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Vision
To become the regional leader in improving
healthcare quality and safety.

Missio n
To promote quality and safety by supporting
healthcare facilities to continuously comply
with accreditation standards.

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Organizational Chart CBAHI Theme

Accreditat io n

Preparation Mo n i t o r i n g

Demographic Background

• Saudi Arabia, officially known as the
Kingdom of Saudi Arabia, is the second
largest Arab state (the first is Algeria) and
comprises the majority of the Arabian
Peninsula.
• According to the census held in 2012, the
population of the country is estimated to be
29,195,895 - the 43rd largest in the world.
• The middle age group of 15-64 makes up the
greatest share of the total population -
about 64.8%.

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Distribution of Healthcare Facilities Healthcare Accreditation Scope

• Large number and wide geographic distribution of healthcare
facilities in KSA.
Type of facility Total n u m b e r i n KSA
MOH- General Hospitals 217
MOH- Specialized Hospitals 35
MOH- Medical cities 3
Total M O H Hospita ls 255
Survey
Non-MOH Govt. Hospitals 42 Standards Surveyors
Private hospitals 131 Process
Total Hospitals 428
Ambulatory Care Centers 2,500
Primary Health centers 2,109
Laboratories 90
Regional & Ref. Labs 7
Total H e a lt h c a r e Facilities: 5,134
HC Operating Co. (estimate) ~200
Total e n titie s 5,334 7

Standard Development
During phase 1, standard development will be done in six streams.
CBAHI has developed two standard manuals, which will be updated
and upgraded; while four new standards programs will be developed:
S ta nd ard Program 2013 2014 2015

1 Hospitals 3rd
(Home Healthcare as a chapter in Edition

Standards 2
the manual)
Primary Healthcare 1st Edition

3 Ambulatory Care 1st Edition

4 National Laboratory Start 2nd Edition

Revision
5 Dental Care Start Effective Date
develop of 1st Edition
6 Psychiatric Start Effective Date
develop of 1st Edition

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Standard Development and Maintenance Bases of National Healthcare Standards Review

• Response to healthcare industry changes;

CBAHI S t a n d a r d D e v e l o p m e n t C o m m i tt e e • Scientific literature
(SDC) • Emerging Quality and Patient Safety Issues;
• Sentinel events reports;
• National and cultural interest;
Review P u b lic atio n D is tr ib u ti o n
• Senior authorities strategic objectives;
• Authority directives in response to the
needs and complains of the public

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Bases of National Hospital Standards Review
• Input from healthcare professionals and
subject matter experts;
Steps and duration of Standards Development
The estimated period between developing the standards and implementation will
be 18 – 24 months. Following are the process steps:
Writing of Standards 8 – 12 months
Pilot of standards for applicability 1m

• Inputs from accredited organizations First Draft 1m

including comments and satisfaction Field Review 1m

surveys. National Consensus 1m

Approval- The Chairman (Council of Health Services) 1 m

• CBAHI surveyors feedback
Posted on CBAHI's website (incorporate feedback) 6m
• CBAHI surveyor’s report quality Design the survey process (parallel to post on line) 2 m

control Pilot of the survey Process (parallel to post on line) 1 m

Implementation of the standards

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Surveyors

ISQua Accreditation

In June 2012 - 2016 Surveyors

16

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Number of Hospital Surveyors Per Sector

The Number of Surveyors
Primary Ministry of Health 10 7 4

HealthCare Hospitals
National Guard - Military 47
- Armed Forces 12
Private Sector

King Faisal Specialist 13

Hospitals
Medical Cities

Universities 19
22

Others

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Number of Hospital Surveyors Per Region Phases of Survey Activities

Najran R e g i o n , 2 Tabouk R e g i o n , 1 H ae l Region , 1 Al B a h a R e g i o n , 1
Al Q a s e e m R e g i o n , 4 Jeezan R e g i o n , 1
Aseer R e g i o n , 4
M a d d i n a h Region , 5
R i y a d h R e g i o n , 41
E a s t e r n R e g i o n , 16

Post
M a k k a h R eg i o n , 58 On Survey
site
Pre
Survey
R i y a d h Re g i o n M a k k a h R eg i o n E a s t e r n Re g i o n M a d d i n a h R eg i o n
Aseer R eg i o n Al Q a s e e m R eg i o n N a j r a n R eg i o n T a b o u k Re g i o n
H a e l Re g i o n Al B a h a R eg i o n Jeezan R eg i o n

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Phases of Survey Activities Surveyors Selection & Training Path

CVs S cre en in g

P r i m a r y S election
PRE SURVEY O N SITE POST SURVEY
Call in te rv ie w

Accreditation Re f e r e n c e Check
Selection of Opening Decision and
surveyors Conference Certification P e r s o n a l In te rv iew

T h e o r e tic a l Tr ain in g (3 days)

Survey Application Survey Activities Appeal Process
P r a c t i c u m (2 days)
O b s e r v a t i o n Visit ( c a n b e m o r e t h a n
Visit Preparation Exit Conference Survey Feedback
one)
M e n t o r e d M o c k Survey Visit
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Visit Preparation

