Per Specialty

Leadership

ANSWER	QUESTION	STD #
Documented evidence of oversight Documented evidence Quarterly, Regular business is done by Executive Committee, until board meeting. The less the board meets, the more the executive committee, is authorized to run business	What is the mechanism? Approvals of mission Monitor the indicators How frequent is the meeting every 3-4 months? So how do we monitor through the indicators monthly ? Is it needed to be signed by the board members or their representative (CEO) is enough to sign?	LD.1.1
Terms of reference covering all elements are enough. Not required Performance evaluation of the board Yearly at least Governing body for MOH is theMinistry of Health itself represented by the head of the regional directorate of health in your respected region, all responsibilities mentioned in the standards should be done by him, or he candelegate some of them to the hospital director in a formal documented approved delegation.	Are the term of references enough? Are the medical bylaws need to be mentioned? Performance evaluation of the boards or the hospital indicators How frequent will it be for the board (bi-yearly or yearly)? Who arethe members of the Governing body in MOH hospitals and responsibilities?	LD.1.2
Signature of the chairperson of the governing body at the time of document approval	To have signature of approval by old or new director general of general directorate so we need to be discussed at the governing board meeting	LD.1.3.1
Not required	If an assignment comes from the general directorate are this needs to discuss the selection from several CVs during the meeting?	LD.1.3.2
Annually at least	What do you mean by regular basis? Does this mean every meeting?	LD.1.3.3
The governing body should approve the org. Chart either on the chart itself or through discussion and approval minutes of the meeting	Do we need a delegation letter to hospital director to approve the items?	LD.1.3.4
This responsibility should be included under the responsibilities of the governing body which described in the document needed in this standard (bylaws or similar document). Additionally, signature of the governing body representative should be clear in the medical staff bylaws	The substandard is not clear, more explanation is needed	LD.1.3.9
Future annual plan covering different departments and major activities including at least manpower, consumables, and equipment in financial or quantitative terms	How do we do annual budget for the hospital?	LD.1.3.10
Adequate staffing can be assessed against staffing plans, and supplies can be assessed by observing their availability based on the scope of service and the workload	How to ensure the governing board providing the adequate resources what is the mechanisms?	LD.1.3.11
The governing body approves the process of delegation	Are the delegation letter covered or must it be still be approved by the director general of health affairs?	LD.1.3.12
Quarterly, Documented regular meeting minutes of ‎the governing body members	What do you mean by regularly? every how many months?	LD.1.4
The three requirements will be assessing all together, education OR training OR experience i.e. proper training and adequate experience can be fine. However, a Bachelor’s degree in a related field is a must.	Does the staff need a certification in hospital administration or local hospital training is adequate?	LD.2.1
YES	Is medical bachelor degree is enough?	LD.2.2
Compliance with laws such as Saudi Council of Health Specialties, civil defense, retention of medical records, etc.	How to prove it?	LD.2.3
Not allowing incompetent staff to practice in the hospital.	How if the recruitment is central?	LD.2.4
By taking action in case of misconduct.	How to account for the professional conduct of the staff?	LD.2.5
Hospital policies that have been approved by governing the body.	What do you mean set by governing body?	LD.2.6
Not only by incidents. And can be on a collective basis.	How to prove review of reported incident is one by one or the monthly report of the committee headed by the medical director?	LD.2.7
Yes	What do you mean by the hospital leadership group?Is it the same like executive committee?	LD.2.8
Yes	How to prove it are through correspondence to the MOH and General Directorate?	LD.2.9
Planning for resources and supporting department heads and communicating with them regarding the availability of resources, as well as through his rounds and unit visits.	How does one ensure?	LD.2.10
Setting and approving processes as well as follow up of implementation.	How does one ensure?	LD.2.11
Through communication with department heads and stores and inventory control as well as committee chairperson.	How does one ensure?	LD.2.12
Identification of those laws and can have copies of them. Laws and regulations worksheet are required mainly to listthe laws governing the hospital according to its reporting authority,as Ministry of Health lawsfor governmental hospitals andMilitary services laws for military hospitals and the like. The answer is yes; you stillneed to include MOH laws and regulations.	What do you mean to have copy of MOH, SOP, Labor laws and regulations? We are currently creating a worksheet for all the laws and regulations mentioned in the CBAHI standards manual (e.g. HR.5.5, ORT.2.1, FMS.4.1) because our hospital considers the CBAHI standards as our laws and regulations. Is needed to be included in the worksheet the rules and regulations from the Ministry of Health?	LD.3.1
Not necessary to have periodical reports but rather to obey those regulations through compliance to their requirements in all hospital practices .	How they ensure this compliance are through monthly reports ?	LD.3.2
Yes	Is an approval adequate?	LD.4.1
Should be approved by the governing body	Through the delegation letter.	LD.4.6
Not enough. EMC is the highest executive team in the hospital and should be led by hospital director or chief executive officer and reports to the governing body.	Is to have the assistance, and maintenance plus quality and nursing directors are enough?	LD.5.1
Usually, in-house training is inadequate.	Are the local hospital training is adequate?	LD.5.2
The revision is not only to re-sign the document but to review it and make a necessary update if any.	What do you mean by current? If every three years are to update the signature only or to have the new version?	LD.5.3
Yes, regarding reference of Executive Management Committee.	Committees’ term of references is adequate?	LD.5.4
Conflict of Interest can be defined as any situation in which an employee is in a position to exploit professional or official capacity in some way for his/her financial/personal benefit.This situation conflicts with the ethical obligations of an individual in the organization. An example of conflict of interest: Financial/Economic Interestis any relationship entered into by the employee or his/her family, other than employment by the hospital, which could result in a financial/economic gain for the employee or his/her family. Financial/Economic interests include consulting income; value or potential value of stock shares, equity holdings; and membership on a company’s Board of Directors or anything of monetary value received from such business. This policy specifically aims to: Define the relations of employees with entities that have business with the hospital; Ensure that the employment of qualified immediate family members and relatives by with the standards set by the hospital; Reduce the probability of inappropriate activities; Ensure that employee exercise substantial responsibility to avoid real/actual as well as perceived conflicts of interest/commitment in their relationship with external organizations; and Protect both the organization and the individuals involved from any appearance of impropriety	CONFLICT OF INTEREST is not understandable; would you clarify more?	LD.6.3.7
Every three years or when there is a change in hospital mission or major change in scope of service	Is mission to be updated yearly? Is it enough to sign on a mission, vision & values?	LD.7.1
Through posters, orientation program, hospital printed materials, hospital web-site, etc	How to communicate?	LD.7.2
It requires a document that describes hospital values and code of conduct adopted.	Can you explain more?	LD.8
Approvals, awareness, and implementation	How to prove this?	LD.8.1
No. Just the mechanism of taking decisions in the committee (e.g., majority vote) and the members that are not allowed to vote like the invited members.	Does it mean the conflict of interest for a member that aren’t allowed to vote?	LD.9.3
Hospital director, his/her assistants (medical director, admin/finance director, nursing director, etc.), and departments heads	What are the definitions of hospital leaders?	LD.10.1
Involvement and participation in plans and projects	How to prove to participate actively?	LD.10.2
Posters, website(if available), newsletters, community representatives are members of governing body	How to communicate quality work to community and customers?	LD.10.3
