Cbahi hospital accreditation guide october 2016

1. Page 1 of 134 Hospital Accreditation Guide Oct-2016 Hospital Accreditation Process Guide October
2016

2. Page 2 of 134 Hospital Accreditation Guide Oct-2016 Introduction The Saudi Central Board for
Accreditation of Healthcare Institutions (CBAHI) Hospital Accreditation Process Guide was developed to
serve as a reference for hospitals during the preparation for accreditation surveys as well as
maintenance of accreditation. This guide is to be used in conjunction with the third edition of CBAHI
Hospital Accreditation Standards manual. It has been created to help hospitals learn about the third
edition of the national hospital accreditation standards’ survey process. In addition, the guide has been
designed to provide hospitals with an authoritative resource to use in preparation for an accreditation
survey. It addresses the activities required for conduction of a hospital survey and form the basis for a
successful accreditation survey. Additionally, it provides hospitals with a means of ongoing self-
assessment and continuous improvement. CBAHI employs a dynamic development process to fulfill our
mission as a driver for continuous improvement. Any further modifications will be communicated to the
hospitals through later editions and amendments. About CBAHI What is CBAHI? CBAHI, or the Central
Board for Accreditation of Healthcare Institutions is a governmental organization that promotes the
quality, value, and optimal outcomes of health. CBAHI currently accredits in the following areas:
Hospitals Primary Healthcare Centers (PHC) Regional labs and blood banks Mission To promote
quality and safety by supporting healthcare facilities to continuously comply with accreditation
standards. Vision To be the regional leader in improving the healthcare quality and safety. Values
Commitment to excellence Team spirit Integrity Professionalism

3. Page 3 of 134 Hospital Accreditation Guide Oct-2016 Registration with CBAHI All hospitals are
required to register with CBAHI. To register, the following steps are followed: 1. Access
www.cbahi.gov.sa in the address bar 2. Choose "Health Care Facility" and click register. 3. You will be
directed to other web page. 4. Start entering your hospital information. After completing all required
information, you are required to: 1. Type the security numbers as they appear on the left bottom of the
page. 2. A message about completion of registration will be displayed specifying the Username and
Password. 3. Use the specified Username and Password to access the hospital portal. Scope of
Accreditation Surveys The scope of the CBAHI survey includes all standards-related functions of the
surveyed hospital. Each assessment survey is tailored to the type, size, and range of services offered by
the hospital. Applicable standards from the hospital standards manual are determined by Healthcare
Accreditation Department (HAD) staff based on the scope of the services provided by the hospital
undergoing a survey. Additionally, the on-site survey team will consider the specific applicability of
individual standards. The following chapters are considered mandatory for all hospitals: 1. Leadership
(LD) 2. Human Resources (HR) 3. Management of Information (MOI) 4. Medical Records (MR) 5. Quality
Management and Patient Safety (QM) 6. Social Care Services (SC) 7. Patient and Family Rights (PFR) 8.
Medical Staff (MS) 9. Radiology Services (RD) 10. Physiotherapy Services (PT) 11. Respiratory Care
Services (RS) 12. Dietary Services (DT) 13. Nursing Care (NR) 14. Patient and Family Education (PFE) 15.
Provision of Care (PC) 16. Anesthesia Care (AN) 17. Emergency Care (ER) 18. Critical Care (ICU – CCU-
PICU) 19. Operating Room (OR) 20. Medication Management (MM) 21. Infection Prevention and Control
(IPC) 22. Laboratory (LB) 23. Facility Management and Safety (FMS)
4. Page 4 of 134 Hospital Accreditation Guide Oct-2016 Goal of Accreditation Surveys The goal of the
survey is to determine if the hospital is in compliance with CBAHI Hospital Accreditation Standards. Also
where appropriate, CBAHI surveyors provide education and consultation to the hospital’s staff
throughout the survey to help them improve their clinical and administrative processes. Assessment of
Compliance The CBAHI expects substantial compliance with all applicable standards. The surveyors
assess compliance with standards through a combination of data sources that include at least one of the
following: 1. Interviews with hospital Leadership, clinical and support staff, patient and family.
Observation of patient care and services provided. 2. Building tour and observation of patient care
areas, building facilities, equipment management, and diagnostic testing services. 3. Review of written
documents such as policies and procedures, orientation and training plans and documents, budgets, and
quality assurance plans. 4. Review of personnel files. 5. Review of patients’ medical records. 6.
Evaluation of the hospital’s achievement of specific outcome measures (e.g., hospital-acquired infection
rates, patient satisfaction) through a review and discussion of monitoring and improvement activities.
Accreditation Decision Rules Hospitals are expected to be in continuous compliance to CBAHI standards.
Full compliance is expected upon the effective date of the standards including the effective date of any
revisions thereto. The hospital must meet all applicable standards at a satisfactory level to become
accredited. Hospitals undergoing their first survey need to demonstrate a track record of four months of
compliance, while hospitals undergoing their triennial survey need to demonstrate twelve months of
compliance prior to survey (or from the effective date of the new standards if less than 12 months). The
effective date of the new requirements in this edition will be January 2016. All standards have one or
more sub-standard(s). The sub-standards are the elements of the standards that are reviewed and
scored by the surveyor on site. Each sub-standard is scored on a three-point scale based on the degree
of compliance with the sub-standard’s requirements: “0” = Insufficient compliance when < 50 %
compliance with the sub-standard and/or compliance is less than two months to the initial survey or less
than six months for the triennial survey. “1” = Partial compliance when ≥ 50 to < 80 % compliance with
the sub-standard and/or compliance is for two to less than four months only prior to the initial survey or
six to less than twelve months for the triennial survey.

5. Page 5 of 134 Hospital Accreditation Guide Oct-2016 “2” = Satisfactory compliance when ≥ 80 %
compliance with the sub-standard or compliance is for four months prior to the initial survey or twelve
months for the triennial survey. “NA” = Not Applicable indicates that the standard/sub-standard does
not apply to the hospital. The overall score of the hospital is automatically calculated by the software
application using the average (arithmetic mean) score of all applicable sub-standards, i.e. as the sum of
all values divided by the number of values added. When one or more chapters, standards, and/or sub-
standards of the standards manual are not applicable in a particular hospital, they are indicated by
“N/A”. Non applicable chapters and standards are not scored and are not included in either the
numerator or denominator of the overall score. Scoring guidelines apply a similar method to sub-
standards requiring a sample for assessment of compliance. For example, if observations are positive in
≥ 80 % of cases, if interviewees provide proper answers in ≥ 80 % or if the average of positive findings in
personnel records or medical records is ≥ 80 %, the score of the sub-standard will be fully met. The
Accreditation Decision Committee shall recommend one of the following accreditation decisions:
Accredited: Accreditation will be awarded when the surveyed hospital demonstrates an overall
acceptable compliance with all applicable standards at the time of the initial (or reaccreditation) on-site
survey, and there are no issues of concern related to the safety of patients, staff or visitors.
Accreditation will also be recommended when the healthcare facility has successfully addressed all
requirements following a conditional accreditation and does not meet any rules for other accreditation
decisions. The decision to grant accreditation is not always straightforward. In some cases though, the
Accreditation Decision Committee may consider the need for more clarification and/or a follow up
focused survey of specific standards/areas of concern or noncompliance before a consensus decision to
grant accreditation can be reached. This will also give the hospital a period of time to come into
acceptable compliance. Scoring Guidelines: Overall score 85% or above and All essential safety
requirements are in satisfactory compliance and No other issues of concern related to the safety of
patients, visitors or staff. Conditional Accreditation: Conditional Accreditation is granted when the
hospital demonstrates a tangible compliance with all applicable standards at the time of the on-site
survey but still has not met requirements for accredited status. The hospital is required then to develop
a “Standards Compliance Progress Report”, followed by a “follow up Focused Survey” if required before
changing the accreditation status. The non-compliant standards may include essential safety
requirements and/or other standards/issues of concern related to the safety of patients, staff or visitors.
Scoring Guidelines: Overall score 75% or above and less than 85% and/or Some of the essential
safety requirements (but not exceeding 25% of them) are not in satisfactory compliance. Preliminary
Denial of Accreditation (PDA):

6 Page 6 of 134 Hospital Accreditation Guide Oct-2016 Preliminary Denial of Accreditation (PDA) is a
stage -rather than a final accreditation decision- that precedes denial of accreditation. The aim of
allowing this stage is to give some additional time for review and/or appeal before the determination to
deny accreditation. It results when there is one or more of the following reasons to justify denying
accreditation: Presence of an immediate threat to the safety of patients, visitors or staff that is
observed by CBAHI surveyors during the on-site survey. Significant noncompliance with the
accreditation standards at the time of the on-site survey. Failure of timely submission of the post
survey requirements after conditional accreditation. The hospital has received conditional
accreditation and was subjected to a follow up focused survey but still could not meet the requirements
for accreditation. Reasonable evidence exists of fraud, plagiarism, or falsified information related to
the accreditation process. Falsification is defined as the fabrication of any information (given by verbal
communication, or paper/electronic document) provided to CBAHI by an applicant or accredited
healthcare facility through redrafting, additions, or deletions of a document content without proper
attribution. Plagiarism is perceived by CBAHI as the deliberate use of other healthcare facility original
(not common-knowledge) material without acknowledging its source. In this case, the hospital is
required to respond to CBAHI by sending an official clarification letter within five working days of the
communication. Refusal by the hospital to receive the survey team and conduct a survey. In this case,
the hospital will receive upfront denial of accreditation and will be subject for exclusion from the
national accreditation program. Denial of Accreditation: Results when a health care facility shows a
significant noncompliance with the accreditation standards at the time of the on-site survey. It also
results if one or more of the other reasons leading to preliminary denial of accreditation have not been
resolved. When the hospital is denied accreditation, it is prohibited from participating in the
accreditation program for a period of six months, unless the Director General of CBAHI, for good reason,
waives all or a portion of the waiting period. Scoring Guidelines: Overall score less than 75% and/or
More than 25% of the essential safety requirements are not in satisfactory compliance. Special scoring
considerations A selected group of standards have been assigned as Essential Safety Requirements
(ESR) indicated with a circular icon that contains the letters ESR in the standards manual. All ESRs should
be in full compliance for the hospital to be accredited. If more than 25% of ESRs are partially or not met,
the hospital will get Conditional Accreditation. The hospital is required then to develop a “Standards
Compliance Progress Report”, followed by a “follow up Focused Survey” if required before changing the
accreditation status. Criticality of the non-compliant standard(s) -i.e. the degree of severity and
immediacy of risk to patients, visitors or staff safety- has several levels. The most serious of which is
when the surveyor notices an immediate threat to safety or quality of care. Examples include: o
Healthcare provider is entering an isolation room without proper Personal Protective Equipment (PPE).