❑ Scheduling of Surveys
❑ Survey Team Composition
❑ Survey Agenda
Survey Process ❑ Survey Logistics

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Survey Activities Survey Process Testing

E vid en ce of C o m p l i a n c e (EOC)
O p e n i n g C on fe ren ce 7 Surveyors distribution
a s:
Survey 3 C o r e T e a m / 3 d a y s visit
D o c u m e n t Review
Activities
M e dic a l Record Cl o se d Review
4 S p e c i a l ti e s / 2 days
M e dic a l Record O p e n Review
visit
I n te r v ie w ( L e a d e r sh i p & Staff)

P e r s o n ne l Files

Unit visit

Ex i t C o nfe ren ce
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Survey Pro c e ss Testing Electronic Applications for Hospitals

Ev ide nc e of C o m p l i a n c e (EOC)
E l e c tr onic
d i s t r i b ut i o n Appli c a t ion
LD Sttaffff Pers.. Interv
Spec.. Reviiew Record Record Observatiion Totall D
III nttteerrrrvviii Intterviiew Fiilles
eew Cllosed
Interviiew
e
Open
m
LD 131 NA 36 1 23 37 NA 247 o
g
MD 141 19 57 16 68 44 NA 350 r
5 a
NR 60 26 9 69 72 NA 260
p
IC 6 NA NA 3 NA 10 70 NA 89 h
i
Ph 66 NA NA NA 12 11 116 16 221 c
LB 92 NA NA 4 NA 7 33 NA 136
Q
FMS 106 NA NA NA NA 12 66 NA 184 u
e
Total 602 19 5 126 38 200 438 16 1444 s
t
i
o
n
n
a
i
r
e

H
Demographic Questionnaire Electronic Application Hospital Standards
o
s
Resources Manual
p
i
t
a
l

R
e
s
o
u
r
c
e

M
a
n
u
a
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Hospital Self Assessment

Application

Hospital Scoring Application

(Comments)
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Hospital Result and Executive
Report
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Hospital Self Assessment Electronic Application Hospital Scoring Application (Comments)

Hospital Result and Executive Report Feedback

Surveyors Competency Assessment

H os pi t a l Pe er /visit How has accreditation made an

impact on healthcare facilities
H e a l t hc a r e Spec ia lty and patient safety?
Ac cr editation Te a m
Department Surveyors Leader
E valuation
Proc ess - Content of Report
- Percentage of
Improvement
- Participation of
CBAHI activity
- Skills

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Quality Dimension - Staff competency - CBAHI score

3

2.5
3

2.5
2
2

1.5 1.5

1
1
Mock 0.
5 Mock
Real Mock
0.5 0 Real

Comparison between Mock and Real Survey Scores Training Workshops to Hospitals

100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%

Workshops for Hospitals E-Exams

• AHA Certification Center
– CHC – Certified Healthcare Constructor
– CHESP – Certified Healthcare Environmental Services Professional
– CHFM – Certified Healthcare Facility Manager
(7) M a i n Workshops (7 ) S p ec ialized W o r k s h o p s – CMRP – Certified Materials & Resource Professional
– CPHRM – Certified Professional in Healthcare Risk Management

1 M e di c a l 2 Pati ent Education • BCEN – Board of Certification for Emergency Nursing

2 N ur s i n g 1 Pain Management – CEN – Certified Emergency Nurse
4 Leadership 1 C o n s c i o u s S e da t i o n
3 Pharmacy 2 Rapid Response • CBIC – Certification Board of Infection Control & Epidemiology
4 L a bor a t or y 1 M e d i c a l Re c or ds – CIC – Certification in Infection Control
5 Facility M a n a g e m e n t 3 M e d i c a t i o n Saf ety
6 I n f e c t i o n C o nt r o l 4 Risk M a nage m e nt • CBPPS – Certification Board for Professionals in Patient Safety
– CPPS – Certified Professional in Patient Safety

• HIMSS – Healthcare Information & Management Systems Society

– CPHIMS – Certified Professional in Healthcare Information & Management Systems

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• HQCC – Healthcare Quality Certification Commission J e d d a h T e s t i ng C e n t e r s i n c e 11 F e b r u a r y 2008

– CPHQ – Certified Professional in Healthcare Quality

• JRC – Joint Commission Resources

N u m b e r of H o s t e d E x a m s = 20
– CJCP – Certified Joint Commission Professional

• NBPHE – National Board of Public Health Examiners

– CPH – Certified in Public Health N u m b e r of E x a m i n e e s = 257

• NBRC – National Board for Respiratory Care

– ACCS – Adult Critical Care Specialty
– CPFT – Entry Level Certified Pulmonary Function Technologist
– CRT – Entry Level Certified Respiratory Therapist
– NPS – Neonatal/Pediatric Specialty
– RPFT – Registered Pulmonary Function Technologist
– RRT – Registered Respiratory Therapist
– (RRT is two separate exams – WRT and CSE)
– SDS – Sleep Disorders Specialty