Evidence of community participation in the hospital planning for healthcare needs. This may be evident in documented meetings with community leaders, inputs of the strategic plan, analysis of customer needs and recommendations and actions taken	What do you mean?	LD.11.1
Communication with community leaders to get feedback on health need assessment and inclusion of these requirements in plans .	How to prove to participate in planning? What is the evidence required?	LD.11.2
Plans should include performance indicators to review performance against those indicators	What do you mean by evaluation by hospital leaders against plans and budgets?	LD.12.6
Plans should include upgrade and replacements if required	What do you mean by The planning process considers the upgrade or replacement of buildings?	LD.12.7
e.g., Nursery, ER, OT	What do you mean by patients care units?	LD.13.4
Annually at least	What the meaning of regular basis?	LD.15.4
Differ from one indicator to the other. And should be clarified in the description of each indicator	What the meaning by regularly?	LD.15.8.2
Annual or other grand meeting, committees, memos	How to be communicated to relevant staff?	LD.15.10
All required staff should be included in the staffing plan	Staffing need to be general or at each specialist for each unit?	LD.16.3
Have the right to accept or reject their employment in the department through clear professional process	How to participate?	LD.16.7
Group of customers, e.g., nursing staff, OPD patients, pharmacists	Who to identify new customer?	LD.19.1
After introducing a new process or modifying an old one, there should be more frequent (differ from one process to the other) monitoring to ensure the good performance of the new/modified process	What do mean by regular?	LD.19.6
According to the standard and organizational chart is needed for each department	Do we need an organizational chart for each department?	LD.26.1
Each department head has to: Identify internal and external customers. Identify customers’ needs Plan to satisfy the customers’ needs. Obtaining feedback about customers’ satisfaction. Correcting performance based on the satisfaction results.	Can you explain how?	LD.27.1
Whenever required, there iswritten agreement or verbal understanding between the department and other clinical departmentsand external customers, explaining the expectations of each party. Interdepartmental communication is fundamental to the provision of quality patient care. Therefore, agreements are used to describe the cooperative relationship between two parties wishing to work together on a project or to meet an agreed upon objective. They outline and memorialize the specific expectations and obligations of each party. Agreements are not to replace hospital policies or practice guidelines. They are used to cover areas that were not covered in hospital policies and other regulatory hospital documents, as the structure and format of those documents usually do not fit the content and structure of agreements. Agreements are writtenin the form of amemorandum of agreement or understanding and usually arefocused on a specific task or work issue, Examples of agreements may include: agreement for holding blood refrigerator in clinical departments, agreement for transporting patients from and to operation rooms, agreement for training of medical students between hospital and medical school, agreement between hospitals during declared emergencies, and blood supply agreement between two hospitals	Does it mean the multidisciplinary policies/clinical guidelines/protocol/ pathways are guiding departments and enforcing systems between departments? Does it mean memos, committees recommendations and RCAs corrective actions binding departments in a certain system?	LD.27.2
No, should be for all hospital departments.	Is it enough for clinical departments?	LD.31.3
Yes, the standard is general forall internal medicine physicians.	Does this apply to general internal medicine physicians only or with that physician with internal medicine background and had subspecialty from internal medicine, e.g., hematology, pulmonology, endocrinology?	HR.12.2.2
Yes, Data Flow verification is accepted for the education and experience (if both were done) but a confirmatory document is needed to prove that (not the receipt) according to HR.5.8 HR need to verify four credentials according to the standard (license, education, training, and experience), the reference lettershave to be verifiedif it refers to the experience of the employee as part of the experience verification. Other credentials need formal documents through which the verification will be done. Primary source verification is required for(license, education,training, certification and experience) for the following staff: New hires during the last four months’ track periodfor hospitals applies forthe initial survey New hires starting from the effective date of the standards (Jan 2016) for hospitals appliesforre-accreditation for the 1st time on CBAHI3rd edition All hospital staff for hospitals applies for re-accreditationon CBAHI3rd edition for the 2nd time. If primary source verification was not done by data flow, the hospitals have to do it themselves. The hospital has to provide evidenceforthe verification of the following: 1- SCHSLicense (if it was ready foremployment and brought by the employee). Can be done through SCHS website. 2- Education (can be through confirmatory documentfrom data flow) 3- Experience or employment(can be through confirmatorydocumentfrom data flow) 4- Training (if will be used to grant new privilege or job responsibility)	Is "data flow document evidence" as the third party accepted by several CBAHI to be the Clinical Staff credential verification required in ESR HR? Or shall HR at the hospital do the verification? Shall HR verify the " reference letters" for clinical staff? Regarding credential from the source for old staff which already licenses from scenes and MOH need to make for them new credential from the source as there is no paper from data flow before? For new medical staff credential, it is enough to have evidence from 3rd party data flow or need to make additional credential by the hospital?	HR.5
Protected time for the attendance of educational activities and team meetings, sponsoring training courses.	How is this supported?	QM.1.4
No need to prove the informal training will be checked during staff interview	How to prove the training informal conducted during mentoring?	QM.2.3
Will be proved by the indicators selected, interview with departments’ heads, the way of data collection analysis and presentation	How to prove this if it is not formal training?	QM.3.3
In the quality or the executive committees	Where to be discussed?	QM.8.1
Will be enough	Now it is categorized as CLBSI-VAP-Cath. Infection-Wound infection	QM.9.2.2
Yes, with the same diagnosis. Selected to detect the cases of immature discharge or cases developed complications	Are with the same diagnosis? What are the rational of this indicator	QM.9.2.9
Managerial risks include any risks not directly related to the clinical care of the patient like financial risks, insurance claims, invoice errors.	What are the managerial risks	QM.13.1
Timely according to the hospital policy and the type of the incidents	What is the appropriate time?	QM.14.3
For QM.15 reporting sentinel events should be done for any SE happened afterJan 2016 (effective date) and their portable events are already listed in the same standard QM.15.2	Do we have to report the sentinel events to CBAHI? IF YES from when and do CBAHI have a list of those reportable sentinel events?	QM.15.3
Available online: AHRQ	Do we need the format of culture assessment?	QM.16.5
To use the information resulted from patient safety activities (e.g., rounds and culture assessment) in initiating improvement projects or risk assessment and risk management.	How to make the integration?	QM.16.8
The site marking should be done while the patient is conscious and to share in locating the site of procedure	What do you mean?	QM.18.4.3
no standard in CBAHI requiring re-approval of P&Pif appointing new hospital director. Signatures are intended to authenticate that the signers have reviewed, recommended, and approved the P&P as written. Therefore, it might not be necessary or practical to revise and approve hospital'svalidP&P due to appointing new hospital director. If your concern is to set forth the responsibility of the newly appointed director (i.e.: department heads and hospital director)towards understanding and implementing P&P, the Job Description is the appropriate place wherein to indicate that the leaders are responsiblefor implementing /following / enforcing related hospitalP&P’s	Hospital Policies and Procedures are still valid; recently we had a newly appointed Hospital Director. Is it necessary to revise all our policies according to our new Hospital Directordueto the approval signatory and dates?	QM.20

