Ambulatory Care Centers Accreditation Guide

Ambulatory Care Centers
Accreditation Guide
(First Edition)
1st June 2021
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Table of Contents
Introduction
Registration with CBAHI
Scope of Accreditation Survey
Goal of Accreditation Survey
Assessment of Compliance
Accreditation Decision Rules
Special Scoring Considerations
Ambulatory Care Centers’ Responsibilities
CBAHI Survey Process
Overview
Pre-Survey Activities
Enrollment for Survey
Application for Survey
Update of Application Information
Resources for Ambulatory Care Centers’ Accreditation
About the Self-Assessment Tool (SAT)
Survey Team Composition
Survey Scheduling and Survey Agenda
On-Site Survey Activities
Survey Team Arrival
Opening Conference and Leadership Interview
Outpatient Area Visit

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Day Procedure Unit Visit
Laboratory Unit Visit
Radiology Unit Visit
Dental Unit Visit
Dermatology & Aesthetics Medicine Visit
Medication Management Tour
Management of Information Tour
Closed Medical Records Review
Personnel Files Review
Surveyors’ Report Preparation
Closing Conference
Post Survey Activities
Accreditation Decision and plan for corrections
Survey Report
Survey Feedback
Accreditation Maintenance
Annex(A): Sample Survey Agenda
Annex (B): Required Survey Documents
Annex (C) : Medical Records Review Tool
Annex (D): Personnel File Review Tool
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Introduction
The Ambulatory Care Centers Accreditation Guide serves as a reference for Ambulatory Care
Centers and surveyors in using the National Standards for Ambulatory Care Centers. The
guide is designed to facilitate learning and understanding of the Ambulatory Care Centers’
accreditation and survey process. It delineates the steps of completing the self-assessment to
assist Ambulatory Care Centers to determine their level of readiness for an accreditation
survey. The guide provides a clear explanation on how the standards, standard goals, and sub-
standards are used as evidences of compliance. It illustrates how the different survey tools
and activities are used by the surveyors with regards to the rating scale and summarizes the
pathway towards accreditation of the Ambulatory Care Center; including maintenance of the
center’s accreditation status once the survey is completed.
To fulfill our mission for driving continuous improvement, the Ambulatory Care Centers
Accreditation Guide will be a dynamic process where revisions shall be communicated to the
Ambulatory Care Centers in a timely manner. The CBAHI leaders are hopeful that the
Ambulatory Care Centers will find the guide beneficial and enable them to demonstrate
compliance with the Ambulatory Care Centers Standards.
Registration with CBAHI
All Ambulatory Care Centers are required to register with CBAHI through the following
steps:
• Access www.cbahi.gov.sa through your computer address bar.
• Choose "Health Care Facility" and select “Login”.
• Click on the icon "register to become a CABHI Accredited Healthcare Facility".
• Enter the Ambulatory Care Center’s information.
After completing all required information:
• Type the security numbers as they appear on the bottom left of the page.
• A message about completion of registration will be displayed specifying the username
and password.
• Use the specified username and password to access the CBAHI portal.
After completing the registration process:
• Access your center portal: www.cbahi.gov.sa/ambportal
• Use the username and password received during the registration process.
Scope of Accreditation Survey
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The scope of the CBAHI survey includes all standards-related functions of the ambulatory
care centers. Each survey is tailored to the type, size and range of services offered by each
specific Ambulatory Care Center. The CBAHI staff determine the applicable standards from
the Ambulatory Care Center Standards based on the scope of services provided at the time of
survey. Additionally, the on-site survey team considers the specific applicability of individual
standards and/or chapters.
The following chapters are considered mandatory for all Ambulatory Care Centers:
• Leadership of the Organization (LD)
• Provision of Care (PC)
• Medication Management (MM)
• Management of Information (MOI)
• Infection Prevention and Control (IPC)
• Facility Management and Safety (FMS)
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Goal of the Accreditation Survey
The goal of the survey is to determine if the Ambulatory Care Center complies with CBAHI
accreditation standards. CBAHI surveyors provide education and consultation to the
Ambulatory Care Center staff throughout the survey as indicated to help them improve their
clinical and administrative processes.
Assessment of Compliance
CBAHI expects substantial compliance with all applicable standards. The surveyors assess
compliance with the 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 center’s achievement of specific outcome measures (e.g., infection
rates, patient satisfaction) through a review and discussion of monitoring and
improvement activities.
Accreditation Decision Rules

