FAQs

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 the Kingdom of Saudi Arabia. 
Originally emerged from the Saudi Health Council as a non-profit organization, CBAHI is primarily responsible for setting the quality and safety standards to ensure a better and safer healthcare.

Its initial official inauguration was due after the Ministerial Decree number 144187/11 on October 2005, which called for the formation of the Central Board for Accreditation of Healthcare Institutions that shall be responsible for the initiation of a national voluntary healthcare accreditation program. In 1434/2013, the Council of Ministers mandated CBAHI accreditation for all healthcare facilities in the Kingdom, and gave it its current name. 

Hospitals and other healthcare facilities can register with CBAHI by completing the Healthcare Facility Registration Form located on CBAHI’s portal. Registration is a quick, yet an important step that provides the Healthcare Accreditation Department at CBAHI with the basic information about the registering facility. 
A system generated auto-reply with a code number is provided to the registering facility upon successful registration. The code number is used for all future communication with CBAHI. 

Accreditation makes a lot of difference, not only to patient safety and quality of care, but in several other ways. Following is a list of possible benefits of accreditation to a healthcare facility:
• Accreditation provides a framework for the organizational structure and management: almost all accreditation standards focus on the governance and leadership structures and functions within a healthcare facility and the appropriate management of its business and day to day activities.
• It helps improve patient safety and minimize the risk of near misses, adverse outcomes, and medical errors: ensuring patient safety through risk management and risk reduction is at the heart of all accreditation standards and is the ultimate goal of the self-assessment and the survey activities.
• It enhances community confidence in the quality and safety of care provided: when a healthcare facility achieves accreditation, the message is clear; its leaders are committed to providing a nationally accepted standard of care in health services delivery.
• Surveyed healthcare facilities have found that seeing their own operation through the eyes of experienced surveyors provided them with a useful, more objective assessment of their internal administrative and clinical processes with effective proposals for further improving their processes and services to the community.
• Accreditation, in the long run, help increase the efficiency and enhances the lean practices, which translate into decreasing waste and more optimal results with less consumption of resources.
• Achieving accreditation helps improve the competitiveness of a healthcare facility: rising public confidence in an accredited facility will eventually encourage more patients to seek care and treatments in that facility which will positively impact its competitiveness in the healthcare sector and increase its market share.
• Achieving accreditation will satisfy the regulations of the Ministry of Health, being the legislative health authority, which is now considering linking the national accreditation by CBAHI with the licensing of the private healthcare
facilities. 
• Registration with CBAHI and enrollment in its national accreditation program is accepted by the Ministry of Health -at this stage- as a satisfactory evidence for the purpose of license renewal. Eventually however, all healthcare facilities operating in Saudi Arabia are required to achieve accreditation by CBAHI.
• Reimbursement by insurers and other third parties is a growing tendency, nationally and internationally, to link achieve accreditation..
• Accreditation provides a robust tool for the continuous quality improvement efforts in the healthcare facilities: striving relentlessly to comply with accreditation standards helps the leadership of the facility to ensure the sustainability of the quality improvement projects and initiatives.
• Accreditation provides for a great learning and educational opportunity: through staff education on the best practices and by adding emphasis on the importance of patient education and patient rights.

CBAHI standards set expectations for hospital performance that are reasonable, attainable, measurable and therefore, survey-able. Standards were built to serve as the basis of an objective evaluation process that can help health care facilities measure, assess and improve performance.

Accreditation itself is not the end, it should rather be viewed as the first step in an endless journey towards quality improvement and excellence. 

A standard describes a healthcare facility’s acceptable performance level. It is usually set at a minimal level designed to protect public health and safety. Accreditation standards, on the other hand, are designed as optimal and achievable which, when met, would lead to a high quality level in a system. The standards are assembled into 23 chapters around key services and functions provided by general hospitals in Saudi Arabia. The chapters included in this hospital standards manual are:
• Leadership (LD)
• Human Resources (HR)
• Medical Staff (MS)
• Provision of Care (PC)
• Nursing Care (NR)
• Quality Management and Patient Safety (QM)
• Patient &Family Education and Rights
              - Patient &Family Education (PFE)
              - Patient &Family Rights (PFR)
• Anesthesia Care (AN)
• Operating Room (OR)
• Critical Care
              - Adult Intensive Care Unit (ICU)
              - Pediatric Intensive Care Unit (PICU)
              - Neonatal Intensive Care Unit (NICU)
              - Coronary Care Unit (CCU)
• Labor &Delivery (L&D)
• Hemodialysis (HM)
• Emergency Care (ER)
• Radiology Services (RD)
• Burn Care (BC)
• Oncology &Radiotherapy (ORT)
• Specialized Care Services
             - Respiratory Care Services (RS)
             - Dietary Services (DT)
             - Social Care Services (SC)
             - Physiotherapy Services (PT)
• Dental Care (DN)
• Management of Information and Medical Records
            - Management of Information (MOI)
            - Medical Records (MR)
• Infection Prevention and Control (IPC)
• Medication Management (MM)
• Laboratory (LB)
• Facility Management and Safety (FMS)
Each chapter has a brief introduction that explains the chapter’s relevance and contribution to safety and quality of patient care. Each standard is composed of a stem represented by a concise statement, followed by one or more sub-standards to clarify further the requirements of the standard. Unlike the older editions of the hospital standards, each substandard is now constructed in a way so that it serves itself as the evidence of compliance, which is going to be measured and scored during the on-site survey.

The process of standards development at CBAHI follows a long and robust methodology to ensure that our standards are correct, evidence-based, relevant and clear. The first draft of CBAHI standards are developed by specialized task forces, focus groups, and standards development committees that utilize input from a variety of sources, including:
• The standards set by the professional scientific societies, locally and internationally.
• Scientific literature review and research studies.
• Relevant laws, rules, and regulations.
• National (or international) emerging issues related to healthcare quality and patient safety.
• Input from health care professionals, providers, and patients.
• Panels of experts and consensus on the so called “best practices”, given the current state of knowledge and technology.

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

All hospitals either public (governmental) or private, licensed as a hospital under the law governing healthcare institutions in ‎Saudi Arabia and have been in operations to provide health care for a minimum of 6 months, are eligible for (and mandated to get) CBAHI Accreditation.

Yes, it does. CBAHI accreditation is a national mandate according to Ministerial Cabinet decree number 371 dated 24/11/1434, under 1st, bullet 5.

Yes, the standards are equally applicable to hospitals according to their scope of service.  

The chapter applicability is decided based on hospital scope of services and CBAHI Accreditation Specialist assessment. All chapters are applicable to all hospitals with the except the chapters related to services not provided by that hospital. 

Three years from the date of certification, as long as the accreditation is maintained.

The first obvious benefit of being accredited is the standardization of practices to be precise, flawless and consistent across the board, discouraging personal preferences. 

The Accreditation Decision Committee may recommend one of the following accreditation decisions:
1. Accredited:
Accreditation will be awarded when a 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 straight forward. 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.

2. 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.

3. Preliminary Denial of Accreditation (PDA):
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.

4. 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.

CBAHI surveyors are highly trained experts who perform the survey visits, they are physicians, nurses, hospital administrators, laboratory medical technologists, pharmacists and other health care professionals. CBAHI is the only health care accrediting body that requires its surveyors be certified. 

The survey team consists of 7 surveyors, including 
• The core team (medical, nursing and leadership) and 
• The Specialty team (infection prevention and control, laboratory, medication management and facility management and safety).