MEDICAL

ANSWER	QUESTION	STD #
As a general rule based on the (10) standards in the HM chapter, it will be applicable to any institution that has the service regardless of the number of patients or machines. As you all are aware the topics of the (10) standards are as follows: 1. Qualified nephrologist 2. Qualified nurse 3. Patient HM plan 4. Admission & Discharge criteria 5. Policies & procedures guide the care of patients requiring HM. 6. Equipment & Machines 7. Infection control guidelines 8. Protection from bloodborne pathogens for patients & staff 9. Water quality 10. Competency of nursing staff	Opinion about the applicability of the hemodialysis chapter when a hospital only provides hemodialysis for only in patients who need urgent dialysis.	HM
Yes, still it will be mandatory that all obstetricians must ALSO be certified.	The criteria indicated is the mandatory ALSO for obstetricians. However, all our obstetricians are certified with a more advanced certificate called OBERT (Obstetric emergency workshop) which is held at our hospital twice a year. Moreover, the Saudi Commission does not indicate a specific certificate in this regard. Therefore, is it mandatory to have ALSO or our OBERT shall be sufficient?
In case that the physician is recruited in the governmental hospital all his privileges will be granted under supervision from one senior staff in his specialty or the medical director if he is the only one or the most senior in his specialty. This is not considered temporary or emergency privileges because this physician will be a member of the hospital medical staff (MS.6). Temporary privileges: This may be granted by the medical director/ CEO to a new physician to practice while waiting for his recruitment documents to be finalized. It should not exceed 90 days. In case the recruitment process requires more than 90 days the solution is in the hand of other parties (hospital, MOH, SCFHS and the recruitment agents) to expedite it. CBAHI standard should not be lowered to suit the delay in recruitment. All parties including SCFHS must be made aware about this essential safety requirement. Emergency privilege: This may be granted by the medical director/ CEO to a physician in two situations: 1. One-time privilege to carry out an emergency procedure. There will be no timeframe for this practice. 2. Emergency temporary privilege for a physician/s to practice in an emergency circumstance. This should not exceed 90 days. In case the institute predict that this emergency circumstances may last more than 90 days it will be appropriate and the time will be enough for them to process routineprivilege for the involved staff while he is working on temporary emergency privilege. In addition, it is well known and is legal that any licensed physician can perform any life-saving procedure at any time. For visiting professors and locums the hospitals must implement the same privileging principles as their permanent staff. In case of an urgent need for an external professor a one time or short time privileges (not to exceed 90 days) may be granted. If the visiting professor or the locum physician visits are recurring, then it will be appropriate to process routine privilege system for them. The emergency privileges are different from the privileges to deal with emergency situation, the definition below is for emergency situation in which the privilege rules are not applied, so any one can do anything to save patient's life regardless his privileges. But emergency (or better called temporary) privileges are those granted form a medical authority in the organization (most probably delegated tothe medical director) when the hospital need a physician form outside the hospital to do a procedure or multiple procedures in the hospital like calling professors from outside the country to do some rare operations. This physician is not a member of the hospital medical staff so temporary privileges will be given to cover a limitedperiodnot more than 90 days providing that the hospital completes hiscredentialingprocess (HR.5).	All governmental hospital appointees are mostly non-Saudi medical staff through " recruitment committees " from outside the kingdom and most of them when they come they require to pass SCHCS exams and interviews to be registered, this process mostly takes between 4-6 months and may be more do this should fail the hospitals if not met " ESR " and are these practical? Regarding emergency privileges by its definition "An emergency situation is one in which serious harm or aggravation of injury or disease is imminent, or one in which the life of a patient is in immediate danger, and any delay in treatment could add to that danger. In the case of an emergency, individuals appointed to the Medical or Allied Health Staff and granted delineated clinical privileges in any category are permitted to do everything possible, within the scope of their license, to save a patient’s life or to save a patient from serious harm. In addition, the individual is obligated to summon appropriate assistance and to arrange for appropriate follow up care, to the extent consistent with prevailing medical practice " so why the hospital make this privileges valid for only 90 days " as required by the standard MS7.4" the hospital should not identify a timeline for such like privileges.	MS.7.4