7. Page 7 of 134 Hospital Accreditation Guide Oct-2016 o Expired catheter is being used during central
line insertion or other invasive procedure. o Bare electrical wire is hanging down without any protection.
o Incompatible blood sample is sent from the operating room while the operation is in progress. o A
new-born is not properly identified. When CBAHI surveyor notices an immediate threat whether linked
or not linked to the standards or the ESRs, the survey team leader will notify the hospital director and
will include the findings in the survey report. Consequently, the hospital will receive a preliminary denial
of accreditation until the issue is resolved through a Corrective Action Plan, and possibly a follow up
focused survey for verification. Hospital Responsibilities Hospital’s survey coordinator When the hospital
completes its survey application, the hospital should select a person to serve as hospital’s survey
coordinator to handle the logistics of the survey visit. The hospital’s survey coordinator designated by
the hospital will serve as the liaison with the Healthcare Accreditation Department (HAD) and the survey
team leader about the survey visit arrangements. Survey Team A list of survey team members, with their
biographies, will be sent to the hospital prior to the survey visit. The hospital should contact the
Healthcare Accreditation Department (HAD) promptly if any surveyor is deemed to be inappropriate due
to conflict of interest or other valid reasons. Note: CBAHI cannot honor requests for specific surveyors
for the purpose of objectivity. Travel Arrangements The hotel and flight reservations will be arranged by
CBAHI. All flights are booked to be the night before the survey. A list of assigned surveyors together with
their flights’ details and mobile numbers will be sent to the hospital’s survey coordinator prior to the
survey. The hospital should arrange ground transportation from the airport to the hotel. The hospital
should decide how to transport the team members each day between their hotel and the hospital and
to any remote sites they will visit as part of the survey. The survey team leader and hospital’s survey
coordinator should determine where and when the team will be picked up or meet at the hotel.
Additionally, the hospital should arrange transportation from the hotel to the airport according to the
departure time of surveyors. Staff Involvement A well-conducted survey requires important information
from a broad range of staff for the deliberations of the survey team. All survey team members interview
different staff categories about a variety of topics to ensure that the team has access to truly
representative information related to implementation of CBAHI standards from staff. Conflict of Interest
CBAHI works to ensure the integrity and fairness of all businesses run by the employees working in the
central office as well as the surveyors. In addition, all healthcare facilities engaged in CBAHI

8. Page 8 of 134 Hospital Accreditation Guide Oct-2016 accreditation process are required to refrain
from any actual or potential act or behavior that might create a conflict of interest including:
Proposing any fee, remuneration, gift, or gratuity of any value to CBAHI employees or surveyors for
performance of their duties or survey-related activities. Employing or contracting or having any
financial relationship with CBAHI employees or surveyors for the purpose of the provision of consulting
or related services in any capacity, either directly or through another party. This includes services
provides in preparation for the survey, assisting in preparation of the self-assessment, conducting mock
surveys, helping in the interpretation of the standards, and alike. All requests for consulting services
utilizing one of CBAHI associates shall be directed to CBAHI central office. Not declaring to CBAHI any
business (including consulting) or recruiting relationship with one or more of CBAHI surveyors either
directly or through another party with whom he or she is affiliated, at any time during the preceding
three (3) years. Survey Logistics Hospitals should provide appropriate logistics that include the following:
A workroom that is large enough for the survey team members to review documents and leave
computers and binders. The workroom needs to be furnished with a desk or table, access to electrical
outlets, and internet access. A workroom(s) for group meetings and interviews with staff as specified
in the survey agenda. Assigning a counterpart for each surveyor who is a responsible person for the
same specialty during the survey. Hospital Observers When the hospital’s team includes an observer,
who may represent a consulting firm or staff from other hospitals, the hospital must inform CBAHI and
obtain its official approval at least one week prior to the survey. Observers must not participate in the
survey activities. CBAHI observers/mentors One or more observers or mentors may join the CBAHI
survey team as part of the surveyors’ training process. Observers and mentors from CBAHI side will be
included in the list of the surveyors sent by hospital accreditation department prior to the survey.

9. Page 9 of 134 Hospital Accreditation Guide Oct-2016 CBAHI Survey Process Overview This section
details the various activities of a hospital survey. For better understanding of the accreditation survey
process, the survey related activities are organized into the following three sections in this guide: Pre-
Survey Activities On-Site Survey Activities Post-Survey Activities Pre-Survey Activities Enrollment for
Survey The accreditation process begins with selection of the hospitals to be surveyed. Each year, CBAHI
selects the hospitals to be enrolled in the accreditation program. CBAHI sends a letter of enrollment to
the selected hospitals to start their application process. Application for Survey After completion of the
enrollment process, hospitals selected for the accreditation process must complete Survey Application
Form available on the CBAHI website. The form contains information regarding the organization and its
facilities and services to enable establishment of a facility profile. The form is divided into sections with
guidelines to clarify the information required for every section. The access to the e-App is provided by
CBAHI to intended hospitals. The encoded data may be saved in stages and updated as needed. The
Survey Application Form is completed as follows: Visit www.cbahi.gov.sa/hsa Enter your user name
and password Complete and submit the hospital demographic questionnaire Under the “Survey
Process” menu, select “Apply for a new Survey” o Select type of survey and the date Not Applicable
chapters Update of Application Information The hospitals are made aware that planning of the surveys
is done according to the scope of services they complete in the application form. If a hospital
experiences significant changes after it submits its application, the changes must be made in the
application form within five (5) business days of this change. Note: The requirement of updating the
application information includes updates of the main contact persons of the hospital to ensure an
ongoing communication channel with the hospital and facilitate, when

10. Page 10 of 134 Hospital Accreditation Guide Oct-2016 needed, timely communication of possible
updates of CBAHI accreditation policies or standards to concerned facilities. Application for
Reaccreditation Survey The update for a re-accreditation survey should be completed by accredited
hospitals. This update for re-survey must be completed and submitted to CBAHI twelve weeks prior to
the accreditation expiration. Resources to Assist Hospitals CBAHI will assign each hospital enrolled for a
survey a HAD’s accreditation coordinator, who will serve as a primary contact between the hospital and
Healthcare Accreditation Department (HAD). This individual will coordinate survey planning and will be
available to the hospital to answer questions and clarify issues related to the survey process. In order to
assist hospitals for preparation of surveys, hospitals are offered the following resources: 1. CBAHI
Standards Manual All hospitals receive a copy of the standards manual upon registration with CBAHI.
This will facilitate for the hospital to gain better understanding of the standards’ requirements as well as
the accreditation policies. The standard manual is divided into three parts: Part I -- Introduction and
explanatory notes Part II -- CBAHI accreditation policies Part III -- Accreditation standards for
hospitals 2. Accreditation Process Guide The Accreditation Process Guide provides additional useful
information to assist hospitals prepare for a survey. Additionally, it emphasizes self-assessment and
ongoing standards compliance and continuous quality improvement. The hospitals are provided with
this guide upon successful registration with CBAHI. 3. Self-Assessment Tool (SAT) A successful self-
assessment will provide valuable information that may be used for modification and improvement of
the performance of the hospital. Upon receipt and review of the hospital’s application, the hospital will
receive electronic access to a self-assessment tool (SAT). The SAT will facilitate for the hospital its self-
assessment and follow up of the progress of implementation. The SAT is fully explained in the
accreditation maintenance section of this document as part of the post-survey activities. 4. Hospital
Orientation Programs (HOP) CBAHI provides orientation programs in different regions of the Kingdom of
Saudi Arabia. It offers hospitals an introduction to the standards and their implementation, the
accreditation policies, as well as the survey process to make the survey preparation successful. Dates
and venues of the orientation programs are communicated to the hospitals in a timely manner. 5. Mock
Survey

11. Page 11 of 134 Hospital Accreditation Guide Oct-2016 Some hospitals will prefer to go for a Mock
Survey but this is subject to the availability of adequate resources at CBAHI and the requirement of its
operational plans. CBAHI therefore is not obliged to respond to all incoming mock survey requests. 6.
Consultative Visit CBAHI provides consultative visits upon request. These visits are optional and depend
on the availability of CBAHI resources. The consultative visits provide in-depth explanation of one or
more of the functions or areas covered by the standards. 7. Requests for Interpretation of Accreditation
Standards and Policies CBAHI responds to requested interpretation of an existing accreditation standard
or policy. Requests must be made in writing. Information on submitting a written request is available on
the CBAHI website. The requester can fill out a “contact us” form. Survey Team Composition Each
accreditation survey is tailored to the type, size and range of services provided by the hospital. A survey
team is organized by CBAHI to conduct the on-site survey in order to determine the hospital’s
compliance with the standards’ requirements. The survey team size and composition is based on a
careful review of the following factors as provided in the application for survey: Size of the facility to
be surveyed, based on average daily census; Complexity of services offered, including surgical and
anesthesia services; Whether the facility has special care units or off-site clinics or locations. Based on
the above information, the CBAHI decides the length of the on-site survey and the number and the
disciplines of the surveyors. In a typical full survey of a hospital, the survey team would include seven (7)
surveyors who will be at the facility for three or more days. One of these surveyors will be assigned as a
team leader. Each hospital survey team is comprised of two teams as follows: The Core team,
composed of three surveyors: administrator, nurse, and physician. The Specialty Team, composed of
four surveyors: Pharmacist, Infection Control specialist, Laboratory specialist, and facility management
and safety specialist. CBAHI may require a surveyor(s) to undergo a limited on-site survey when, in the
judgment of CBAHI, such an evaluation is warranted. This limited survey focuses on particular area(s)
identified by CBAHI. Examples may include, but not limited to, a specific issue such as a complaint or a
sentinel event and evaluating changes introduced by the hospital that were not available the time of a
previous survey. The survey team and the duration of the survey are determined by CBAHI on an
individual bases. The scope of the survey is limited to addressing the related issues. There is no set
agenda. Survey Team Members The survey team members are experienced health professionals, who
have been trained as surveyors. Prior to the survey, the surveyors review information related to the
hospital from the following: Application information Mid-term self-assessment and related
corrective action plan(s)

12. Page 12 of 134 Hospital Accreditation Guide Oct-2016 Offsite required documents Any other
relevant documents as decided by CBAHI These documents provide the surveyors an opportunity to
verify whether the facts in the hospital documents are consistent with the actual practice. These facts
are taken into consideration while evaluating the corresponding CBAHI standards. Each member of the
survey team is responsible about a set of chapters and occasionally with few standards from other
chapters in relation to his/her specialty. In general, the surveyors are allocated to chapters as follow:
Leadership & Quality Management Surveyor o Leadership (LD) o Human Resources (HR) o Management
of Information (MOI) o Medical Records (MR) o Quality Management and Patient Safety (QM) o Social
Care Services (SC) o Patient and Family Rights (PFR) Medical Surveyor o Medical Staff (MS) o Radiology
Services (RD) o Physiotherapy Services (PT) o Respiratory Care Services (RS) o Dental Care (DN) Nursing
surveyor o Dietary Services (DT) o Nursing Care (NR) o Patient and Family Education (PFE) Chapters
evaluated jointly by medical and nursing surveyors o Provision of Care (PC) o Anesthesia Care (AN) o
Burn Care (BC) o Emergency Care (ER) o Labor and Delivery (L&D) o Hemodialysis (HM) o Critical Care
(ICU – NICU – PICU – CCU) o Operating Room (OR) o Oncology and Radiotherapy (ORT)

