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Central Board of Accreditation for Healthcare Institutions ?????? ??????? ??????? ??????? ??????

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Central Board of Accreditation for Healthcare Institutions . CBAHI SURVEY PROCESS – PowerPoint PPT presentation

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Title: Central Board of Accreditation for Healthcare Institutions ?????? ??????? ??????? ??????? ??????


1
Central Board of Accreditation for Healthcare
Institutions ?????? ??????? ??????? ???????
??????
  • CBAHI SURVEY PROCESS

2
Introduction form CBAHI chairman
3
(No Transcript)
4
  • Session 1
  • Introduction

5
Introduction
6
Accreditation
  • An organization is assessed by an
  • external body to determine its performance
    compliance with agreed standards and
  • the impact of its services on the patients.

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7
International Accreditation Body
Accreditation Organizations
National Accreditation Body
CBAHI Central Board for Accreditation of
Health care Institutions
8
The CBAHI Accreditation Standards
  • The CBAHI Accreditation Standards were developed
    by a consensus process of health care experts
    representing
  • MOH
  • national guards hospitals
  • KFSHRC
  • University hospitals
  • Private hospitals
  • Security Forces hospital
  • Saudi Council for Health Specialties
  • MRQP team
  • the standard have been approved by DR. HAMMED
    ALMANE (Minster of health) National Standards
    Preparation committee on 21-24 May 2006.

9
CBAHI Accreditation Purpose
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10
Mission
  • Improvement of healthcare quality standards in
    the Kingdom by supporting healthcare institutions
    to implement and accredit the medical quality
    standards and patient safety by national origin
    working systems, universal implementation, and
    distinguished efficiency.

11
  • Vision
  • Prestigious Global Commission in Healthcare
    quality development field.
  • Values
  • Commitment to excellence
  • Belief in team work
  • Application of quality standards
  • Holistic approach
  • Integrity

12
CBAHI Theme
13
  • Session 2
  • How CBAHI Supports Hospitals?

14
How CBAHI Supports Hospitals?
15
WWW.CBAHI.ORG/RM
cbahi
16
Std. Statement
Std. Intent
Preparation Tool (PT)
Teaching tools
Sample
17
SELF ASSESSMENT
The process starts with the Hospital completing
the self assessment
  • www.cbahi.org/hospital

18
Hospital Accreditation Guide
  • The hospital can download the HAG from this
    site
  • www.cbahi.org/hospital

19
Hospital Accreditation Guide
20
Hospital Accreditation Guide
21
Hospital Reporting Site
  • Preparation Tools (PT) are statements that detail
    the specific performance expectations and/or
    structure or process that must be in place
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  • PT are evaluated by the following scale
  • 0 insufficient compliance
  • 1 minimal compliance
  • 2 partial compliance
  • 3 satisfactory compliance

22
Example of MS chapter
MS.23. The department head shares his/her findings with the Medical Director and works closely to improve and correct their deficiencies. MS.23. The department head shares his/her findings with the Medical Director and works closely to improve and correct their deficiencies. MS.23. The department head shares his/her findings with the Medical Director and works closely to improve and correct their deficiencies.
Preparation Tool(s) Preparation Tool(s) Preparation Tool(s)
Code Preparation Tool PSOI
MS.23.PT1 Evidence of communication between the head of department and medical director Interview
MS.23.PT2 Sampling of quality improvement project in the medical departments refetc. sharing findings Observation
MS.23.PT3 The meeting minutes contain evidence that the department head shares his/her findings with the Medical Director Document Review
23
Example of pharmacy chapter
PH.2. The pharmacy has a clear mission, vision, and values. PH.2.1  Mission is clearly written, posted, and verbalized by pharmacy staff. PH.2.2  Vision is clearly written, posted, and verbalized by pharmacy staff. PH.2.3  Values are clearly written, posted, and verbalized by pharmacy staff. PH.2. The pharmacy has a clear mission, vision, and values. PH.2.1  Mission is clearly written, posted, and verbalized by pharmacy staff. PH.2.2  Vision is clearly written, posted, and verbalized by pharmacy staff. PH.2.3  Values are clearly written, posted, and verbalized by pharmacy staff. PH.2. The pharmacy has a clear mission, vision, and values. PH.2.1  Mission is clearly written, posted, and verbalized by pharmacy staff. PH.2.2  Vision is clearly written, posted, and verbalized by pharmacy staff. PH.2.3  Values are clearly written, posted, and verbalized by pharmacy staff.
Preparation Tool(s) Preparation Tool(s) Preparation Tool(s)
Code Preparation Tool PSOI
PH.2.PT1 Pharmacy mission, vision, and values are clearly written Document Review
PH.2.PT2 Pharmacy mission, vision, and values are posted Observation
PH.2.PT3 Pharmacy mission, vision, and values are verbalized Interview
24
Example of IC chapter
IC.16. There is a system that separates patients with communicable diseases and those who are colonized or infected with epidemiologically important organisms from other patients, staff and visitors. IC.16.1 There are written policies procedures that address standard isolation precautions. IC.16. There is a system that separates patients with communicable diseases and those who are colonized or infected with epidemiologically important organisms from other patients, staff and visitors. IC.16.1 There are written policies procedures that address standard isolation precautions. IC.16. There is a system that separates patients with communicable diseases and those who are colonized or infected with epidemiologically important organisms from other patients, staff and visitors. IC.16.1 There are written policies procedures that address standard isolation precautions.
Preparation Tool(s) Preparation Tool(s) Preparation Tool(s)
Code Preparation Tool PSOI
IC.16.PT1 Written Policies and procedures on standard and isolation precautions. Document Review
IC.16.PT2 Evidence of staff awareness of standards and isolation precautions (Interview) Interview
IC.16.PT3 Evidence of compliance with standard and isolation precautions Observation
25
  • Session 3
  • Survey Process