The medical director must fulfill the criteria in MS2. The governing body whether it is corporate or local isresponsible for approving the Medical Staff Bylaws as in LD1. For day to day business, the appointed deputy medical director may sign for the medical director. No specific criteria in the standards for deputy medical directorbut he must be a senior qualified member of the medical staff appointed by the medical director and approved by the governing body. Of course not possible for those who does not have a license from the Ministry of Health to sign the policies and procedures work.	Is there any specific criterion for selection of Medical director and deputy medical director? Who is responsible for approving the Medical Staff Bylaws? Who is authorize to sign policies and procedures?	MS 2
The hospital has to develop a privilege list approved by the head of the unit and to the credentialing and privileging committee	Privileging is part of Recruitment / Job description	MS. 7
Radioactive Iodine standards are distributed in more than one chapters but mainly in FMS chapter. Only one sub-standard is in ORT chapter; therefore, ORT may be considered NA even in the hospital where radioactive iodine is used. Hence the use of radioactive materials will be well covered by other chapters	What are the ORT standards applicable if the hospital provides active radioiodine for thyrotoxicosis (Graves’ disease )?
It can be considered NA is providing there is a contract/agreementand ensure care coordination.	CCU what is required for small hospital having the only cardiologist with 30 beds capacity and 2 ICU beds?
It can be considered NA is providing there is a contract/agreementand ensure care coordination.	Physical therapy is it OK to be outsourced?
May be considered NA, providing there are a clear policy and procedure regarding the care of pediatric patients requiring intensive care and proper training of staff.	PICU what is the requirement putting in mind when we do not have pediatric surgery, but we have ENT?
It is accepted as it is in the hospital system	APDG for clinical affairs that supervise Nursing – chairs Medical Executive Committee Responsible for Education
The Hot Lab is only for nuclear medicine. Clinical ‎laboratory will be covered by laboratory ‎standards. ‎	Regarding "hot lab" unit visit; is it about "nuclear ‎medicine" or does it include the " clinical laboratory" ‎premises? ‎

Laboratory

ANSWER	QUESTION	STD #
YES	According to CBAHI standard #5, Anti-neoplastic drugs should be included in the list of high-alert medications. Should hazardous medications like (BCG, colchicine, cyclosporine, mycophenolate mofetil, carbamazepine,etc.) be included in the list as well? As per (NIOSH) LIST	MM.5
Should be included but in a separate list entitled "hazardous chemicals."	Should hazardous chemicals be included in the list of high-alert medications or is it enough that they are mentioned in the policy?	MM.5
As you know, somecytotoxic chemotherapy medications are used for non-oncology patients. When CBAHI standard refers to chemotherapy as a high-risk medication, it extends to the medication itself regardless of its use because the risk comes from the medicine, not from the disease. To make it short, yes you need to list all cytotoxic, immune suppressants and chemotherapy that you have in your hospital.	Since we are not an oncology center and don't have the facility to prepare these medications in aseptic conditions, yet we have these medications used for different indications as anti-rheumatic such as methotrexate. Accordingly, do we have to put these chemotherapeutic agents in a list and state their indications and to add it to our hospital's high alert medications list or should we transfer the patients to the specialized oncology center?	MM.5
CBAHI will never ask you to do something one way or the other. We are looking for near misses and actual errors. I am sure you appreciate the fact that you need to look globally at the overall incidence before breaking the data down according to NCCMERP.	Regarding Medication error, I added the total number of ISMP classification type of errors and contributing errors together but put each on a separate graph. On the other hand, Clinical Auditing and Ministry believe that the analysis should be in one unified graph. Which do you think is the most accurate thing to do?	MM.41
Yes, as long as they are classified as hazardous. You need to review them one by one.	Acetic Acid Solution---- gentian violet---pot.Iodide---pot.permanganate---wax glycerin---benzyl benzoate---borax---hydrogen peroxide---methyl salicylate---boric acid---icthammol---paraffin oil---castor oil---clove oil---iodine---salicylic acid---pot.chloride---silver nitrate---menthol---soft paraffin---talc powder---soda lime tincture benzoin---lanoline---zinc oxide. Should all of the above items be included in the list of hazardous chemicals or should we include those classified by (OSHA) only?	MM.5
The Root cause analysis should be done for all significant or potentially significant medication errors not only in case of sentinel event as per CBAHI standards.	There is an active reporting for medication errors, but none of it has been classified as a sentinel event. So we did not deal with a sentinel event to perform a root cause analysis. Fortunately, it didn’t occur.	MM.41
All drugs by name should be included in the list. It is not enough to mention the drug class because some people may not know that a particular drug they have on the shelf belongs to the class you mentioned in your list.	Should all available drugs under a certain class be mentioned in the list of high-alert medications or could they be attached as a separate list for simplicity?	MM.5