13. Page 13 of 134 Hospital Accreditation Guide Oct-2016 Medication Management Surveyor o
Medication Management (MM) Infection Control surveyor o Infection Prevention and Control (IPC)
Laboratory surveyor o Laboratory (LB) Facility Management and Safety surveyor o Facility
Management and Safety (FMS) Survey Scheduling and Survey Agenda The Healthcare Accreditation
Department (HAD) handles all scheduling and survey agenda arrangements for surveys in cooperation
with the relevant hospital representative(s). Information received from the hospital through the
completion of the survey application form will guide the flow of the survey. The agenda of the visit
reflects the activities to take place during the survey. CBAHI surveyors and hospital’s staff will
participate in those activities. A survey agenda has been developed for a survey that reflects a 3 days
survey, which is the duration of most surveys carried out by CBAHI. Hospitals with wider scope of
services and larger bed capacity (such as tertiary care hospitals and physically large facilities with
multiple buildings and locations) may have a survey for 4 or 5 days with a corresponding agenda of the
same duration. The Healthcare Accreditation Department (HAD) will communicate the survey agenda to
the hospital at least three weeks (3) prior to the survey. For more details on standard agenda items,
please refer to Annex A. Please note that the prayer time difference in the various regions of the
Kingdom may affect the survey agenda for the business lunch time. For more details on the hospital
representatives and agenda item requirements, please refer to each activity detailed in this guide.
Scheduling and postponement of surveys are detailed in the accreditation policies section of the
standards manual. The Self-Assessment Tool (SAT) The self-assessment tool (SAT) has been developed to
assist hospitals measure their compliance with CBAHI standards, maintain a status of accreditation
readiness, and oversee the quality and safety of patient care. The tool is aimed at leadership working in
a hospital. It is intended for use by the hospital leadership, planners, hospital committees’ team
members, and other personnel with a responsibility for their facility’s plans, policies, and procedures. It
has been designed to encourage participants to meet together and discuss issues relating to compliance
as well as non-compliance with CBAHI standards. The tool is expected to provide hospitals with means
of evaluating their plans, policies, procedures and capabilities against current CBAHI standards.
Additionally, it provides an opportunity for members of the management team to reflect on their
progress, think about areas for improvement and focus their improvement activities on areas that are
relevant to CBAHI standards. The CBAHI hopes that this tool will enable the hospital to: Identify its
own strengths and weaknesses Identify and take forward areas for improvement

14. Page 14 of 134 Hospital Accreditation Guide Oct-2016 Understand more clearly the issues that are
of interest to CBAHI Export the data for analysis and evaluation by CBAHI How this self-assessment
tool is constructed The SAT is designed to walk the user through all the CBAHI hospital accreditation
standards. The tool is designed to include all standards arranged per chapters that parallel the CBAHI
standards manual. The tool allows the users to keep track of the specific planning and response
considerations their hospital has addressed. This SAT contains a number of sections under each chapter:
A standard section that contains a standard with its related sub-standards drawn from current CBAHI
standards manual. An activity section that contains the activity (and related activities, if applicable)
that will be used to assess this sub-standard. A document description section that contains the name
and the description of the document required in this sub-standard (if applicable). A scoring section
contains scoring points which you consider when reflecting on a sub-standard statement. A comments
box gives you space to record the assessment findings of your compliance, highlight strengths and
weaknesses and document your improvement plan. How frequently should the self-assessment be
performed? CBAHI accreditation policies require hospitals to conduct self-assessment during
preparation for an initial survey and at the middle of an accreditation cycle of an accredited hospital,
i.e., eighteen months after awarding accreditation. During preparation for an initial survey, the SAT
facilitates the process of evaluation of the hospital’s readiness for an accreditation survey in addition to
helping the hospital in preparation for the survey. o All registered hospitals with CBAHI should do self-
assessment and submit to CBAHI within 3 months of notification of their enrollment in CBAHI visit plan
per that year. o To be eligible for CBAHI visit you should have a SAT score of 70% or more and all ESRs
are in full compliance. o If SAT score below 70% and/or ESRs are not in full compliance, the hospital will
be not eligible for CBAHI visit temporarily till re-submission of SAT again after more 3 months to re-
evaluate their readiness and hospital visit will be decided thereafter. Three months before the middle
of an accreditation cycle (fifteen months after the accreditation award), each accredited hospital will be
notified regarding its due time for submission of its SAT. The hospital has three months to conduct and
submit its self-assessment. The hospital is required to send CBAHI its self-assessment together with an
action plan for standards that are not in full compliance. The CBAHI requirements related to the mid-
term self-assessment are detailed in the accreditation policies section of the standard manual. CBAHI
considers that the self-assessment is an important part of the process of hospital improvement, and is
recommended to be an ongoing activity within the hospital. Hospitals are recommended to perform the
self-assessment more frequently (e.g., quarterly) to ensure ongoing compliance, look at progress
overtime, and consequently improve the quality and safety of services provided. How to use this tool
There are three point rating scales which ask you where the hospital is with respect to the issues
underlying the sub-standards. The hospital staff record which standards the hospital has insufficient
compliance, partial compliance or satisfactory compliance. Each sub-standard is scored from 0–2 where
15. Page 15 of 134 Hospital Accreditation Guide Oct-2016 0 = insufficient compliance, 1 = partial
compliance, and 2 = satisfactory compliance. Some standards may not be applicable to your hospital.
These standards should be marked as “NA” = Not Applicable. The rating scales are expected to help you
determine where to focus your improvement efforts. When you repeat the self-assessment, the rating
scales may also help you to monitor the progress you have made over time. The self-assessment results
in the compilation of compliance reports. These reports are then used to identify non-compliance areas
as well as other opportunities for improvement. Initiating and maintaining improvement steps are most
effective when they are planned and implemented organization-wide. The hospital leaders collaborate
with relevant staff members to prioritize, plan and implement corrective action plans that address all
identified noncompliant areas. The action plan should identify all non- compliant standards, the
required interventions with defined dates, the responsible staff members, and as applicable, monitoring
measures that ensure sustainability of the implemented interventions. These plans, when implemented
and routinely monitored, contribute to the proper compliance with standards and consequent provision
of quality care. How the hospitals can access the self-assessment tool The SAT is freely available on the
hospital portal to use. Upon registration, the hospital receives a user name and password that are used
to download the tool. This section is designed for users responsible for self-assessment administration
and completion of the online self-assessment. It provides step-by-step instructions on how to complete
a task. The self-assessment is an internet based program that provides features for: • Entering self-
assessment findings • Sending surveys to respondents for completion Appearance may differ in other
environments. If you require further assistance, contact the System Administrator at had@cbahi.gov.sa
System requirements The online self-assessment is best viewed in the latest Internet Explorer or Google
Chrome. Minimal system requirements include: How to login and use • visit
http://www.cbahi.gov.sa/hsa o Enter your user name number and password • Select “Self-Assessment
Tool” from the main menu. Fill the Self-assessment application form CBAHI will then approve your
self-assessment application form and an email will be sent to your facility informing you about the
approved Self-assessment record • Set your N/A chapters • Click the transaction name link under
“Transaction” column to begin your self-assessment. You will be required to specify an SAT surveyor
for each of the specialties. Upon submitting the surveyor details for each of the specialty, an email will
be sent to the email you specified – informing them about their username and password - for each of
the specialty

16. Page 16 of 134 Hospital Accreditation Guide Oct-2016 The assigned surveyor can now start scoring
his own domain by logging in to: http://www.cbahi.gov.sa/hsa by using the username and password in
the email. After each of the surveyors for each specialty has finished scoring all their scorable items,
the “FINALIZE & SUBMIT” button on the same row with the same transaction will be enabled – this
means that all scorable items have been scored and can now be submitted to CBAHI Click “FINALIZE &
SUBMIT” and click “OK” to submit your “Self-Assessment” An email will be received by CBAHI about
your SAT submission.

17. Page 17 of 134 Hospital Accreditation Guide Oct-2016 Off-Site Survey Activities The hospital
scheduled for the onsite survey shall send a list of the off-site required documents, listed below, for the
off-site review by the surveyors at least two (2) weeks prior to the date of the onsite survey. The list
shall be communicated, as a signed and scanned PDF document, with the Healthcare Accreditation
Department (HAD). List of policies to be sent prior to the survey # Document Name Related Standards 1.
Policy for Development and Maintenance of Policies LD.20 2. Medical Records Documentation Policy
MR.5 3. Information confidentiality, security, and integrity PFR.7, MOI.6 4. Committee Management
Policy LD.9 5. Policy for Delegation of Authority LD.17 6. Strategic Plan LD.11.2, LD.11.3, LD.12.1,
LD.12.2, LD.12.3, LD.12.4, LD.12.5, LD.12.6, LD.12.7, LD.15.1, LD.15.2, LD.15.3, LD.15.4, LD.15.5, LD.15.6,
LD.15.11 7. Policy for Contracted Services LD.21, IPC.1 8. Job Description Policy HR.3 9. Policy for
Management of Personnel Files HR.4 10. Probationary Period Evaluation Policy HR.8 11. Regular
Performance Evaluation Policy HR.9 12. Safe Disposal of Medical Wastes Policy LD.23, IPC.26 13. Medical
staff bylaws MS.1.1, MS.1.2, MS.1.3, MS.1.4, MS.1.5, MS.1.6 14. Multidisciplinary Medication
Management Plan MM.4.1 15. Hospital Drug Formulary MM.8.1 16. Pharmacy Organization Structure
MM.2.1 17. Pharmacy Scope of Services LD.28.2 18. Safety of the Building Management Plan FMS.1.1.1
19. Security Management Plan FMS.1.1.2 20. Life/Fire Safety Management Plan FMS.1.1.6 21. Internal
Disaster Management Plan FMS.1.1.5 22. External Disaster Management Plan FMS.1.1.4 23. Hazardous
Materials and Waste Management Plan FMS.1.1.3 24. Medical Equipment Management Plan. FMS.1.1.7
25. Utility Management Plan. FMS.1.1.8 26. Civil Defense License/Assessment Report along with
corrective action plan. FMS.4.1, FMS.4.2 27. Safety Committee Terms of Reference FMS.3.1, FMS.3.2,
FMS.3.3 28. Running construction/Renovation/Demolition works (if applicable) FMS.5.1

18. Page 18 of 134 Hospital Accreditation Guide Oct-2016 Role of the Visit Team Leader: Responsibilities
of the team leader include but not limited to: Review the uploaded hospital profile. Review hospital
website (if any) for any additional information related to the survey. Ensure all logistical arrangements
for survey visit via communication with HAD’s accreditation coordinator. Coordinating with hospital
visit coordinator to finalize the hospital chapter applicability. Coordinating with hospital visit
coordinator to finalize the survey agenda. Clarify the purpose of the survey visit for the health care
facility leaders. Ensure abidance by the agenda according to the allocated activities. Deal with any
conflicts arising between surveyors and/or with the hospital. Communicate with hospital visit
coordinator the required medical records and personnel files prior to review sessions. Coordinate and
arrange a new session “if needed”.