To become accredited, the Healthcare Facility (HCF) must meet all applicable standards at
an acceptable level. CBAHI utilizes a multilevel process for making accreditation and
reaccreditation decisions. This is to ensure fairness, consistency, objectivity, and accuracy.
Therefore, CBAHI benefits from any relevant report and/or significant findings or issues of
concern related to the surveyed facility that were brought to its attention by relevant health
authorities or past accreditation surveys.
Accreditation decisions are released and communicated to the HCF within thirty (30) days
after the conclusion of the survey visit. The accreditation decision-making process is based
on:
• The findings of the survey team members as recorded in the survey report.
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• Discussions between the surveyor and the specialty team leader (STL)regarding the
survey findings.
• Review of the draft report by the participating HCF for feedback or correction of any
issues of fact before the accreditation decision is made.
• Review/discussion during the meeting of the Accreditation Decision Committee
(ADC). This committee may request additional evidence before making a final
recommendation for the accreditation decision. All accreditation decisions are then
ratified by the CBAHI Director General.
It is important to note that the decision to grant accreditation is based primarily on the
findings of the on-site survey as recorded by the surveyors in the survey report. The overall
numerical score the HCF obtains is only one important factor upon which the Accreditation
Decision Committee (ADC) members rely when making their recommendation. Other
factors are:
• Criticality of the non-compliant standard(s), for example the degree of severity and
immediacy of risk to patients, visitors or staff safety.
• Any concerns regarding the non-compliant standard(s), for example the degree of
severity and immediacy of risk to patients, visitors or staff and the facility.
When a CBAHI surveyor notices an immediate threat, whether or not it is directly linked to
the standards, the survey team leader will directly notify the HCF director and include the
findings in the survey report.
Each standard is composed of a stem statement and sub-standard(s). The sub-standard is the
evidence of compliance to be scored by the surveyor during the on-site survey. Each sub-
standard has an equal weight and is scored on a three-point scale as follows:
0 = Insufficient Compliance (less than 50% compliance with the standard).

1 = Partial Compliance (50% to less than 85% compliance with the standard; not
applicable to the core standards).
2 = Satisfactory Compliance (85% and more compliance with the standard).
N/A = Not Applicable
The score of each standard is calculated using the sum of the scores of the sub-standards
divided by the maximum score of all the sub-standards. The overall score of the HCF is
calculated using the sum of the scores of all the applicable sub-standards divided by the
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maximum score.
When one or more chapters of the Ambulatory Care Standards are not applicable to a
particular HCF, they are indicated by “N/A.” Non-applicable chapters are not scored and are
not included in either the numerator or denominator of the overall score.
The Accreditation Decision Committee (ADC) shall recommend any of the following
accreditation decisions:
Accredited
Accreditation will be awarded when the surveyed HCF demonstrates an overall satisfactory
compliance with all applicable standards at the time of the initial (or re-accreditation) on-site
survey, and when there are no issues of concern related to the safety of patients, staff,
visitors or the facility itself. Accreditation will also be recommended when the HCF has
successfully addressed all post-survey requirements and does not meet any rules for denial.
Scoring Guidelines:
• Overall score 75% or above.