Medication Management

ANSWER	QUESTION	STD #
As a general rule based on the (10) standards in the HM chapter, it will be applicable to any institution that has the service regardless of the number of patients or machines. As you all are aware the topics of the (10) standards are as follows: 1. Qualified nephrologist 2. Qualified nurse 3. Patient HM plan 4. Admission & Discharge criteria 5. Policies & procedures guide the care of patients requiring HM. 6. Equipment & Machines 7. Infection control guidelines 8. Protection from bloodborne pathogens for patients & staff 9. Water quality 10. Competency of nursing staff	Opinion about the applicability of the hemodialysis chapter when a hospital only provides hemodialysis for only in patients who need urgent dialysis.	HM
Yes, still it will be mandatory that all obstetricians must ALSO be certified.	The criteria indicated is the mandatory ALSO for obstetricians. However, all our obstetricians are certified with a more advanced certificate called OBERT (Obstetric emergency workshop) which is held at our hospital twice a year. Moreover, the Saudi Commission does not indicate a specific certificate in this regard. Therefore, is it mandatory to have ALSO or our OBERT shall be sufficient?
In case that the physician is recruited in the governmental hospital all his privileges will be granted under supervision from one senior staff in his specialty or the medical director if he is the only one or the most senior in his specialty. This is not considered temporary or emergency privileges because this physician will be a member of the hospital medical staff (MS.6). Temporary privileges: This may be granted by the medical director/ CEO to a new physician to practice while waiting for his recruitment documents to be finalized. It should not exceed 90 days. In case the recruitment process requires more than 90 days the solution is in the hand of other parties (hospital, MOH, SCFHS and the recruitment agents) to expedite it. CBAHI standard should not be lowered to suit the delay in recruitment. All parties including SCFHS must be made aware about this essential safety requirement. Emergency privilege: This may be granted by the medical director/ CEO to a physician in two situations: 1. One-time privilege to carry out an emergency procedure. There will be no timeframe for this practice. 2. Emergency temporary privilege for a physician/s to practice in an emergency circumstance. This should not exceed 90 days. In case the institute predict that this emergency circumstances may last more than 90 days it will be appropriate and the time will be enough for them to process routineprivilege for the involved staff while he is working on temporary emergency privilege. In addition, it is well known and is legal that any licensed physician can perform any life-saving procedure at any time. For visiting professors and locums the hospitals must implement the same privileging principles as their permanent staff. In case of an urgent need for an external professor a one time or short time privileges (not to exceed 90 days) may be granted. If the visiting professor or the locum physician visits are recurring, then it will be appropriate to process routine privilege system for them. The emergency privileges are different from the privileges to deal with emergency situation, the definition below is for emergency situation in which the privilege rules are not applied, so any one can do anything to save patient's life regardless his privileges. But emergency (or better called temporary) privileges are those granted form a medical authority in the organization (most probably delegated tothe medical director) when the hospital need a physician form outside the hospital to do a procedure or multiple procedures in the hospital like calling professors from outside the country to do some rare operations. This physician is not a member of the hospital medical staff so temporary privileges will be given to cover a limitedperiodnot more than 90 days providing that the hospital completes hiscredentialingprocess (HR.5).	All governmental hospital appointees are mostly non-Saudi medical staff through " recruitment committees " from outside the kingdom and most of them when they come they require to pass SCHCS exams and interviews to be registered, this process mostly takes between 4-6 months and may be more do this should fail the hospitals if not met " ESR " and are these practical? Regarding emergency privileges by its definition "An emergency situation is one in which serious harm or aggravation of injury or disease is imminent, or one in which the life of a patient is in immediate danger, and any delay in treatment could add to that danger. In the case of an emergency, individuals appointed to the Medical or Allied Health Staff and granted delineated clinical privileges in any category are permitted to do everything possible, within the scope of their license, to save a patient’s life or to save a patient from serious harm. In addition, the individual is obligated to summon appropriate assistance and to arrange for appropriate follow up care, to the extent consistent with prevailing medical practice " so why the hospital make this privileges valid for only 90 days " as required by the standard MS7.4" the hospital should not identify a timeline for such like privileges.	MS.7.4
The medical director must fulfill the criteria in MS2. The governing body whether it is corporate or local isresponsible for approving the Medical Staff Bylaws as in LD1. For day to day business, the appointed deputy medical director may sign for the medical director. No specific criteria in the standards for deputy medical directorbut he must be a senior qualified member of the medical staff appointed by the medical director and approved by the governing body. Of course not possible for those who does not have a license from the Ministry of Health to sign the policies and procedures work.	Is there any specific criterion for selection of Medical director and deputy medical director? Who is responsible for approving the Medical Staff Bylaws? Who is authorize to sign policies and procedures?	MS 2
The hospital has to develop a privilege list approved by the head of the unit and to the credentialing and privileging committee	Privileging is part of Recruitment / Job description	MS. 7
Radioactive Iodine standards are distributed in more than one chapters but mainly in FMS chapter. Only one sub-standard is in ORT chapter; therefore, ORT may be considered NA even in the hospital where radioactive iodine is used. Hence the use of radioactive materials will be well covered by other chapters	What are the ORT standards applicable if the hospital provides active radioiodine for thyrotoxicosis (Graves’ disease )?
It can be considered NA is providing there is a contract/agreementand ensure care coordination.	CCU what is required for small hospital having the only cardiologist with 30 beds capacity and 2 ICU beds?
It can be considered NA is providing there is a contract/agreementand ensure care coordination.	Physical therapy is it OK to be outsourced?
May be considered NA, providing there are a clear policy and procedure regarding the care of pediatric patients requiring intensive care and proper training of staff.	PICU what is the requirement putting in mind when we do not have pediatric surgery, but we have ENT?
It is accepted as it is in the hospital system	APDG for clinical affairs that supervise Nursing – chairs Medical Executive Committee Responsible for Education
The Hot Lab is only for nuclear medicine. Clinical ‎laboratory will be covered by laboratory ‎standards. ‎	Regarding "hot lab" unit visit; is it about "nuclear ‎medicine" or does it include the " clinical laboratory" ‎premises? ‎