19. Page 19 of 134 Hospital Accreditation Guide Oct-2016 On-Site Survey Activities Understanding the
organization and assessing compliance is accomplished through a number of activities specified in the
survey agenda. The survey commences with an opening conference followed by a review of documents’
session. A facility tour and departments/units’ visits are also conducted during the on-site survey where
the surveyors observe compliance with standards, interview staff, and examine open patient medical
records and additional documents. This is followed by reviewing a selected sample of closed medical
records as well as personnel files Survey Team Arrival The surveyors arrive at the hospital early enough
for a timely start to the survey activities as per the survey agenda. Upon arrival, surveyors will present
their CBAHI identification. The surveyors will meet in the designated room provided by the hospital.
Surveyor Planning Session: Only surveyors attend this meeting which will include the following
activities: Discuss the aim of this meeting & the survey. Introduce team members. Discuss survey
schedule. Review list of departments/units/areas/programs/services within the organization (scope of
services). Review the organization chart and map of the organization including items in the hospital
demographic date and hospital website (if any). Review list of discharged patients (with diagnosis).
Prepare for the opening conference. Review the roles of hospital observers (if any). Liaise with
hospital leaders to take permission for FMS chapter photos (if required). Review the non-applicable
chapters/standards issues (if any). Team leader should address the following with colleagues: o
Hospital counterparts & interaction with them. o Required documents, personnel files & medical
records. o Report significant issues or adverse events to Visit Team Leader (VTL). o Scoring guideline. o
Keeping their laptops’ information safe. o The importance of communication among team members. o
Time management. o Be thorough in examination of the information provided and keep an open mind.

20. Page 20 of 134 Hospital Accreditation Guide Oct-2016 o Treat all information provided by other
team members with confidence during the review. o Timely data entry. o Daily team meetings (time &
venue). o Strengths & areas for improvement. o Required materials for exit conference. Opening
Conference Objectives To explain the scope of survey and what is expected from the hospital during
the survey. To orient the surveyors about the hospital’s structure, scope of services, staffing, mission,
and vision. To officially start the on-site survey. Participants From CBAHI: The entire survey team
From Hospital: it may include o Hospital Director o Medical Director o Nursing Director o Administrative
Director o Operations Director o Quality Improvement Director o Surveyors' counterpart Logistics A
workroom that is large enough to hold all participants with data show facility. Agenda: The team
leader will introduce survey team members. The hospital leadership will introduce: o The hospital
scope of services o Highlight the hospital improvement initiatives. o The surveyors' counterpart to
facilitate the smooth flow of the survey process. Team leader may: Discuss any modification in the
agenda with the hospital leaders.

21. Page 21 of 134 Hospital Accreditation Guide Oct-2016 Request a short meeting with hospital
director or medical director for further clarification of the scope of activities that were doubted. Clarify
any confusion regarding certain applicability and scope of services with the hospital leaders. Review of
Documents Objectives To evaluate compliance with standards that should be evidenced in written
documents. Participants From CBAHI: The entire survey team From Hospital: Staff who are familiar
with the hospital’s documents Logistics A workroom that accommodates the surveyors together with
staff familiar with the hospital’s documents. Procedures Documents required to be reviewed include,
but not limited to, policies and procedures manuals, plans, meeting minutes, and quality indicators. The
required documents for review must be current and approved by relevant leaders. To facilitate the
review of documents, the documents required for review during the document review session of the on-
site survey must be available at the time of the survey. The hospital is expected to organize the required
documents in binders for easy access. The hospital is required to organize the documents required for
review for each surveyor in a separate binder. The binders should be arranged according to the list
provided in this guide in Annex B. At the discretion of the survey team, surveyors may request additional
documents for review during the survey. It shall be noted, by the hospital, that whenever a standard
or a substandard listed in the CBAHI Standards Manual requires a policy and procedure, the hospital
shall prepare the required policy and procedure for the document review session of the on-site survey
listed below, whether or not it is specified in the list of required documents. When the hospital elects
to present the required documents in an electronic format, the hospital should provide a printer to be
used in case a surveyor requires a hard copy of any document. It is very much encouraged that the
staff accompanying the surveyor (i.e., the surveyor counterpart) are oriented to the document
arrangement. Surveyors Business Lunch: Only surveyors attend this meeting which will include the
following activities: o Survey team present their findings with special emphasis to cross-linked items. o
Team members may request colleagues from other chapters to assess/check doubtful issue/s related to
their specialty.

22. Page 22 of 134 Hospital Accreditation Guide Oct-2016 o Team members to present any
major/significant issue encounter during the survey. o Team members to report encountered difficulties
in time management. o Team members to clarify any activity-overlap issue. o Team members present
their next survey activities. Surveyors End of the Day Meeting: Only surveyors attend this meeting
which will include the following activities: o Team members to present items for presentation at the
debriefing session. o Team members to present items for possible discussion during the upcoming
committees meetings. o Team members present their next day survey activities. Surveyors Debriefing
There should be no surprises in the survey report, because the surveyors will have already raised any
issues and the hospital is kept abreast of findings. During the survey, the surveyors maintain ongoing
communication with their counterparts from the hospital. This occurs informally as questions arise. The
surveyors present their findings to their counterparts for discussion and clarification. This allows for
direct face-to-face interaction with the surveyors, allows the hospital to clarify or explain possible
discrepancies or compliance issues, and allows for consultation and education. Additionally, the daily
debriefing and the closing conference, at the end of the survey, allow hospitals to challenge cited
deficiencies. Finally, the hospital will review a draft exit report for feedback or correction of any issues of
fact as a step before making the accreditation decision. Medical Records Review (Closed and Open)
Objectives To gather information about compliance with the standards that require documentation in
the medical records. To assess the care processes provided to the patients. Participants From CBAHI:
The entire survey team with the exception of the FMS & LD Surveyors. From Hospital: At the discretion
of the hospital, staff familiar with the contents of the medical records. Logistics Closed medical records
are reviewed in the same workroom utilized during the documents review session. Open medical
records are reviewed during unit visits. Procedures

23. Page 23 of 134 Hospital Accreditation Guide Oct-2016 Surveyors will use both closed and open
medical records. While closed records determine the past practice and the frequency of a deficient
practice, open patient records reflect services provided at the time of the survey. See Annex C for
standards requiring documentation in the medical records. The selection of closed medical records for
review is guided by the services provided by the hospital and any available source of information during
the period prior to the survey such as the top diagnoses and procedures and patient discharge lists. The
open medical records for review are selected from a list of active records provided by the hospital.
Selection Criteria Physician Closed Medical Record Review o A sample of medical records will be
requested within the look-back period for the survey (4 months prior to the 1st cycle of accreditation
and 1 year for subsequent accreditation cycles).and it will include –but not limited to- the following: 1.
Dental case with high risk procedure 2. Day surgery patient 3. Two patients transferred to other hospital
4. Two major surgery patient 5. Two emergency patients with multiple consultations 6. ICU patient 7.
NICU patient 8. CCU patient 9. Two hemodialysis patients 10. Two patients with outpatient visits 11.
Two physiotherapy patients referred from inpatient 12. Patients involved in major incident 13. Two
Interventional radiology procedure to check both RD and sedation standards. If interventional RD is not
applicable, ask for sedation files The laboratory surveyor will review (20) Closed MR; o Five with a
history of therapeutic phlebotomy/apheresis o Five with a history of blood transfusion o Five with a
history of adverse transfusion event o Five with a history of surgical pathology studies Nursing Closed
Medical Record Review o A sample of medical records will be requested within the look-back period for
the survey (4 months prior to the 1st cycle of accreditation and 1 year for subsequent accreditation
cycles).and it will include –but not limited to- the following: 1. Two terminally ill patient referred to
home care (if applicable) or referred to any other service 2. Two patient transferred to other
organizations 3. Two surgical patient 4. Two Sedation patient discharge directly to home after the
procedure 5. Two patient refused treatment
24. Page 24 of 134 Hospital Accreditation Guide Oct-2016 6. Two ICU patient 7. Two CCU patient 8. Two
delivery patient 9. Two patient with nutritional risk 10. Two patient receiving therapeutic diet Personnel
Files Review Objectives To evaluate standards related to human resources such as staffing,
recruitment, staff qualifications, job descriptions, orientation and education, and staff evaluation.
Participants From CBAHI: The entire survey team. From Hospital: At the discretion of the hospital,
staff familiar with the contents of personnel files. Logistics Personnel files are reviewed in the same
workroom utilized during the documents review session. Procedures Hospitals are required to have
the requested personnel files (mentioned below as well as files randomly selected during the survey)
ready prior to the personnel files review session. The surveyors will provide the hospital with the
randomly selected personnel files list required to be reviewed during the session. The selection may
include, but not limited to, medical and administrative staff, new hires, nurses, technicians, and
contractors. See Annex D for standards requiring personnel files review. As the hospital may have
more than one location for the filling of the processes under assessment, the hospital should guide the
surveyors about the different ways for their documentation. Hospitals are encouraged to present the
needed documentation in one location to ensure comprehensiveness of personnel data and the
employment history in the hospital. These issues should be clarified prior to starting of the session. To
facilitate the personnel files review, hospitals are required to ensure availability of the following
elements, as applicable, in the personnel files: - Educational certificates - Orientation and education -
License and registration - Job Description - Performance evaluation - Credentialing of clinical staff -
Privileging of medical staff

25. Page 25 of 134 Hospital Accreditation Guide Oct-2016 Required Personnel Files LD & QM Surveyor
Hospital Director Head of Medical Department Finance Director Quality Director HR Director
Medical Records Director Medical Records Staff Clinical Coder Part Time Department Head Duty
Manager Head of Social Services Social Workers Patient Safety Officer Randomly selected files: o
Contracted Worker o New Hire o Admin Staff o Medical Staff o Nursing Staff MD Surveyor Medical
Director Head of OB/GYN Head of Anesthesia Head of OR Head of ICU Head of PICU Head of
NICU Head of CCU Head of Hemodialysis Head of ER Head of Radiology Head of Burn Unit
Head of Oncology & Radiotherapy Head of Respiratory Therapy Head of Physiotherapy Head of
Dental Randomly selected files: o Physician who perform sedation o Anesthesiologist o Psychiatrist o
Hemodialysis physician o Hemodialysis nurse o ER physician o ER Nurse o ICU physician o PICU physician