26
Survey Process
27
CBAHI Surveyor Team
(1) or two (2) days)
(3) or four (4) days
All seven will go together first day during
accreditation surveys and may be on different day
during mocks.
28
CBAHI Survey Process
  1. Hospital accreditation Result has to be approved
    by the Central Board before it is given to the
    hospital.
  2. The surveyors are not permitted to provide hints
    to the hospital regarding the accreditation
    status .

29
Applicability of Chapters and Standards
  • In general, organization wide chapters are
    mandated chapters.
  • They are
  • Leadership, Medical Staff and provision of care,
    Nursing, Quality and Patient Safety, Patient and
    family rights, patient and family education,
    Infection control, pharmacy, laboratory, facility
    management and safety, management of information
    and medical records. Ambulatory services,
    Emergency Room, Anesthesia, Dietary Service, and
    Social Work functions are applicable to all
    hospitals.

30
Applicability of Chapters and Standards
Chapter Chapter specialty Applicability
Chapter VII Intensive Care Unit (ICU) 1. Adult, Pediatric (ICU/PICU 2. Coronary Care Unit (CCU) 3. Neonate (NICU) ICU All hospitals - Pediatric ICU based on scope of services CCU applies for hospitals providing invasive cardiac procedures NICU for hospitals providing obstetric care
Chapter IX Labor Delivery (LD) For hospitals providing obstetric care
Chapter X Haemodialysis (HM) For hospitals providing renal dialysis
Chapter XIII Burn Care (BC) Based on Scope of Services
Chapter XIV Medical Radiation Oncology (MRO) Based on Scope of Services
Chapter XV Psychiatry (PS) For hospitals providing in-patient psychiatry services
Chapter XVI Specialized Areas (SA) Rehabilitation (RH) Based on Scope
Chapter XVII 2. Dental Services (DN) Based on Scope
31
Scoring Method
  • The hospital must meet all the applicable
    standards elements at a satisfactory level to
    become accredited. Each standard element is
    scored on a four-point scale
  • Initial Survey
  • 3 Fully Met when 75 compliance with the
    standards elements.
  • 2 Partially Met when 50 to lt 75
    compliance with the standards elements.
  • 1 Minimally Met when 25 to lt 50
    compliance with the standards elements.
  • 0 Not Met when lt 25 compliance with the
    standards elements.

32
Accreditation Decision Rules
  • General Principles
  • All CBAHI chapters have equal weight regardless
    of the standard contents. Additionally, all
    standards within a chapter weigh equally.
  • Each standard is assigned ONE point. The ONE
    point is divided equally among the elements when
    more than one required element exists.

33
Accreditation Decision Rules
  • The score of each standard represents the mean
    score of the included elements.
  • Each chapter score is calculated as the mean of
    standards scores. The overall hospital score is
    calculated as the mean of the scores of all
    chapters. All scores are presented as percentage.