FMS

ANSWER	QUESTION	STD #
All correspondences with Healthcare Affairs Directorate and any payments done and approved by the hospital are fine.	How governmental hospital can avail a budget and which applicable laws and regulations since we have specific MOH rules and regulations?	FMS.1.4
Hospital leadership and FMS team.	Who is responsible for the provision of those laws and regulations because they are scattered, and nothing is added in one folder?	FMS.4
External Disaster policy should identify the max number that can be evacuated. Worldwide percentage is 10%	How can we evaluate the number of beds to be evacuated since it depends on of the admitted cases on that day?	FMS.16.1.7
A departmental disaster plan is different from hospital disaster plan, such as laboratory plan.	Can we depend on the hospital-wide plan because we are roles & responsibilities on it instead of designing department plans all of them are the same?	FMS.17.2
By installing new walls and fire rated doors, It is possible even in old buildings. Fire compartment size differs between inpatient and outpatient areas.	The age of some of the hospitals is timeworn, so how can we overcome those obstacles?	FMS.19.3
Once a year is enough regardless of staff situation.	Is it enough to train the staff when they are newly hired upon the hospital orientation programs and through the drills?	FMS.19.5
Adding emergency landing devices (UPS) and wiring between elevator control panel and fire detection system have no relation with building age.	How will it apply to the old hospitals?	FMS. 21.4
So many old hospitals had done it. Unavailability of suppression system means the facility is unsafe.	How will it apply to the old hospitals?	FMS. 22.1
Only critical equipment.	How can we avail backup for the major equipment i.e.: MRI, CT and Gama Camera?	FMS.25.9
Pressure monitor should be fixed on the wall to enable staff monitoring pressure. Central monitoring is not mandatory.	Is it acceptable to monitor all types of air flow manually as our hospital is timeworn and no way for the central monitoring?	FMS.35
The hospital should have separate sewage lines for effluent, contaminated and storm water, STP (Sewage Treatment Plant), grease trap, decay tank, lab waste liquid sink, etc.	How can we assure the Sewage handling and disposal is safely conducted in an efficient and sanitary manner according to professional codes of practice and do you mean by this code?	FMS.38
This sort of device is available in the local market; the hospital can rent as well. The thermographic inspection should be conducted once a year of all circuit breakers in critical areas.	The first problem is we have been searching for a company provide this type of imaging in KSA for a long time, and we did not find a single specific one? Secondly, each location mentioned in the standard has three to four circuits, do we need to apply thermostatic for each or per location?	FMS.30.2
The hospital should have separate sewage lines for effluent, contaminated and storm water, STP (Sewage Treatment Plant), grease trap, decay tank, lab waste liquid sink, etc. MOMRA of Saudi Arabia.	What exactly you mean by the professional code? WHO standard, UNICEF, Saudi Specification, or our hospital policies?	FMS.38.1
Fire resistance walls are needed for all hospital buildings and critical areas such as Laboratory, technical rooms (such as generator rooms, boilers room if applicable, elevator rooms, workshops, etc.) the idea behind this requirement is to resist the fire to expand out of premises. Now how the surveyorwill check this and what evidence of compliance he needs to see?Mainly the surveyor will check the building drawingsthat shows the fire rated walls distribution but not any drawings. All technical drawings must be approved and stamped bya consultant company who is registered under the civil defense of the region.	What are the high-risk areas you are looking for? What kind of evidence do you need? Clarification on the comment of"evidence notavailable."	FMS.23
MOH do not have standards related to hospital buildings! CBAHI standards which are in parallel with AIA (American Institute of Architect)are highlighting the issue of Isolation rooms in general and specifically for the medical waste room that should be:- 1) Negative pressured. 2) Equipped with Pressure indicator outside the room to monitor desired negative pressure and to alarm, if the readingis out of range. 3)A HEPA filter (with routine checks and replacement as per manufacturer recommendation) 4) Necessary PPEs such as (gloves, masks, and plastic boot shoes) 5)A sink with water supply and drainage. These are the requirements andof course it should be noted that all medical waste rooms must be outside of the facility as recommended by MOH for proper transfer of medical waste with the contractor on a daily basis and not allowed to have it inside the facility asit is asource of infection.	We were requested by MOH to build medical waste room outside the building with no comments from their side about negative pressure requirement, the surveyor though discussed during his visit that it should be negative pressure,do we still have to design it under negative pressure? Even if it is completely separated and not connected to the hospital building by any means?	FMS. 35
The hospital should refer to OSHA guidelines regarding eye shower and emergency shower as CBAHI standards will not mention every single detail.	The standards statement is mentioning obstructions for safety showers without determining the locations and availability of safety showers and eye wash. If there is a preference from CBAHI, it would be great to take it into consideration	FMS.24
This substandard is so clear; no obstacles should hinder safety equipment. It is not findings it is a standard.	It is not clear from the statement whether it is a finding or a note for further discussion	FMS.24.2
It is accepted as long the system is effective running, and the staff is aware of it.	Is it enough to have Names of all employees called, including their contact numbers and action cards?	FMS.16
load monthly 30 minutes this is mandatory. With load.	SFHP Assessment: The Hospital is conducting power testing on without load.	FMS.31.2
weekly offload is mandatory and should be without load.	SFHP Assessment: This is done monthly instead of weekly.	FMS.31.2
There is a machine will be used for full load test, during testing hospital will be running by main power with an option to abort the testing in case there is power interruption in governmental power supply	SFHP Assessment: Engineering conducts this procedure without load.	FMS.31.2
Our reference pertinent to ventilation parameters is ASHREA (American Society of Heating, Refrigerating and Air-Conditioning Engineers). However, attached please find Table 7-1 that showing no certain relative humidity is required in laboratory area (marked in yellow). The hospital can order the book as reference “Guidelines for Design and Construction of Hospitals and Outpatient Facilities” via this link: https://www.fgiguidelines.org/#	Regarding CBAHI standard about the measurement of humidity in the lab, I want to know more about this standard: From where can I buy it? What are criteria of standardizing a machine? How can I Assure of its quality? What is the acceptable What are the Guidelines for usage? Are there specific criteria (hot spot) for choosing the place? What are the basis of corrective action when there is deviation of control?	FMS.36
The key word of this standards is " consumption." The hospital has to clearly identify it is the average use of electricity, water,oxygen and medical air. Then the next stage to have a backup equal to this consumption for 48 hours. Cylinders are the appropriate solution for both medical air and oxygen.	Will thestandby tank for oxygen and medical air be enough or we must havecylinders?	FMS.32.8