26. Page 26 of 134 Hospital Accreditation Guide Oct-2016 o NICU physician o CCU physician o OB/GYN
physician o Burn Unit physician o Oncology physician o Respiratory Therapist o Physiotherapist o Dentist
o Dental Technician o New hire NR Surveyor Nursing Director Deputy nursing director Nurse
involved in restraint Nursing assistant OR nurse manager ICU nurse manager PICU nurse manager
NICU nurse manager CCU nurse manager OB/GYN nurse manager ORT nurse manager
Hemodialysis nurse manager ER nurse manager Burn unit nurse manager Randomly selected files:
o Nurse involved in sedation o ICU nurse o PICU nurse o NICU nurse o CCU nurse o OB/GYN nurse o
Midwifes o Newborn nurse o Hemodialysis nurse o ER nurse o Burn unit nurse o ORT nurse o Dietary
supervisor o Dietitian o New hire MM Surveyor Pharmacy Director Pharmacy Quality coordinator
IV pharmacist IV technician TPN pharmacist TPN technician

27. Page 27 of 134 Hospital Accreditation Guide Oct-2016 Chemotherapy pharmacist Chemotherapy
technician Drug Information pharmacist Randomly selected files: o Nurse compounding sterile
products o Medication administration nurse o Selected pharmacy staff o New hire IC Surveyor IC
Director IC Practitioners CSSD Supervisor CSSD staff Randomly selected files: o Contracted worker
o Sample From Hospital o New hire LB Surveyor Lab director Lab supervisor Lab sections heads
Lab technicians Blood bank technicians POCT technician Randomly selected files: o POCT staff o
Contracted worker o New hire FMS Surveyor FMS Director Safety Officer Staff Handling Nuclear
Material Security Staff House Keeper Store Keeper Biomedical Engineer Electrical Engineer
Maintenance Engineer SFDA Liaison Officer HVAC System Maintenance Engineer Water System
Maintenance Engineer/Technician PMG System Maintenance Engineer/Technician Randomly
selected files: o Maintenance staff

28. Page 28 of 134 Hospital Accreditation Guide Oct-2016 o Nursing Staff o Contracted Worker o New
Hire

29. Page 29 of 134 Hospital Accreditation Guide Oct-2016 Facility Tour and Unit Visits Objectives To
interview staff to evaluate their education about the standards. To observe the implementation of
standards and ensure that they are in place, e.g., condition of the hospital (FMS chapter) and infection
control practices (IPC chapter). To examine open medical records in patient care areas. To review
additional documents in respective departments/services, e.g., pharmacy, laboratory, infection control,
and facility management and safety. To interview patients. Participants From CBAHI: The entire
survey team From Hospital: Staff and management involved in the patient’s care or other services in
the area visited. Logistics Hospitals should assign a counterpart for each surveyor to guide the
surveyor to the various survey sites. Procedures During this activity, the surveyor moves through the
hospital and visits all areas of the hospital that affect the delivery of care and services. The From
Hospital are interviewed, facilities are observed, and records are checked to ensure compliance with
certain standards’ requirements. This activity also includes a facility tour conducted for review of
infection control and facility management and safety standards. The surveyors determine the units,
departments, and other areas to be visited during the survey process. At all times during the unit
visits, the surveyors gather information with minimal disruption of the daily activities of the hospital
being surveyed. Hospitals are expected to have their key personnel present during their respective
area visit. In addition, the surveyors may request a particular staff category, when needed. Specialty-
specific visits and a facility tour are also included in this activity. Surveyors will interview individuals
responsible for managing the following departments / committee(s) in addition to review of related
documents in their respective departments. Areas/departments visited by surveyors during the
specialty-specific visits include: Laboratory (LB chapter): laboratory department. Pharmacy (MM
chapter): pharmacy, outpatient clinics, and any other area where a medication may exist. Facility
Management and Safety (FMS chapter): roof, kitchen, laundry, generator, electrical room, medical gases
room, workshops, main store, reverse osmosis plant, biomedical workshop, procedures room, central
sterilization, patient care rooms, bathrooms, waste

30. Page 30 of 134 Hospital Accreditation Guide Oct-2016 collection rooms, staircases, corridors, main
entrances, emergency exits, isolation room, ambulances, and nurse stations. Infection Control (IPC
chapter): operating rooms, central sterilization, kitchen, infection control unit, isolation rooms, staff
health clinic, laundry, dental clinic, and any other areas that may be used by patients.

31. Page 31 of 134 Hospital Accreditation Guide Oct-2016 CBAHI SURVEY / MEETINGS AND
COMMITTEES: No . Activity Venue/ Room Set- up Day Duration Chairperson 1. 1st Day Surveyor planning
session Conference Style Room 1st Day 30 minutes VTL 2. Opening Conference Hospital Auditorium 1st
Day 30 minutes VTL 3. Surveyors’ Business Lunch U Shape 1st Day 60 minutes VTL 4. 1st Day Surveyors
End of the Day Meeting Conference Style Room 1st Day 60 minutes VTL 5. 2nd Day Surveyor planning
session Conference Style Room 2nd Day 30 minutes VTL 6. 2nd Day Surveyors Debriefing Hospital
Auditorium 2nd Day 30 minutes VTL 7. 2nd Day Surveyors’ Business Lunch U Shape8 2nd Day 60 minutes
VTL 8. 2nd Day Surveyors End of the Day Meeting Conference Style Room 2nd Day 60 minutes VTL 9.
Planning for Quality Interview Conference Style Room 2nd Day 30 minutes LD 10. Quality Management
Interview (Data Management Session) Conference Style Room 2nd Day 90 minutes LD 11. Planning for
Pharmacy and Therapeutics Committee Interview Conference Style Room 2nd Day 15 minutes MM 12.
Pharmacy and Therapeutics Committee Interview Conference Style Room 2nd Day 45 minutes MM 13.
Planning for Environmental Safety Committee Interview Conference Style Room 2nd Day 15 minutes
FMS 14. Environmental Safety Committee Interview Conference Style Room 2nd Day 45 minutes FMS
15. Planning for Infection Control Committee Interview Conference Style Room 2nd Day 15 minutes IPC
16. Infection Control Committee Interview Conference Style Room 2nd Day 45 minutes IPC 17. Planning
for Contracts Review Conference Style Room 2nd Day 15 minutes IPC or FMS 18. Contracts Review
Conference Style Room 2nd Day 45 minutes IPC or FMS 19. 3rd Day Surveyor planning session
Conference Style Room 3rd Day 30 minutes VTL 20. 3rd Day Surveyors’ Business Lunch U Shape 3rd Day
60 minutes VTL 21. Planning for Executive Leadership Interview Conference Style Room 3rd Day 30
minutes VTL

32. Page 32 of 134 Hospital Accreditation Guide Oct-2016 22. Executive Leadership Interview
Conference Style Room 3rd Day 60 minutes VTL 23. Exit Conference Hospital Auditorium 3rd Day 30
minutes VTL

33. Page 33 of 134 Hospital Accreditation Guide Oct-2016 Executive Leadership Interview Session Aim:
To clarify and discuss findings encounter during the survey. The survey team may also explore the
leadership’s support for different functions within the organization by forwarding, to the Executive
Interview Session, survey activities related to patient and family rights, outcomes of hospital
committees, and departmental improvement projects. Attendees: CBAHI: The entire survey team.
Hospital: 1. Governing Body representative 2. Hospital Director 3. Medical Director 4. Operations
Director 5. Nursing Director 6. Quality Improvement Director 7. Others may be invited based on need
(VTL will ifor the hpspita; QM Duration: 60 minutes Schedule: To be held on the 3rd day of the survey,
before compiling the Exit Report”. Surveyor Planning for the interview: The survey team must hold a
planning session prior to the interview to arrange the questions and/or clarification in a logical
sequence. The VTL should alert the team to: 1. Link their questions to the survey activities 2. Have clear
and specific questions without any unnecessary/lengthy introduction. 3. Not to be drifted toward
presenting their final findings. 4. As needed, address their question to specific member of the panel 5.
Manage the time properly and use polite gestures to stop the counterparts from dilatation. Interview
Session Agenda: 1. Introduction; the VTL shall iterate the aims of the interview session and introduce
the survey team.

34. Page 34 of 134 Hospital Accreditation Guide Oct-2016 2. Discussion; Survey team members who
have forwarded survey activity(ies) to the session will take turns in presenting their questions/inquiries
as per the agreed upon sequence. 3. Closing; the VTL shall bring the meeting to closure by identifying
the remaining activity in the survey agenda, convening the projected time for the “Exit Conference”
35. Page 35 of 134 Hospital Accreditation Guide Oct-2016 Quality and Patient Safety Committee and
Data Management Session Aim: To have an overview on the hospital-wide quality improvement and
patient safety program, including how data and information are managed and communicated to end
users to better hospital services. Attendees: Current members of the committee with a minimum
number to meet the quorum as per terms of reference. According to the available specialties in the
hospital, the following are the least number required to attend: 1. Chairman of the committee 2. Quality
Director 3. Medical Director 4. Nursing Director 5. Risk Manager 6. Medical Records Manager 7.
Healthcare Information System Manager 8. Other specialties QI designees as per hospital 3 – 5 main
services 9. Operations/Logistic representative 10. One project team (team leader and a team member)
Duration: 90 minutes (30 minutes for review of related documents + 60 minutes Interactive discussion)
Schedule: To be held on the 2nd day of the survey. Avoid overlap with any other meetings to augment
membership attendance. Agenda: 1. Introduction 2. Hospital presentation on the quality improvement
and patient safety program to include: a. QI program structure b. QI program flow (how it is integrated
with other hospital-wide programs) c. Highlight on an improvement project d. Performance indicators’
monitoring process e. Key performance indicators’ reports submitted to the governing body f. Risk
management initiatives and data trends g. Management of data and information processes i.
Information needs assessment process ii. Information management structure iii. Data management
education and training iv. Data and report flow and management 3. Open discussion between surveyor
and hospital representative. 4. Other topics may be raised and discussed based on the surveyor findings
during the hospital visit. Required Documents: The hospital is requested to have documentations related
to its quality improvement program, patient safety initiatives, risk management program and activities,
data and information management process, and improvement projects present during this session.
These may include, but not limited to: 1. Terms of reference of the quality improvement committee,
patient safety team or equivalent. 2. Committee membership list.