• All core standards are fully met.
• All applicable standards score 50% and above.
Denial of Accreditation
Denial of accreditation results when significant noncompliance is demonstrated 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 the initial denial of accreditation have not been resolved. When the
HCF is denied accreditation, it is prohibited from participating in the accreditation program
for a period of six months unless the Director General of CBAHI, with good reason, waives
all or a portion of the waiting period.
Accreditation may be denied as a result of one or more of the following issues:
• Overall score less than 75%, or one of the core standards is not in full compliance or
an applicable standard scores less than 50%.
• 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.
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• Failure to submit the post-survey requirements in a timely manner.
• The HCF was subjected to a 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 HCF through redrafting, additions or deletions of a
document’s content without proper attribution. CBAHI perceives plagiarism as the
deliberate use of other HCF original (not common knowledge) material without
acknowledging its source.
• Refusal by the HCF to allow a survey to be conducted.
Special Scoring Considerations

• A selected group of standards have been assigned as core standards indicated with a
colored (C) in the Ambulatory Care Standards. Compliance with the core standards is
determined by applying an all or none rule (full score or zero) during the on-site
survey. There is no partial compliance for core standard.
• Criticality of a non-compliant standard (the degree of severity and immediacy of risk)

- When a CBAHI surveyor notices an immediate threat to patients, visitors, staff or
building safety, whether directly linked or not linked to the standards, the surveyor
notifies the team leader. The survey team leader then notifies the Ambulatory Care
Center’s director and includes the findings in the survey report. The criticality of non-
compliant standards affects the accreditation decision and require interventions as
detailed in the accreditation policies section of the Ambulatory Care Center
Standards. Examples of an immediate threat to safety or quality of care include:
o A Healthcare provider is entering an isolation room without proper Personal

Protective Equipment (PPE).
○ The use of an expired medication.
o Bare electrical wire is exposed without any protection.
o A patient is not properly identified.
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Ambulatory Care Centers’ Responsibilities
Survey Visit Coordinator

The Ambulatory Care Center selects a person to serve as the “survey visit coordinator” to
handle the logistics of the survey visit. The survey visit coordinator serves as the liaison with
CBAHIs Healthcare Accreditation Department (HAD) and the visit team leader (VTL)
regarding the survey visit arrangements.
Survey Team
A list of survey team members, with their biographies, is sent to the Ambulatory Care Center
prior to the survey visit. The Ambulatory Care Center contacts CBAHI promptly if any
surveyor is deemed to be inappropriate due to conflict of interest or other valid reasons. No
surveyor can specifically be requested to conduct a survey in line with maintaining
objectivity.
Travel Arrangements
CBAHI arranges the survey team’s hotel and flight reservations. All flights are booked for
the night before the survey. A list of assigned surveyors with their flight details and mobile
numbers is sent to the Ambulatory Care Center’s survey visit coordinator prior to the survey.
The Ambulatory Care Center arranges transportation from the airport to the hotel, from the
hotel to the Ambulatory Care Center, and to any remote sites as part of the survey visit. The
visit team leader and survey visit coordinator determine where and when the team should be
picked up or met at the hotel. At the conclusion of the survey visit the Ambulatory Care
Center arranges the transportation from the hotel to the airport according to the departure
time/s of the surveyors.
Staff Involvement
A well-conducted survey requires important information from a broad range of staff for the
deliberations by the survey team. The survey team members interview different categories of
staff on a variety of topics to ensure that the team has access to representative information
related to staffs’ implementation of CBAHI standards.
Conflict of Interest
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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 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 provided in preparation for the survey, assisting in preparation of the self-
assessment, conducting mock surveys, helping in the interpretation of the standards,
or other similar activities. All requests for consulting services utilizing one of the
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
The Ambulatory Care Center 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 is furnished with a desk or table,
access to electrical outlets and internet.
• A workroom for group meetings and interviews with leadership and staff as specified
in the survey agenda.
• Assigning a counterpart, who is a responsible person in the same specialty, to each
surveyor for the duration of the survey.
Center’s Observers
When the Ambulatory Care Center’s team includes an observer(s), who may represent a
consulting firm or staff from another ambulatory care center, the Ambulatory Care Center
must inform CBAHI and obtain official approval prior to the accreditation survey. Should
approval be granted, the afore mentioned observer(s) are not allowed to participate in the
survey visit activities.
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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 the CBAHI side will be included in the list of
surveyors sent to the center prior to the survey.
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CBAHI Survey Process
Overview
This section details the various activities of an ambulatory care center survey. For a better
understanding of the accreditation survey process, the survey related activities are organized
into three sections:
• Pre-Survey Activities
• On-Site Survey Activities
• Post-Survey Activities
Pre-Survey Activities
Enrollment for Survey
The accreditation process begins with selection of the ambulatory care centers to be surveyed.
Each year, CBAHI selects the centers to be enrolled in the accreditation program. CBAHI
sends a letter of enrollment to the selected centers to start their application process.
Application for Survey