Nursing

ANSWER	QUESTION	STD #
For ACLS, Critical Care areas (ICU, CCU) ER, Conscious Sedation Areas (Radiology, Endoscopy) OR, Recovery Room For PALS, PICU, Pediatric ER, Pediatric OR. NRP for NICU. ATLS for ER.	Which critical areas must have ACLS?	HR.12.2
For ACLS, Critical Care areas (ICU, CCU) ER, Conscious Sedation Areas (Radiology, Endoscopy) OR, Recovery Room For PALS, PICU, Pediatric ER, Pediatric OR. NRP for NICU. ATLS for ER.	Which critical areas must have ACLS?	HR.12.2.1
Yes, Data Flow verification is accepted for the education and experience (if both were done) but a confirmatory document is needed to prove that (not the receipt) according to HR.5.8.	Is "data flow document evidence" as the third party accepted by CBAHI to be the Clinical Staff credential verification required in ESR HR? Or shall HR at the hospital do the verification?	HR.5
HR needs to verify four credentials according to the standard (license, education, training, and experience), the reference lettershave to be verifiedif it refers to the experience of the employee as part of the experience verification. Other credentials need formal documents through which the verification will be done.	Shall HR verify the "reference letters" for clinical staff?	HR.5
Yes, all head nurses and above nursing related posts are mandated to have a minimum of B.S.C qualification and to show an evidence of seeking registration as a specialist in Saudi Council. Please note that nurses who are registered as technicians by Saudi Council and possess BSC can apply for specialist status where they have to set the exam set for this purpose and have a recommendation from their institution to do so.	Is it a mandated requirement that all head nurses are supposed to have a BSN degree and hold a specialist license in Saudi council.	NR.9
It is required that Nursing department presents a quality improvement plan as well as a continuous educational program to meet the standard requirement. The nursing quality plan that was signed by the nursing director has to be in line with the hospital quality plan.	We would like to ask if the hospital-wide quality plan is enough to meet the standards in question or is it mandatory for the Nursing Department to develop their own quality plan.	NR.1.5
Bachelor's Degree in Nursing Training in the specialty area supported by recognized education -With a minimum of 4 years of experience post registration -Out of which, 3 years as a charge nurse.	What are the levels of education, training, and experience required?
Yes.	Does a BSN degree sufficient the educational requirement?
With a minimum of 4 years of experience post registration - Out of which; 3 years as a charge nurse.	What would be an adequate number of years to meet the experience component?
Training in the specialty area supported by recognized education.	What specialized training is required (if any)?
Please refer to Table 1	Qualifications of Saudi council classification Training certificate example

