The hospital meets all licensing requirements to operate (and therefore, has a valid license when applicable), as indicated by the statutes and regulations of the Ministry of Health.
The hospital meets any additional licensing requirements as indicated by other relevant authorities (particularly, valid certificate from the Civil Defense, and any radiation-related licensing requirements from King Abdul Aziz City for Science & Technology).
The hospital meets the legal definition of a hospital as per the regulations of the Ministry of Health and the international guidelines in this regard :
- Licensed as a hospital under the law governing healthcare institutions in Saudi Arabia.
- It has an organized medical staff (doctors and continuous nursing services under the supervision of registered nurses and technicians).
- Maintains permanent and full time facilities that include inpatient beds for the care of overnight resident patients, i.e. bed and board.
- Provides diagnosis (has laboratory and radiology services) and medical or surgical treatment primarily for, but not limited to, acutely sick and injured patients. (This manual is not for facilities providing treatment for patients with mental illness or providing treatment in special inpatient care facilities e.g. long term care facilities).
- It provides emergency and intensive care services.
The hospital provides healthcare services addressed by the CBAHI’s National Hospital Standards.
The hospital has been in operation for at least (12) months before the on-site survey.
Accreditation Pathway
CBAHI is committed to its mission of promoting healthcare quality and patient safety by supporting healthcare facilities to continually comply with accreditation standards. There are several activities a healthcare facility will go through to obtain CBAHI accreditation.
Registration with CBAHI
Registration with CBAHI for the purpose of accreditation is required for all eligible healthcare facilities, and is the first step towards attaining accreditation whether for hospitals or for all other accreditation programs offered by CBAHI.
Hospitals are required to register by completing the
Healthcare Facility Registration Form available on CBAHI’s homepage. Registration is a quick, yet an important step that provides the Healthcare Accreditation Department at CBAHI with the basic information about the registering facility. Upon successful registration, the facility seeking CBAHI accreditation shall receive the following resources:
National Standards for Hospitals
Hospital Accreditation Guide
The Hospital Accreditation Guide provides all required information to help the hospital prepare for the survey visits. It contains an abstract of each survey activity that includes logistical needs, session objectives and suggested participants.
Hospital Orientation Program (HOP)
CBAHI provides ongoing HOPs at different locations throughout the year. Hospitals are highly encouraged to attend at one of HOPs offered by CBAHI, free of charge. Although any hospital can attend, the priority goes for hospitals selected for the current year accreditation program. During these orientation sessions, standards, accreditation policies, and survey process are all explained in detail. This is a good opportunity for the hospital representatives to enquire about the intent of a standard and how it will be implemented. Dates and venues of the orientation programs will be communicated to the hospitals in a timely manner.
Self-Assessment Tool (SAT)
All hospitals enrolled in accreditation are required to conduct a comprehensive self-assessment using the SAT provided by CBAHI. This tool is intended to support the hospital in assessing how close it is to a satisfactory compliance with the standards and requirements. It also gives an idea of how much preparation and time the hospital needs before it can request a survey visit. Usually, SAT is for the internal use of the healthcare facility but it might be required by CBAHI to help deciding on the preparedness of the facility prior to conducting a survey.
Self-assessment is utilized by several other accreditation organizations to help them –if properly and objectively conducted- to have a better insight on the baseline situation of each hospital and provides for a common communication tool between the hospital seeking accreditation and the accrediting body. When both parties reach a compromise about the level of preparedness for a survey visit based on the self-assessment findings, a survey can be scheduled at a tentative date suitable for both.
Mock Survey
Upon reaching a satisfactory level of compliance with all applicable standards, a mutual agreement is made concerning the exact date of a Mock Survey, which is recommended but not mandatory. Some hospitals may go for an upfront Real Survey.
For enquiries related to mock and real surveys, please contact:
nhs@cbahi.gov.sa
Requesting CBAHI for a survey
Regardless of the type of survey (mock/ real survey) three activities are to be completed by the hospital before conducting a survey visit:
Service Agreement
All provisions of this agreement must be reviewed before sending survey application.
Survey application form
The hospital has to submit successfully a completed Survey Application Form.
Evidence of payment of surveying fees
There are two ways to send the surveying fees to CBAHI:
1- The hospital could deposit the required fees in CBAHI’s bank account and send a copy of receipt to CBAHI (scanned copy or actual receipt).
2- Alternatively, it could also send a certified cheque to CBAHI.
Real survey
The maximum number of mock surveys a healthcare facility can go for is two surveys within two years from the date of first real visit. The elapse of six months shall be deemed the minimum time interval between two consecutive real surveys. This, however, should not be misinterpreted as an “open-ended” exercise. Therefore, hospitals that will eventually prove to be incapable of achieving accreditation after using up the permissible number of real visits by CBAHI will be excluded temporarily or permanently from the national accreditation program and referred to the relevant authorities for further action.