The HAD consists of four main departments, each playing a specific role in organizing and accrediting healthcare facilities within the Kingdom.
Departments of HAD:
Health Accreditation Management is divided into four main departments, each focusing on delivering essential healthcare services with high quality. These are:
1- Hospital Accreditation Department: This department is responsible for evaluating and accrediting hospitals according to the third edition of NHS3, issued in 2016. Additionally, this department oversees the Acute Coronary Syndrome Program, launched in 2024, and supervises the Essential Safety Standards Compliance Program (AMAN Program).
2- —Primary Healthcare Centers Accreditation Department: This department focuses on visiting Ministry of Health primary healthcare centers and centers affiliated with other ministries, universities, and government bodies.
3- External Medical Centers “Ambulatory Accreditation Department”: Covers medical complexes and non-hospital centers that provide specialized outpatient services, such as dental centers.
4- Programs and Specialized Centers Accreditation Department: Specializes in accrediting healthcare centers with a specific focus, such as laboratories, blood banks, and home healthcare centers.
Responsibilities of Health Accreditation Management:
1- Conducting periodic assessments of healthcare facilities:
Scheduling healthcare facilities for evaluation visits.
Ensuring that all necessary technical preparations are completed.
Assessing facility readiness for accreditation.
Evaluating compliance with modern standards, including non-applicable (N/A) standards and those specific to different departments.
Reviewing assessments regularly. 2- Issuing evaluation and follow-up reports:
Preparing detailed reports following assessments.
Reviewing necessary modifications in line with established policies. 3- Monitoring the implementation of corrective plans after visits:
Ensuring healthcare facilities adhere to the required corrective plans to maintain compliance with standards.
4- Resolving technical disputes and mediating between surveyors and healthcare facilities:
Addressing any conflicts between assessors and healthcare facility management.
Ensuring a smooth accreditation process. 5- Reviewing accreditation decisions:
Preparing accreditation decision forms.
Overseeing the approval process by the authorized personnel at the center. 6- Supervising the Accreditation Decision Committee and the Appeals Committee:
Coordinating meetings related to accreditation decisions and appeals.
Ensuring the implementation of final recommendations.
Reviewing objections submitted by healthcare facilities regarding accreditation decisions.
7- Handling complaints and inquiries:
Addressing complaints related to the survey process and visit procedures.
Coordinating with relevant departments to resolve inquiries.
8- Issuing accreditation certificates and informing healthcare facilities of results:
Issuing and delivering accreditation certificates to facilities that have met the required standards.
Maintaining records of facilities that did not meet accreditation requirements. 9- Monitoring compliance violations related to the accreditation process:
Identifying and addressing violations to maintain accreditation integrity. 10- Scheduling evaluations and managing timelines:
Creating schedules to ensure timely evaluation visit 11- Updating accreditation status on the facilities' website:
Maintaining transparency by updating "CBAHI" platform data.
12- Monitoring healthcare facilities’ compliance with accreditation standards:
Conducting periodic visits and continuous evaluations to ensure sustained adherence to healthcare standards.
13- Preparing analytical reports on healthcare facility performance:
Collecting and analyzing data to track improvements in evaluation processes and healthcare service delivery.
14- Review feedback from healthcare facilities and assessors on the evaluation process.
15- Following up on operational activities related to agreements and partnerships made by the center.
16- Identifying safety issues and risks related to standard implementation, including major incidents and reportable events.
17- Tracking improvement projects and success stories linked to standard applications.
Importance of Health Accreditation Management:
Health Accreditation Management is a fundamental pillar in ensuring evaluation visits are conducted effectively, verifying that safe and high-quality healthcare services are provided.
Through periodic assessments and continuous follow-ups, the management guarantees the highest standards of healthcare for the community.