36. Page 36 of 134 Hospital Accreditation Guide Oct-2016 3. Minutes of meetings for the tracking
period. 4. Managerial and clinical performance monitoring indicators 5. Patient safety indicators. 6.
Improvement projects or programs (may include list of projects and teams if available) 7. Improvement
activities based on information resulting from data analysis 8. Risk management program 9. Patient
safety program 10. Key performance indicators’ reports submitted to the governing body 11. Incidents
reporting system and data trends 12. Annual review of committee performance 13. Information needs
assessment process and report 14. Information management related activities, education and reports

37. Page 37 of 134 Hospital Accreditation Guide Oct-2016 Infection Prevention and Control Committee
Interview Aim: To have an overview about the infection prevention and control program and to ensure
it is implemented in the hospital as a multidisciplinary process. To discuss the role of the committee in
monitoring and supporting the IPC program. Attendees: CBAHI: Infection Control Surveyor. Hospital:
Current members of the committee with a minimum number to meet the quorum as per terms of
reference. According to the available specialties in the hospital, the following are the least number
required to attend: 1. Chairman of the committee 2. Infection Control Director 3. Infection Control
Practitioner 4. Nursing Director 5. Infectious Disease Consultant 6. Other specialties as per hospital main
services Duration: 60 minutes (15 Min. for review of related documents + 45 Min. Interactive discussion)
Schedule: To be held on the late afternoon of the 2nd day of the survey. Avoid overlap with quality and
data session or any other meetings to augment membership attendance. Agenda: 1. Introduction 2.
Discussion about the essential role of the committee and its outcome 3. Review of the required
documents 4. Other topics may be raised and discussed based on the surveyor findings during the
hospital visit. Required Documents: The hospital is requested to have documentations present at the IC
review session 1. Terms of reference of the IC committee. 2. Committee membership list. 3. Meeting
minutes. 4. Committee annual report 5. Surveillance report

38. Page 38 of 134 Hospital Accreditation Guide Oct-2016 Pharmacy and Therapeutics Committee
Interview Aim: To have an overview about the medication management program and to ensure it is
implemented in the hospital as a multidisciplinary process. To discuss the role of the committee in
monitoring and supporting the medication management program. Attendees: CBAHI: Medication
Management Surveyor. Hospital: Current members of the committee with a minimum number to
meet the quorum as per terms of reference. According to the available specialties in the hospital, the
following are the least number required to attend: 1. Chairman of the committee 2. Pharmacy Director
3. Nursing Director 4. Infectious Disease Consultant 5. Internal Medicine consultant 6. Surgery
Consultant 7. Pediatrics Consultant 8. Ob/Gyn Consultant 9. Other specialties as per hospital main
services 10. Logistic Representative Duration: 60 minutes (15 Min. for Review of related documents + 45
Min. Interactive discussion) Schedule: To be held on the afternoon of the 2nd day of the survey. Avoid
overlap with quality and data session or any other meetings to augment membership attendance.
Agenda: 1. Introduction 2. Discussion about the essential role of the committee and its outcome 3.
Review of the required documents 4. Other topics may be raised and discussed based on the surveyor
findings during the hospital visit. Required Documents: The hospital is requested to have
documentations present at the P&T review session 1. Terms of reference of the P&T committee. 2.
Committee membership list. 3. Meeting minutes for the last twelve months. 4. Drug Formulary. 5.
Relevant indicators (e.g. drug utilization review reports)

39. Page 39 of 134 Hospital Accreditation Guide Oct-2016 Environmental Safety Committee Interview
Aim: To have an overview on how the hospital manages its facilities and ensures safety of its
employees, patients, and visitors at all times. To discuss the activities of the safety committee and the
optimal utilization of its functions in improving a safe work and care environment at the hospital.
Attendees: CBAHI: Facility Management and Safety (FMS) Surveyor. Hospital: Current members of
the committee with a minimum number to meet the quorum as per terms of reference and according to
the available specialties in the hospital, it should include at least twelve (12) members: 1. Biomedical
Engineering director 2. Housekeeping manager 3. Infection Control representative 4. Laboratory
representative 5. Medical staff (E.R) 6. Non-medical maintenance director 7. Nursing director 8. Quality
director 9. Radiation safety officer 10. Risk manager 11. Safety Officer 12. Security officer Duration: 60
minutes (15 Min. for Review of related documents + 45 minutes interactive discussion) Schedule: To be
held on the afternoon of the 2nd day of the survey. Avoid overlap with other meetings to augment
membership attendance. Agenda: 1. Introduction 2. Discussion on the committee role and its outcome
3. Discussion on the required programs 4. Discussion on risk management process related to hospital
and environmental hazards 5. Other topics may be raised and discussed based on the surveyor findings
during the hospital visit. Required Documents: The hospital is requested to have documentations related
to safety committee. These may include, but not limited to: 1. Terms of reference of the Safety
Committee. 2. Committee membership list. 3. Agenda and meeting minutes approved by the hospital
director. 4. Attendance sheet. 5. Facility safety tour reports. 6. Corrective and preventive action plans
and budgeting of long-term upgrading and replacement resulted from facility tours.
40. Page 40 of 134 Hospital Accreditation Guide Oct-2016 7. Occurrence Variance Reports (OVRs)
related to the FMS program with proper action plan to avoid reoccurrences. Contracted Services
Interview Session Aim: To have an overview on how outsourced and contracted services are planned,
monitored, managed, and improved in the hospital. To discuss the role of hospital stakeholders in
ensuring the level of safety and quality of outsourced and contracted services. Attendees: CBAHI:
Facility Management and Safety (FMS) and Infection Control Surveyors. Hospital: Hospital entity in
charge of establishing and monitoring outsourced and contracted services leaders, including: 1. Hospital
director or his/her designee 2. Manager of hospital operations or equivalent 3. Manager of
administrative and financial division or equivalent 4. Infection control representative 5. Laboratory
representative 6. Manager of non-medical maintenance or equivalent 7. Manager of bio-medical
engineering or equivalent 8. Manager of support services (housekeeping, laundry, and pest control – if
outsourced) 9. Food services manager (if outsourced) 10. Nursing administration representative 11. Risk
manager Duration: 60 minutes (15 Min. for Review of related documents + 45 minutes interactive
discussion) Schedule: To be held on the afternoon of the 2nd day of the survey. Avoid overlap with other
meetings to augment membership attendance. Agenda: 1. Introduction 2. Hospital presentation to
address the following outline within the scope of the related standards requirements: h. Number of
outsourced services/ contracts i. List of contracted companies (within the hospital premises and off-site)
j. Company selection processes k. Outsourced and contracted services performance monitoring tools
and process l. Roles and responsibilities in monitoring contracted services m. Outsourced/contracted
services’ performance monitoring reports and flow processes n. Sample of outsourced/contracted
services performance monitoring reports content o. Sample of actions taken by hospital leadership
based on contract monitoring reports p. Risk management process related to a company with
unsatisfactory compliance q. New employees screening and immunization process for contracted
workers r. Contract renewal process

41. Page 41 of 134 Hospital Accreditation Guide Oct-2016 s. Contracts to manage constructions and
renovation works t. Open discussion 3. Other topics may be raised and discussed based on the surveyor
findings during the hospital visit. Required Documents: The hospital is requested to have
documentations related to safety committee. These may include, but not limited to: 1. Policies and
procedures to ensure the quality and safety of all contracted services, including company/service
selection criteria. 2. Policies and procedures indicating how to track and monitor all contracted services
3. Sample contract 4. List of laws and regulations relevant to the scope of contracted services (e.g.
medical waste disposal laws). 5. Number of renewed contracts and contracts that were aborted. 6. New
employees screening and immunization process for contracted workers. 7. Laboratory services contract
(if outsourced). 8. Contracts to manage constructions and renovation works. 9. Policy to address agent
or contractor repairs. 10. Evidence for reporting medical supplies adverse effects. 11. Corrective and
preventive action plans and budgeting of long-term upgrading and replacement resulted from
contracted services monitoring outcome. 12. Occurrence Variance Reports (OVRs) related to the
contracted services program with proper action plan to avoid reoccurrence.

42. Page 42 of 134 Hospital Accreditation Guide Oct-2016 Report Preparation session (before exit
conference) Only surveyors attend this meeting which will include the following activities: Objectives
To prepare an initial exit report that can be shared with the hospital at the end of the on-site survey To
provide the hospital with the possible challenges and areas for improvement Provide the hospital with
the list of non-compliant “ESR’s” that need immediate leadership attention. Participants From CBAHI:
The entire survey team. Logistics A workroom that can accommodate all the surveyors together
Procedures After each surveyor has completed scoring all the sub-standards under his scope of on-site
assessment, the whole team has to integrate their findings into one report that will be shared with the
hospital at the end of the on-site survey. The Visit Team Leader (VTL) shall be responsible to ensure
integration of the findings and recommendations for the sub-standards that are scored by more than
one surveyor to ensure accuracy and reliability of the initial report. Closing Conference Objectives To
provide the hospital with an initial overview on the outcome of the survey. To allow the hospital to
clarify or explain possible discrepancies or compliance issues. To provide the leaders with the
hospital’s strengths and areas for improvements. Participants From CBAHI: The entire survey team
From Hospital: Chief medical and administrative staff of the hospital. It is encouraged that various From
Hospital (especially those at supervisory levels) attend this session. Logistics A workroom that is large
enough to hold all participants. Procedures At the conclusion of the on-site survey, after collection of
final data, the surveyors hold a closing conference at which they present key findings and the hospital’s
areas for improvement. Exit report will be provided to the hospital director including the draft of major
findings in ESRs and

43. Page 43 of 134 Hospital Accreditation Guide Oct-2016 other standards in all specialties. Other
information provided may include how the hospital could have access to the detailed report and
possible follow-up decisions or activities. As the surveyors are “fact finders” for the CBAHI, they do not
render the final accreditation decision, but instead they report findings to the CBAHI. Therefore, during
the exit conference, the surveyors will not state whether the hospital will be awarded an accreditation.
Members of the leadership group are encouraged to take this opportunity to comment and provide
feedback on the findings for which there are issues of interpretation, as well as express their
perceptions of the survey.

44. Page 44 of 134 Hospital Accreditation Guide Oct-2016 Post Survey Activities Accreditation Decision
and plan for correcting ESR’s Following completion of the survey, CBAHI renders an accreditation
decision and delivers a report. Types of possible accreditation decisions, follow up activities, required
accreditation maintenance activities are fully explained in part two of the standards manual. The
surveyed hospital receives official documents from CBAHI detailing the accreditation decision and any
required follow-up activities within thirty days after the conclusion of the survey. Hospitals will be able
to access the survey report through the use of their username and password through the hospital portal.
Survey Report CBAHI provides a survey report to the hospital for on-site visits. The first page of the
report contains items such as the dates of the survey, the names of the surveyors, the services and sites
assessed, and the scope of the survey and the standards used. The main part of the report contains the
findings of the survey team for all sub-standards that had insufficient or partial compliance. Survey
Feedback In order to evaluate and improve its performance, CBAHI appreciates each surveyed hospital’s
feedback. This feedback is very beneficial in ensuring the continuing growth and improvement of
CBAHI’s accreditation program. An email is sent to the hospital’s survey coordinator after the survey
visit has been completed requesting their feedback about CBAHI standards, survey process and
surveyors’ performance

45. Page 45 of 134 Hospital Accreditation Guide Oct-2016 Terms of Accreditation The CBAHI
accreditation is granted for a three years period. CBAHI will send a renewal letter to accredited hospitals
describing how to begin the renewal process before the accreditation expires. Accreditation
Maintenance The maintenance of the accreditation process pertains only to hospitals already
accredited. When a hospital receives accreditation, the hospital is responsible for maintaining
compliance with the CBAHI standards for the full duration of the accreditation term. CBAHI reserves the
right to review the accreditation status where there is substantial evidence to suggest that accreditation
standards are not being met. CBAHI adopted procedures that facilitate maintenance of accreditation.
These procedures are intended to create an ongoing “maintenance of accreditation” signaling that once
a hospital has achieved accreditation, a process of continuous improvement maintains the accreditation
status. The maintenance of accreditation procedures are fully described in the accreditation policies part
of the third edition of the CBAHI standards manual. As part of accreditation maintenance procedures,
the mid-term self-assessment serves as an opportunity for a hospital to engage in a process of rigorous
self-review and improvement against CBAHI standards. .

