The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) is a non-profit official organization that certificates to all public and private healthcare facilities operating in Saudi Arabia. Its function is to set healthcare quality and patient safety standards against which all healthcare facilities are evaluated.
Currently, there are three CBAHI accreditation programs: The Hospital Accreditation Program, The Primary Healthcare Center Accreditation Program, and the Central Blood Banks and Reference Laboratories Accreditation Program. Also it has been announced that two more programs will be incorporated: the Home Healthcare Services Accreditation Program and the Ambulatory Healthcare Centers Accreditation Program.
CBAHI accreditation is mandatory for all healthcare facilities, including hospitals, polyclinics, blood banks, and medical laboratories, and this recognition is a prerequisite for renewal of the operating license.
Benefits of the CBAHI accreditation
▪️ Provides a framework for the organizational structure and management.
▪️ Helps improve patient safety and minimize the risk of adverse outcomes and medical errors.
▪️ Enhances community confidence in the quality and safety of care provided.
▪️ It increases efficiency and enhances lean practices, which translates into decreasing waste and achieving optimal results.
▪️ Will satisfy the regulations of the Ministry of Health.
▪️ Better reimbursement by increasing confidence of patients, insurers and other parties.
▪️ Provides a robust tool for continuous quality improvement efforts in healthcare facilities.
As of June 2023, 300 hospitals have successfully obtained the CBAHI accreditation in Saudi Arabia. An additional 89 hold unaccredited status, 20 have Conditional Accreditation, and four faced revocation. Organizations not listed yet might be scheduled for a survey visit.
CBAHI’s Hospital Accreditation Program
The National Hospital Standards for Hospitals is a program launched for all hospitals in the Kingdom of Saudi Arabia. This is the third edition of this initiative, which started to be effective on January 1st, 2016.
All hospitals operating in the country are eligible for CBAHI accreditation. However, the healthcare organizations that want to request a survey visit must fulfill all of the following requirements:
▪️ Meets all licensing requirements to operate.
▪️ Meets any additional licensing requirements as indicated by other authorities.
▪️ Meets the legal definition of a hospital:Licensed as a hospital under the Saudi Arabia law.
▪️ It has an organized medical staff (doctors and continuous nursing services).
▪️ Maintains permanent and full-time facilities, including inpatient beds for the care of overnight resident patients.
▪️ Provides diagnosis (has laboratory and radiology services) and medical or surgical treatment primarily.
▪️ It provides emergency and intensive care services.
▪️ Has been in operation for at least 12 months before the on-site survey.
As this initiative means a standard, all hospitals are equally assessed to their scope of service in their processes, policies, and requirements, regardless of their bed capacity. Also, this award is valid for three years from the certification date as long as it is maintained.
The standards are divided into 23 chapters covering key services and functions provided by general hospitals.
How to achieve CBAHI Accreditation for hospitals
This is the pathway that hospitals must follow towards obtaining the national recognition.
Registration with CBAHI. As a first step, hospitals must complete the Healthcare Facility Registration Form, informing basic information about the registering facility. Upon successful registration, the facility shall receive useful resources for preparation.
Hospital Orientation Program (HOP). CBAHI provides ongoing Hospital Orientation Programs at different locations throughout the year. Hospitals are highly encouraged to attend one of the HOPs. During these orientation sessions, standards, accreditation policies, and survey processes are all explained in detail.
Self-Assessment Tool (SAT). All hospitals enrolled in accreditation are required to conduct a self-assessment using the tool provided by CBAHI. This instrument is intended to support the hospital in evaluating how close it is to a satisfactory compliance, and also gives an idea of how much preparation and time the hospital needs before requesting a survey visit.
The SAT provides communication between the hospital in preparation and the accrediting body. When both parties reach a compromise about the level of preparedness for a visit, a survey can be scheduled at a tentative date suitable for both.
Mock Survey. Upon reaching a satisfactory level of compliance with all applicable standards, a mutual agreement is made concerning the exact date of a Mock Survey, which is recommended but not mandatory. Some hospitals may go for an upfront Real Survey.
Requesting CBAHI for a survey. Three activities must be completed before conducting a survey visit:
1️⃣Service Agreement. All provisions of this agreement must be reviewed before sending the survey application.
2️⃣Survey application form. The hospital has to submit successfully a completed Survey Application Form.
3️⃣Evidence of payment of surveying fees.
Real survey. To earn and maintain accreditation, a hospital must undergo an on-site survey by the CBAHI survey team. CBAHI survey is structured to be an intelligent search for areas of nonconformance to the standards rather than a checklist exercise. Generally, the hospital survey team comprises seven healthcare professionals: The Core team (administrator, nurse, and physician) and the Specialty Team (Pharmacist, Infection Control Specialist, Laboratory specialist, and facility management and safety specialist).
A hospital's maximum number of real surveys for achieving accreditation is two attempts within two years. Six months is the minimal time interval between two consecutive real surveys. Therefore, hospitals that will eventually prove incapable of achieving accreditation will be suspended from participating in the national accreditation program for 12-18 months and referred to the relevant authorities for further action.
Accreditation decision rules
As a general rule, the hospital must meet all applicable standards at an acceptable level to become accredited. Decisions are communicated to the hospital within 30 days after the conclusion of the survey visit. Each standard is composed of a stem statement and sub-standards. The sub-standard is the evidence of compliance to be scored by the surveyor during the on-site survey and is scored as follows:
0 = Insufficient Compliance (Less than 50% compliance with the standard).
1 = Partial Compliance (From 50% to less than 80% compliance with the standard).
2 = Satisfactory Compliance (80% and more compliance with the standard).N/A = Not Applicable
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 on-site survey.
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 tangible compliance with all applicable standards during the on-site survey but still needs to meet the requirements for accredited status.
The hospital is required then to develop a “Standards Compliance Progress Report”, followed by a “Follow up Focused Survey”.
Scoring guidelines:
▪️ Overall score 75% or above and less than 85% and/or
▪️ Some of the essential safety requirements are not in satisfactory compliance.
Preliminary Denial of Accreditation (PDA):
This stage (rather than a final accreditation decision) 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.
▪️ Significant noncompliance with the accreditation standards.
▪️ Failure of timely submission of the post survey requirements after Conditional Accreditation.
▪️ Evidence of fraud, plagiarism, or falsified information.
▪️ Refusal by the hospital to receive the survey team and conduct a survey. In this case, the hospital will receive an upfront denial of accreditation and will be excluded from the accreditation program.
Denial of Accreditation:
It results when a healthcare organization shows significant noncompliance with the accreditation standards during the on-site survey. When the hospital is denied accreditation, it is prohibited from participating in the accreditation program for six months.
Scoring guidelines:
▪️ Overall score less than 75% and/or
▪️ More than 25% of the essential safety requirements are not in satisfactory compliance.
Accredited healthcare facilities are required to maintain their accreditation status by showing their continued compliance with the standards and requirements throughout the accreditation cycle and in accordance with the specified time frames.
Once accreditation is achieved, hospitals may display the CBAHI logo, accreditation certificate and seal on their communication assets denoting their accreditation status.
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