Table1

Standard #	Standard/Sub-Standard	Qualifications	Saudi Council Qualifications	Training Certificate
OR.2.1	The nurse manager in charge of the operating room is a qualified registered nurse with training, education, and experience in operative care.	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.
TICU.2.1	The nurse manager is a registered nurse qualified by education, training and, experience in managing critically ill patients.	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.
PICU.2.2	The nurse manager develops and collaborates with other departments as needed for developing policies and procedures for the pediatric intensive care unit (e.g., policies and practices related to infection control).	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.
NICU.2.1	The nurse manager is qualified by education, training, and experience in neonatal intensive care.	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.
CCU.2.1	The nurse manager is qualified by education, training, and experience in coronary care units.	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.
L&D.3.	The nurse manager in charge of the obstetrics department is a qualified registered nurse with education, training and experience in obstetrics.	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.
HM.2.1	The nurse in charge of the hemodialysis unit is a qualified registered nurse with training, education or experience in hemodialysis.	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.
ER.3.1	The nurse manager in charge of the emergency department is a qualified registered nurse with bachelor’s degree in nursing and appropriate education, training, and experience in emergency care.	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.
ORT.4.1	The nurse manager is a registered nurse qualified by education, training, and experience in the field of oncology/radiotherapy.	Minimum bachelor’s degree holder	Nurse Specialist	Recognized course in the specific area.

Infection Control

ANSWER

QUESTION

STD #

As we all know, an 'anteroom' is usually located between the negative pressure isolation room (Airborne Infection Isolation Room "AIIR")and the outside corridor of the healthcare facility.

Among the important reasons of this requirement is tohelp to prevent the infectious particles in the isolation room from escaping to the corridor and hence transmitting the infections to other unprotected staff/patients. This could be largely prevented through the availability of the ante-room which serves as an 'air lock' between the AIIR & the healthcare facility as when an isolation negative pressure room door is open, we expect to lose the negative pressure immediately and if there is an anteroom (that is usually neutral or slightly negative to the outside corridor), then the overall integrity of the suite is maintained with no or very minimal risk of spreading the infections to other people or places within the healthcare facility as mentioned above.

It serves as a site for hand washing, gowning and storage of protective clothing (gloves, aprons, masks).

Is it mandatory to have Negative Pressure room in ER or HEPA filter will be sufficient?

IPC 15.1

Air changesare accepted to be monitored as per hospital policy and manufacturer's recommendations."

1. The monitoring of air exchange is very difficult to be donebecause of practical reasons as we do not have the right tools to perform this.

IPC.15.3.3

Monitoring of air changes per cycle is accepted to be monitored as per hospital policy and manufacturer's recommendations.

As this is not possible for the Engineering Department to monitor as required by CBAHI, because the hospital has 47 negative pressure rooms, we would like to ask the CBAHI experts thru your kindness if monthly monitoring of air exchange is enough already?

IPC.15.3.3

As per CBAHI standards, the availability of an ante-room (that serves as a site for hand washing, gowning and storage of protective clothing) is mandatory. It is one of the Essential Safety Requirements (ESRs).

According to ministry of health, we most have negative pressure rooms, and we are in our process to have a new negative pressure rooms
The problem came that we do not have enough space for the ante- room.
So I need to check CBAHI standards for the ante -room, is it mandatory to have anteroom or we can run the isolation rooms without it since we will have at least 12 air cycle per hour?

CBAHI developed trilogy for this standard( rigid objective, flexible way and rigid achievement)

The mean and the end objective of this standard is to protect HCWs, patients, visitors, and others, through regularly and ongoing checking that an isolation room is always operating under negative pressure with appropriate air flow

Making surethat the capability of method, technique, design parameter and device is safely, accurately and reliably monitoring a pressure difference through (direct /indirect both, Visual/auditory remote alarm, smoke trail /tissue testing, Manometer/ Velometer…etc. ) is the responsibility of each hospital and depends upon hospital’s own policy and manufacturer’s recommendation .

So the IPC 15.3.3 does not mandate the way by which the negative pressure is checked. Instead, it facilitates whatever mean is convenient to the hospital in concordance with its policy and manufacturer’s recommendations

What does that mean?

It means that the Biomed engineer has to go inside the room daily and close all door tightly and wait for some timeto be able to measure the velocity of the air coming from theair source in the room which is the air-condition?

The procedure has to be done daily in every single room with apatient admitted to negative pressure room.

So imagine the amount of work needed and also the risk of exposurefor the Biomed.

IPC.15.3.3

To comply with CBAHI standard IPC 17.2, the hospital must provide a negative pressure procedure room for bronchoscopy procedures (as bronchoscopies are mainly performed to diagnose TB). Using HEPA filter will not be considered as fully compliant.

Cleaning and disinfection should be carried out by trained staff, in a disinfection designated area with traffic control in place and using approved disinfectant. It should be done according to hospital policy and procedures considering manufacture’s recommendations. The hospital should ensure the availability of adequate personal protective equipment for staff use as needed.

IPC.17.2 For bronchoscopy, the following is applied:

IPC.17.2.1Bronchoscopy is performed in a room with negative air pressure and at least twelve air changes per hour. Personal protective equipment is available including N-95/N-99 masks.

IPC.17.2.2Cleaning of the bronchoscopes begins immediately after the procedure to prevent drying or hardening of organic debris.

IPC.17.2.3Bronchoscopes are disinfected as per manufacturer’s recommendation.

Consequently, the ICU HOD in our hospital raised the issue of performing bronchoscopy in ICU in negative pressure room is not feasible especially if ICU negative pressure room is occupied already by another patient. Also, there are cases from regular ward scheduled for bronchoscopy at endoscopy unit where No negative pressure room in the endoscopy unit.

In this regard, we are raising our concern if we can use a HEPA filter during the bronchoscopy procedure in case if the procedure to be done and no negative pressure room is available, to comply with said CBAHI standard (IPC 17.2.1).

IPC 17.2.1

FAQs

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