46. Page 46 of 134 Hospital Accreditation Guide Oct-2016 Annex A Standard Survey Agenda

47. Page 47 of 134 Hospital Accreditation Guide Oct-2016 Note 1: For the Medical and Nursing
Surveyors’ Units Visit, please select the units from the following list and specify it in the particular slot in
the schedule, taking in consideration that both surveyors shall not be visiting the same area at the same
time. The sequence of units shall be determined based on the physical layout of the organization that
will allow a smooth flow and ideal utilization of the surveyor time. Please note that this is a standard
agenda so according to the hospital scope of services you may add or eliminate some units. Units to be
visited by the medical surveyor: 1. ER; 2. OR; 3. Surgical Ward; 4. Medical Ward; 5. Pediatrics Ward; 6.
ICU; 7. PICU; 8. NICU; 9. CCU; 10. OPD; 11. Physiotherapy; 12. Radiology; 13. Oncology; 14. Dental; 15.
Hemodialysis; 16. L&D; 17. Burn Unit; and 18. Day Surgery. Units to be visited by the nursing surveyor: 1.
ER; 2. OR; 3. L&D; 4. Surgical Ward; 5. Medical Ward; 6. Pediatrics Ward; 7. ICU; 8. PICU; Standard
Survey Agenda

48. Page 48 of 134 Hospital Accreditation Guide Oct-2016 9. NICU; 10. CCU; 11. OPD; 12. Oncology; 13.
Nursery; and 14. Burn Unit. The information verification session at the third day of the survey is a
specially designed session to allow more flexibility for the surveyor if he/she wants to verify any of the
information collected over the three survey days Note 2: For the FMS Surveyors’ Units Visit, please
select the units from the following two lists (external and internal locations) and specify it in the
particular slot in the schedule, surveyors shall not be visiting the same area at the same time. The
sequence of units shall be determined based on the physical layout of the organization that will allow a
smooth flow and ideal utilization of the surveyor time. Please note that this is a standard agenda so
according to the hospital scope of services you may add or eliminate some units. Exterior locations to be
visited by the FMS surveyor: 1. Construction, renovation or demolition project; 2. Medical Waste Store
Room; 3. Hospital roof; 4. Elevator Service Room; 5. Hospital gates/ Entrances / Handicap access; 6.
Kitchen; 7. Laundry; 8. Ambulances; 9. Holding Areas; 10. Technical Rooms; 11. Electrical Rooms; 12.
Central store; 13. Biomedical Engineering Workshop; 14. Generators; 15. Chillers; 16. Central Medical
Gas Station; 17. RO Plant, 18. Fire Pumps; 19. Boilers; 20. Septic Tank; and 21. Parking area/ Handicap
slots.

49. Page 49 of 134 Hospital Accreditation Guide Oct-2016 Interior locations to be visited by the FMS
surveyor: 1. Hospital Lobby and gates; 2. Corridors/ Staircases/ Assembly Points; 3. Elevators; 4. MRI; 5.
ICU/NICU/ isolation rooms; 6. Operating Rooms; 7. Emergency Room/ Triage Areas; 8. In-Patient
Rooms/Bathrooms/ Special Needs Bathrooms; 9. Children Playroom; 10. Laboratory; 11. Radiology
Department; 12. Nuclear Medicine; 13. Dermatology Clinic/ Laser room(s); 14. Delivery room; 15.
Nursery; 16. Female wards; 17. Central sterilization service department; 18. Medical records; 19.
Emergencies Command Center; 20. Nursing Stations; 21. Safety Department; 22. Sub-stores/ Pharmacy
store; 23. Pantries and staff lounges; 24. Cardiology Units; 25. Dialysis Unit; 26. Dental Unit; 27. Data
Center (servers room); 28. Clean utility; 29. Dirty utility; and 30. Janitorial closet.

50. Page 50 of 134 Hospital Accreditation Guide Oct-2016 TYPE OF SURVEY – FACILITY NAME DAY 1, Day
of the week, DD MMM, YYYY (Morning) Time/Activity LD MD NR IC MM LB FMS 08:00 To 08:30 Activity
Surveyor Planning Session Location 08:30 To 09:00 Activity Opening Conference Location 09:00 To 12:00
Activity Document Review Document Review Document Review Document Review Document Review
Document Review Document Review Location Counterpart(s) 12:00 To 13:00 Activity Surveyors'
Business Lunch Location

51. Page 51 of 134 Hospital Accreditation Guide Oct-2016 DAY 1, Day of the week, DD MMM, YYYY
(Afternoon) Time/Activity LD MD NR IC MM LB FMS 13:00 To 14:00 Activity Unit Visit Unit Visit Unit Visit
Documents Review Unit Visit Documents Review Documents Review Location(s) (Social Services)
(Inpatient Pharmacy) Counterparts 14:00 To 15:00 Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit
Visit Lab Leadership Interview Facility Tour Location(s) (Patient Affairs) (CSSD / Endoscopy / Laundry) (ER
/ Ambulance) Counterparts 15:00 To 16:00 Activity Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Unit
Visit Facility Tour Location(s) (Medical Supply / Admission Office/ Duty Manager Office) (Utility Rooms /
Waste Segregation Areas / Morgue) (OPD / Outpatient Pharmacy) Counterparts 16:00 to 17:00 Activity
Data Entry / Surveyor Meeting Location Quality meeting room

52. Page 52 of 134 Hospital Accreditation Guide Oct-2016 DAY 2, Day of the week, DD MMM, YYYY
(Morning) Time/Activity LD MD NR IC MM LB FMS 08:00 To 08:30 Activity Surveyor Planning Session (list
of “Closed Medical Records” should be provided at the end of session) Location 08:30 To 09:00 Activity
Day One Debriefing Location 09:00 To 10:00 Activity QM Department Visit Unit Visit Unit Visit Unit Visit
Unit Visit Unit Visit Facility Tour Location(s) (NICU / PICU / ICU/CCU) (Pharmacy Warehouse /Narcotics)
Counterparts 10:00 To 11:00 Activity QM Committee Interview Unit Visit Unit Visit Unit Visit Unit Visit
Unit Visit Facility Tour Location(s) (Burn Unit / Regular Ward/Staff Health Clinic) (IV Clean Room) (TPN /)
Counterparts 11:00 To Activity Data Management Session Unit Visit Unit Visit IC Committee Unit Visit
Unit Visit Facility Tour

53. Page 53 of 134 Hospital Accreditation Guide Oct-2016 12:00 Interview Location(s) 11:00 to 11:30
(Chemotherapy) Counterparts: 11:30 to 12:00 Pharmacy Admin/QI Meeting Counterparts 12:00 To
13:00 Activity Surveyors' Business Lunch Location

54. Page 54 of 134 Hospital Accreditation Guide Oct-2016 DAY 2, Day of the week, DD MMM, YYYY
(Afternoon) Time/Activity LD MD NR IC MM LB FMS 13:00 To 14:00 Activity Unit Visit Unit Visit Unit Visit
Unit Visit P and T Committee Interview Unit Visit Facility Tour Location(s) (Medical Records (OR)
Counterparts 14:00 To 15:00 Activity Unit Visit Closed Medical Records Review Closed Medical Records
Review Unit Visit Unit Visit Closed Medical Records Review Environmental Safety Committee Interview
Location(s) (Inpatient Unit/ OPD/ Hospital Tour) (ER) (Dental / Kitchen) (ICU / NICU) Counterparts 15:00
To 16:00 Activity Unit Visit Closed Medical Records Review Closed Medical Records Review Contract
Review Unit Visit Closed Medical Records Review Contract Review Location(s) (Finance / Purchasing /
Academic Affairs / IT) ( Medical /Surgical) Counterparts 16:00 To 17:00 Activity Data Entry / Surveyor
Meeting Location
55. Page 55 of 134 Hospital Accreditation Guide Oct-2016 DAY 3, Day of the week, DD MMM, YYYY
(Morning) Time/Activity LD MD NR IC MM LB FMS 08:00 To 08:30 Activity Surveyor Planning Session (list
of “Personnel Files” should be provided at the end of session) Location 08:30 To 10:00 Activity Unit Visit
Unit Visit Unit Visit Unit Visit Unit Visit Unit Visit Facility Tour Location(s) HR Department (Dialysis /
Water Plants) (L&D, OR, Radiology, Conscious Sedation Area and extemporaneous preparations)
Counterparts 10:00 To 11:00 Activity Personnel Files Review Personnel Files Review Personnel Files
Review Personnel Files Review and Closed Medical Records Review Personnel Files Review Personnel
Files Review Personnel Files Review Location Counterparts 11:00 To 12:00 Activity Information
Verification Information Verification Information Verification Information Verification Information
Verification Information Verification Information Verification Location(s) 12:00 To 13:30 Activity
Business Lunch and Preparation for the Executive Leadership Interview Location

56. Page 56 of 134 Hospital Accreditation Guide Oct-2016 DAY 3, Day of the week, DD MMM, YYYY
(Afternoon) Time/Activity LD MD NR IC MM LB FMS 13:30 To 14:30 Activity Executive Leadership
Interview Location 14:30 To 16:00 Activity Data Entry and Preparation of the Exit Report Location 16:00
To 16:30 Activity Pre-Exit Conference Meeting with Hospital Leadership (Optional Session) Location
Counterparts 16:30 To 17:00 Activity Exit Conference (Optional session if the facility opt to have “Pre-
Exit Conference”) Location

