified during a midterm assessment. This plan outlines steps the HCF will take to address the concerns and achieve compliance.

If a HCF doesn't submit its midterm assessment within 60 days without a valid reason, CBAHI may temporarily suspend its accreditation. If the delay reaches 90 days, accreditation might be revoked.

A serious, unexpected event that results in death or significant harm to a patient is known as a sentinel event. HCFs must report these events to CBAHI within five working days.

Accredited HCFs must notify CBAHI about significant changes to their structure, operations, or regulations. These changes could include new services, location expansions, or a change in ownership.

CBAHI may conduct a focused survey to evaluate the impact of significant changes reported by an accredited HCF. This ensures the changes don't affect the quality of care.

If an accredited HCF fails to notify CBAHI about significant changes within 60 days without a valid reason, their accreditation may be temporarily suspended. Failure to address the delay within 90 days can lead to accreditation revocation.

A Root Cause Analysis (RCA) is a thorough investigation to determine the underlying causes of a sentinel event. It helps identify potential risks and develop a plan to prevent similar events.

CBAHI will review the RCA and the accompanying risk reduction action plan to ensure the HCF has taken steps to address the root causes and prevent similar sentinel events.

CBAHI actively seeks to improve its processes, including standard development, to better meet the needs of its partners. Continuous improvement ensures the standards remain effective.

An event caused by healthcare that leads to serious patient harm or death, not due to the patient's underlying illness.

The process of openly discussing and explaining sentinel events with patients and families, providing transparency.

A form used to report sentinel events to CBAHI, including details about the event and corrective actions taken.

A formal investigation conducted by CBAHI to identify the root causes of a sentinel event (severe, unexpected event). It aims to prevent similar events from occurring in the future.

A plan developed after a Root Cause Analysis to reduce the risks identified and prevent future sentinel events. It outlines specific actions to mitigate those risks.

A diagram that visually represents the hierarchical structure of a healthcare facility, showing the reporting relationships between different departments and individuals.

A process for identifying, assessing, and managing potential risks to the healthcare facility, patients, and staff. It aims to prevent adverse events and ensure patient safety.

CBAHI expects all healthcare facilities (HCFs) to act with honesty and sincerity throughout the accreditation process. This includes maintaining compliance even after receiving accreditation.

CBAHI may suspend or revoke a facility's accreditation if they find evidence of violations.

CBAHI may receive reports from government agencies, complaints, or media about potential violations of accreditation standards.

CBAHI may take action if a facility poses an immediate threat to patients or staff.

Failing to meet deadlines for accreditation-related tasks, like submitting corrective action plans, is a violation.

Failing to report a serious event, like a patient death or injury, without a valid reason is a violation.

Misusing the CBAHI accreditation seal or providing false information is a serious violation.

Discouraging staff or patients from reporting concerns to CBAHI is a violation.

Lack of commitment to continuous compliance with CBAHI standards is a violation.

Violating any other CBAHI policies or procedures is a violation.

CBAHI may issue a letter of 'At Risk of Suspension', suspend accreditation, or revoke accreditation if an accredited healthcare facility (HCF) violates standards.

CBAHI decides on the best course of action based on the severity of the violation, its frequency, previous accreditation history, the source of the information, and the findings of their inquiry.

A focused or full survey might be conducted to validate concerns about an HCF's compliance with CBAHI standards.

CBAHI surveys can be scheduled or unscheduled, and announced or unannounced, depending on the severity of the violation.

Surveys can cover all services or only those with serious concerns, and HCFs are usually charged for them, regardless of the outcome.

If an HCF refuses a CBAHI survey, their accreditation may be revoked.

Accreditation can be regained after suspension, but only after a 12-month prohibition period. Revocation is more serious, with an 18-month ban.

CBAHI communicates new accreditation decisions to relevant authorities and publishes them on their website.

The CBAHI Director General can waive part or all of the prohibition period in suspension or revocation cases, if a good reason exists.

CBAHI aims to ensure high-quality healthcare by enforcing standards and taking disciplinary action when necessary.

CBAHI randomly chooses accredited facilities for brief, unplanned surveys. This happens every year to ensure accredited centers maintain standards between regular surveys. No extra fees are charged.

A facility may be chosen for a validation survey, a separate visit to assess surveyor consistency, within a month after their accreditation decision report. This visit doesn't impact the facility's accreditation status and is free.

Before a CBAHI survey, the facility must sign a document agreeing to the terms and confirm they've paid the accreditation fees. This ensures they are fully prepared and committed to the process.

All information gathered during the accreditation process, except the healthcare facility's accreditation status, areas included in the survey, and standards used, is kept confidential.

This happens when CBAHI receives a request for clarification from health authorities or public health agencies.

Healthcare facilities that meet CBAHI standards are granted accreditation, which means they meet quality and patient safety requirements.

CBAHI investigates complaints against accredited healthcare facilities (HCFs) to ensure they meet accreditation standards and maintain patient safety.

Any issues of a personal nature or individual disputes should be addressed by the HCF or local health authority, not by CBAHI.

If a complaint relates to CBAHI standards, CBAHI will assess the risk based on factors like severity and likelihood, and may investigate further.

CBAHI may contact the HCF regarding a complaint or even visit the facility to verify compliance with standards.

A facility can appeal a CBAHI accreditation decision if they believe it was based on inadequate information, inconsistent reports, surveyor bias, or a failure to consider relevant information.