34
Accreditation Decision Rules
  • Accredited The hospital is awarded
    accreditation if
  • the overall compliance score equals to or more
    than 80
  • No more than 2 chapters score less than 50

35
Accreditation Decision Rules
  • We were asked
  • Why the passing mark is 80?
  • And the answer is
  • We do not have bold standards
  • More than 70 of our standards are essential
    structural standards.

36
Accreditation Decision Rules
  • Accreditation Denied The hospital will be
    denied accreditation if
  • the overall score is less 70 or
  • more than 2 chapters score less than 50

37
Accreditation Decision Rules
  • 70 to 79
  • Hospitals scoring from 70 to 79 is required to
    be resurveyed within 90 days of the result for
    chapters that score less than 50

Validity of accreditation every 3 years
38
  • Session 4
  • HOSPITAL SURVEY ACTIVITIES

39
Survey Activities
Agenda
40
Hospital Survey Activities
41
Documents Review
  • The hospital is expected to prepare binders to
    facilitate the review of their documents in
    relation to compliance to the CBAHI National
    Hospital Standards.
  • The binders to be organized according to the list
    provided in this guide.
  • The list reflects the arrangements based on the
    surveyor conducting review (not based on the
    chapters).
  • It is very much encouraged that the surveyor
    counter-part is oriented to the document
    arrangement.

42
Document Review General Guidelines
  • The scope of this activity is to ensure hospital
    adherence to the CBAHI requirements, especially
    that most standards main requirements are the
    presence of policies and/or completion of certain
    records
  • The 1st document surveyors need to review and
    clarify as a team is the hospitals' policy
    management system (policy on policies), which is
    addressed in LD.28. The hospital should introduce
    their system in the opening conference.

43
Document Review General Guidelines
  • If a needed document is not available the
    surveyor will ask the hospital representative to
    present it preferably within the survey day. The
    hospital will be given chance to present any
    missing evidence within the survey period.

44
Document Review General Guidelines
  • (PH-IC-FMS-LAB) for specialty area, evidence of
    compliance must be presented within the specialty
    survey day (by the end of day 1)
  • Hospitals will be considered in compliance with
    the standards requirements if a track record of
    the past four (4) months of the survey date was
    presented, such as meeting minutes and data
    trends or 4 meeting minutes.

45
Medical Records Review General Guidelines
  • Hospitals are requested to have the list of the
    last month discharge patients ready by the
    Surveyors Planning Session on day 1.
  • Required medical record list will be requested
    after the Opening Conference based on the month
    discharged cases
  • Hospitals to clarify their documentation
    guidelines prior to the medical records review
    session to smooth the process

46
Personnel File Review General Guideline
  • The scope of the personnel file review is the
    completeness of documentation of the recruitment,
    orientation, evaluation, continuing education,
    privileges and competencies process and
    monitoring.
  • Hospitals are encouraged to present the needed
    documentation in one location to ensure
    comprehensiveness of personnel data and history
    during his/her employment in the organization.

47
Leadership Interview
  • Decision making process based on data,
  • Participation in quality improvement activities
  • Understanding of patient safety concept and
    goals,
  • Understanding of hospital mission,
  • Sentinel events and OVR reporting, Root Cause
    Analysis
  • Patient and family right

48
Staff Interview and Observations
  • Unit rounds for Staff Interview and Observations
  • posting and knowledge of hospital mission,
  • OVR reporting,
  • understanding of assigned jobs,
  • Understanding of infection control guidelines,
  • Understanding of safety and security codes,

49
Visits to Patient Care settings
  • During these visits the survey team may talk with
    managers, direct care providers, and patients.
    The team also observe
  • Reviews open medical records
  • Environment of care
  • Infection control
  • Patient care
  • Staff communications
  • Patient rights issues

50
Hospital Survey Report
Hospitals will be able to access their survey
report through their "hospital portal". The
report face-sheet will show the overall final
score and the scores of each chapter.
51
(No Transcript)
52
Hospital Feedback Form
Hospitals are requested to complete a Hospital
Survey Feedback form after the survey visit has
been completed
53
CD Content
  • HAS visit Agenda
  • Hospital Accreditation Guide
  • Application form (demographic questionnaire)
  • Survey tools packages
  • Hospital self assessment Application
  • HAS presentation
  • HAS visit report
  • Acknowledgment letter

54
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Thank You.
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