Primary Healthcare Center Accreditation Program (First Version)

Second program in terms of precedence at CBAHI
Primary Healthcare Center Accreditation Program (First Version)

 

 

 

       

           

Primary healthcare facilities provide basic preventive and curative care and are thereby considered to be the cornerstone of healthcare in the Kingdom of Saudi Arabia. With more than 2,000 primary healthcare centers in the Kingdom, improving performance standards and establishing safety guidelines is a high priority for CBAHI.

 

Addressing this need, action committees collaborated with relevant authorities to develop a draft of the National Standards for Primary Healthcare Centers. Field studies were then conducted to ensure the suitability of the standards. As a result, a revision was issued to accommodate current conditions. The first edition of the National Standards for Primary Healthcare Centers was approved by the Saudi Health Council and was issued in Muharram 1433 AH (November 2011 AD). 

 

 

 

 

       
      


  • Eligibility for Accreditation:

    All licensed primary healthcare centers in the Kingdom of Saudi Arabia will be eligible for CBAHI accreditation in accordance with the following criteria:
  • The center provides healthcare services addressed by the CBAHI’s National Primary Healthcare Centers Standards.
  • The center 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 center has been in operation for at least 6 months before the survey visit.
  • The laboratory 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 a Primary Healthcare Center (PHC) or for all other accreditation programs offered by CBAHI.
    Primary healthcare centers 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 following resources will be provided to the center seeking CBAHI accreditation:

  • National Standards for Primary Healthcare Centers.
  • Primary Healthcare Centers Accreditation Guide.

  • Healthcare Accreditation Guide provides all required information to help the center prepare for the survey visits. It contains an abstract of each survey activity that includes logistical needs, session objectives and suggested participants.

    Primary Healthcare Centers Orientation Programs
    CBAHI provides ongoing orientation programs at different locations throughout the year. Primary healthcare centers are highly encouraged to attend at one of orientation programs offered by CBAHI, free of charge. Although any primary healthcare center can attend, the priority goes for the center 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 center 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 Primary healthcare centers in a timely manner.

    Self-Assessment Tool (SAT)

    All primary healthcare centers enrolled in accreditation are required to conduct a comprehensive self-assessment using the SAT provided by CBAHI. This tool is intended to support the center 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 center 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 center and provides for a common communication tool between the center 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 primary healthcare centers may go for an upfront Real Survey.

    For enquiries related to mock and real surveys, please contact: phc@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 PHC before conducting a survey visit:
  • Service Agreement
  • All provisions of this agreement must be reviewed before sending survey application.
  • Survey application form
  • The PHC has to submit successfully a completed Survey Application Form
  • Evidence of payment of surveying fees
  • There are two payment methods for submitting survey fees to CBAHI:
    1. The PHC could deposit the required fees in CBAHI’s bank account and send a copy of receipt to CBAHI (scanned copy or actual receipt).
    2. The PHC could send CBAHI a certified cheque.

    Real survey
    The maximum number of mock surveys a PCH 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, PCHs 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.