57. Page 57 of 134 Hospital Accreditation Guide Oct-2016 Annex B Required Survey Documents

58. Page 58 of 134 Hospital Accreditation Guide Oct-2016 1. Leadership & Quality Management
Surveyor (Closed Session) Required Documents Related Standards Policy on Policy 1. Policy for
Development and Maintenance of Policies LD.20.1 Laws and Regulations 2. Laws and Regulations
Worksheet e.g. HR.5.5, ORT.2.1, FMS.4.1, etc.) LD.3.1 3. Evidence of Hospital Compliance with Relevant
Laws and Regulations LD.3.2, LD.2.3 Hospital Leadership /Governing Body 4. governing body formation
document LD.1.1 5. Governing Body Bylaws or Similar Document LD.1.2 6. Administrative Policies and
Procedures Manual LD.6.3, LD.6.1 7. Policy for Delegation of Authority LD.1.3 8. Governing Body
Meeting Minutes LD.1.4 9. Reports from Hospital Director to Governing Body LD.2.5 10. Evidence that
the Leadership Supporting Hospital Safety LD.2.7 11. Hospital Executive Committee LD.2.8, LD.5.1,
LD.5.4, LD.5.5, LD.5.6, LD.14.2, LD.14.3, LD.24.2 12. Evidence of Hospital Director Response to the
Authorities LD.2.9 13. Reports and Communications about Performance Quality LD.10.3 14. Evidence of
Community Leaders Participation in Planning LD.11.2 15. Key Performance Indicator Report LD.15.8 16.
Policy for Vertical and Horizontal Communication LD.18.1 17. Policy for Handling Incoming External
Requests LD.18.5 18. Evidence on Response to any Incoming Requests LD.18.6 19. Contracts Oversight
Process LB.1.4 Hospital Scope of Services 20. Hospital Scope of Services LD.4.1, LD.4.2, LD.4.3, LD.4.4,
LD.4.5, LD.4.6 Hospital Strategic Plan 21. Mission Statement LD.7.1, LD.7.4, LD.7.5 22. Hospital Code of
Conduct LD.8.1, LD.8.2, LD.8.3, LD.8.4 23. Document Identifying Relevant Community Leaders LD.11.1
24. Hospital Strategic Plan LD.11.2, LD.11.3, LD.12.1, LD.12.2, LD.12.3, LD.12.4, LD.12.5, LD.12.6, LD.12.7,
LD.15.1, LD.15.2, LD.15.3, LD.15.4, LD.15.5, LD.15.6, LD.15.11 Hospital Budgeting Process 25. Hospital
Budgeting Process LD.13.2, LD.13.3, LD.13.4, LD.13.5 Hospital Staffing Plan 26. Hospital Staffing Plan
LD.16.1, LD.16.2, LD.16.3, LD.16.4, LD.16.5 Hospital Committees 27. Policy for Committee Management
LD.9.1, LD.9.2, LD.9.3 28. Committee Terms of Reference (Sample) LD.9.3

59. Page 59 of 134 Hospital Accreditation Guide Oct-2016 29. Terms of Reference of Patient
Rights/Patient Advocacy Committee PFR.1.1 30. Terms of Reference of Research Committee PFR.16.3
31. Medical Records/Forms Committee MR.16.2 Leadership & Quality Management Surveyor (Units
Documents) Required Documents Related Standards Human Resources 1. Human Resources Manual
HR.1.3 2. Laboratory/facility policy on job description and samples of job descriptions (lab staff) HR.3.1
3. Policy for Delegation of Authority LD.17.1, LD.17.2 4. Policy for Management of Personnel Files HR.4.1
5. Policy for Credentialing and Privileging HR.5.1 6. Departmental and Job Orientation Program HR.7.1 7.
Policy for Probationary Period Evaluation HR.8.1 8. Policy for Regular Performance Evaluation HR.9.1 9.
Policy for Staff Complaint HR.14.1 10. Evidence of Staff Complaints Management HR.14.3 11. Evidence
for Exit Interview HR.15.4 12. General Hospital Orientation Program / Employee Handbook PFR.2.1
Education and Training Department 13. Training Needs Assessment HR.10.1, HR.10.2 14. Policy for
Continuing Education HR.11.1 15. Evidences of support of Staff Education HR.11.2 16. Continuing
Education Program HR.11.3 Quality Management Department 17. Hospital Organization Chart QM.3.4
18. Departmental Scope of Services QM.1.1 19. Quality Improvement Plan/Program QM.4.1, QM.4.2,
QM.4.3, QM.4.4, QM.2.1, QM.2.2 20. Risk Management Program QM.13.1, QM.13.2, QM.13.4, QM.13.5,
QM.13.9, QM.13.10, QM.13.11, QM.13.13 21. Terms of Reference of Patient Safety Committee
QM.16.4, QM.16.9 22. Patient Safety Culture Assessment Report and Actions QM.16.5 23. Leadership
Patient Safety Rounds QM.16.6 24. Policy for Incidents Reporting QM.14.1, QM.14.2 25. Terms of
Reference for Quality Improvement Committee/Council QM.14.4, QM.14.6 26. Policy for Sentinel Events
QM.15.1, QM.15.2 27. Reports of Sentinel Events QM.15.3, QM.15.4, QM.15.5, QM.15.6 28. Data
Management Education/Training Program MOI.5.1, MOI.5.2, MOI.5.3 29. Performance Improvement
Projects/Reports QM.12.1, QM.12.2, QM.12.3 30. Hospital Indicators Reports MOI.4.2, QM.10.1,
QM.10.2, QM.10.3

60. Page 60 of 134 Hospital Accreditation Guide Oct-2016 31. Evidence on Systematic Approach of New
or Modified Processes LD.19.1 32. List of Identified Customers and their Needs LD.19.2 33. Risk
Assessment LD.19.4 34. Pilot Testing Report LD.19.5 35. New Process Indicators LD.19.6 36. Staff
Training Records for New Processes LD.19.7 Patient Affairs 37. Patient and Family Rights Statement
PFR.1.3, PFR.4.2, PFR.8.1, PFR.8.2, PFR.8.3 38. Policy for Patient and Family Rights PFR.1.4, PFR.8.1,
PFR.8.2, PFR.8.3, PFR.8.4, PFR.17.5 39. General Hospital Orientation Program / Employee Handbook
PFR.2.1 40. Policy for the Protection of Patient Belongings PFR.4.1, PFR.4.3 41. Policy for Information
Confidentiality, Security and Integrity PFR.7.1, PFR.7.2 42. Terms of Reference of Research Committee
PFR.7.2 43. Patient's Booklet/Handbook PFR.8.6 44. Policy for Patient Complaint PFR.14.1 45. Evidence
of Patient Complaints Management PFR.14.3 46. Patient Satisfaction Program PFR.15.1, PFR.15.2 Social
Services 47. Policy For Refusal of Treatment PFR.11.1, PFR.11.2, PFR.11.3 PFR.11.4, PFR.11.5 48. Policy
on "No Code" PFR.12.1 49. Policy for Experimental Research PFR.16.1, PFR.16.2, 50. Sample of patient's
informed consent for participating in research. PFR.16.4, PFR.16.5 Medical Records 51. Departmental
Staffing Plan MR.1.3 52. Policy for Medical Records Documentation MR.5.1, MR.5.6 53. Policy for
Medical Records Protection MR.6.3, MR.13.1, MR.13.3 54. Policy for Access to Medical Records MR.9.1
55. Medical Records Management Process MR.11.3, MR.15.1, MR.15.2 56. Policy for Medical Records
Retention MR.12.1, MR.12.2 57. Policy for Release of Medical Records MR.14.1, MR.14.2, MR.14.3 58.
Medical Records Review Reports MR.17.1, MR.17.2, MR.17.3, MR.17.4, MR.17.5 IT 59. Policy for Data
and Information Retention MOI.2.5, MOI.8.1, MOI.8.2, MOI.8.3 60. Policy for Information
Confidentiality, Security and Integrity MOI.6.1, MOI.6.2, MOI.6.3, MOI.6.4, MOI.6.9 Property Control 61.
Evidence for Qualification of Medical Suppliers LD.23.2 62. Documents Reflecting Implementation of
Safe Management of Medical Supplies and Devices Process LD.23.4, LD.23.9 63. Medical Supplies and
Devices Inspection Reports LD.23.5 64. Evidence for Reporting Medical Supplies Adverse Effects LD.23.6
61. Page 61 of 134 Hospital Accreditation Guide Oct-2016 65. Risk Assessment QM.24.6 Hospital-wide
66. Departmental Organization Chart LD.26.1, LD.26.2 67. Departmental Mission Statement LD.27.1,
LD.28.2 68. Departmental Scope of Services LD.28. 2 69. Annual Departmental Plan LD.15.9 70.
Departmental Staffing Plan LD.30.2, LD.30.3, HR.2.1, HR.2.3, HR.2.4 71. Departmental Meeting Minutes
LD.18.2 72. Policy for Development and Maintenance of Policies LD.20.1, LD.20.2 73. Policies and
Procedures LD.20.3, LD.20.4 74. Interdepartmental Agreement LD.27.2 75. Departmental Manual
LD.29.1 76. Multidisciplinary Policies and Procedures (Sample) LD.29.2 77. Departmental Request for
Resources and Staffing LD.30.1 78. Performance Improvement Projects/Reports LD.31.1, LD.31.2,
LD.31.4 79. Departmental Indicators Report LD.31.3 80. Evidences of rewarding recognized staff HR.15.1
81. Information System Downtime Procedures and Forms MOI.9.1

62. Page 62 of 134 Hospital Accreditation Guide Oct-2016 2. Medical Surveyor (Closed Session) Required
Documents Related Standards Medical Staff Bylaws 1. Medical Staff Bylaws MS.1.1, MS.1.2, MS.1.3,
MS.1.4, MS.1.5, MS.1.6 Medical Committees 2. Medical Executive Committee MS.3.1, MS.3.2, MS.3.3,
MS.3.4, MS.10.3 3. Cardiopulmonary Resuscitation Committee PC.32.7, MS.18.1, MS.18.2, MS.18.4,
MS.18.5 4. RRT Committee Meeting Minutes PC.33.4 5. Credentialing and Privileging Committee MS.5.1,
MS.5.2 6. Policy for Credentialing and Privileging MS.6.2, MS.6.6, MS.7.3, MS.7.4 7. Hospital Mortality
and Morbidity Committee MS.12.1, MS.12.2, MS.12.3, MS.12.4, MS.12.5, MS.12.6 8. Medical
Records/Forms Committee MS.13.1, MS.13.2, MS.13.3, MS.13.4 9. Utilization Review Committee
MS.14.1, MS.14.2, MS.14.3 10. Operating Room Committee MS.17.1, MS.17.2, MS.17.3, MS.17.4 11.
Oncology and Radiotherapy Committee/Tumor Board ORT.5.1, ORT.5.2, ORT.5.3, ORT.5.4 12. Committee
Terms of Reference (Sample) LD.9.3 Medical Staff Performance Evaluation 13. Documented Evidence of
Peer Review MS.4.4 14. Policy for Unplanned Review of Medical Staff Performance MS.8.2 15.
Credentialing and Privileging Committee MS.10.2 a.Policies for Patient Care Hospital-wide 16. Policy for
Patient Assessment and Re-assessment PC.6.1 17. Policy for Care of Psychiatric Patient PC.27.3, PC.28.1,
PC.28.2 18. Policy for Cardio-pulmonary Resuscitation PC.32.1, PC.32.2 19. Cardio-pulmonary
Resuscitation (CPR) Form PC.32.3 20. Policy for Rapid Response Team PC.33.1 21. Policy for Care of
Vulnerable Patient PC.34.1, PC.34.2 22. Policy for Patient Transfer PC.38.9, PC.39.1, PC.39.4 23. Policy
for Informed Consent PFR.10.1, PFR.10.4 24. Policy for Moderate and Deep Sedation/Analgesia AN.13.1,
AN.14.1, AN.14.2 a.Policies for Organ Donation 25. Policy for Organ Donation ICU.12.5, PC.43.1, PC.43.3,
PC.43.4, PFR.18.1, PFR.18.3, PFR.18.4, ICU.12.1, ICU.12.2, PICU.13.2, CCU.13.1, CCU.13.2, CCU.13.5 26.
Policy for Organ Transplantation PC.43.2, PC.43.3