After completion of the enrollment process, the ambulatory care centers selected for the
accreditation process complete the Survey Application Form available on the CBAHI portal.
This form collects information regarding the organization, its facilities and services to
establish the ambulatory care center’s profile. The form is divided into sections with
guidelines to facilitate accurate completion of the form. The access to the e-Application is
provided by CBAHI to the intended ambulatory care centers. The encoded data may be saved
in stages and updated as needed. The Survey Application Form is completed as follows:
• Open the web browser e.g., Internet Explorer.
• Type www.cbahi.gov.sa/ambportal in the address bar
• Enter your username and password.
• Complete and submit the center demographic questionnaire.
• Under the “Survey Process” menu, select “Apply for a New Survey”
• Fill the required information and submit to CBAHI.
Update of Application Information
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The Ambulatory Care Center is made aware that planning of the surveys is done according to
the scope of services as documented in the survey application form. If the Ambulatory Care
Center experiences significant changes after its submission, the amendments are made in the
survey application form within five (5) business days. The update for a re-survey must be
completed by the accredited ambulatory care center and submitted to CBAHI twelve weeks
prior to the accreditation expiration.
Update of the main contact points of the Ambulatory Care Centers ensures an open
communication channel with the Ambulatory Care Center and timely communication of
accreditation policies and standards modifications to the ambulatory care centers.
Resources for Ambulatory Care Centers’ Accreditation

CBAHI will assign each Ambulatory Care Center enrolled for a survey a HAD’s
accreditation coordinator, who will serve as a primary contact between the center and
Healthcare Accreditation Department (HAD). This individual will coordinate survey
planning and will be available to the center to answer questions and clarify issues related to
the survey process. In order to assist centers for preparation of surveys, Ambulatory Care
Centers are offered the following resources:
1. National Standards for Ambulatory Care Centers First Edition

The Ambulatory Care Centers Standards facilitates access and understanding of the
standards’ requirements as well as the accreditation policies. The Ambulatory Care Center
Standards is divided into four parts:
- Part I - Introduction and Explanatory Notes
- Part II - Accreditation Policies
- Part III -Accreditation Standards
- Glossary and acronyms
2. Ambulatory Care Centers Accreditation Guide

The Accreditation Guide provides useful information in preparation for the ambulatory care
center survey.
3. Self-Assessment Tool (SAT)

The first task for the Ambulatory Care Center is to complete an initial self-assessment to
determine its readiness and preparation for the survey. The Ambulatory Care Center
evaluates its organizational structure, operational processes, outcomes and organizational
effectiveness based on compliance to the standards. The Standards contains an explanation
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for standard clarification and guidance. Prior to a survey visit, each ambulatory care center
completes and submits a self-assessment report. A successful self-assessment provides
valuable information that may be used to modify and improve said ambulatory care center’s
performance.
About the Self-Assessment Tool (SAT)

The self-assessment tool assists ambulatory care centers to measure their compliance with
CBAHI standards, maintain a status of accreditation readiness, and oversee the quality and
safety of patient care. It is intended for use by the ambulatory care center’s leadership,
planners, committee members, and staff responsible for the ambulatory care center’s plans,
policies, and procedures. The SAT participants meet and discuss the issues related to
compliance and non-compliance with the ambulatory care standards. CBAHI hopes that the
SAT enables the ambulatory care centers to:
• Identify its strengths and weaknesses
• Identify and act on areas for improvement
• Understand more clearly the issues that are of interest to CBAHI
• Export the SAT data for analysis and evaluation.
Design of the SAT

The SAT is designed in a checklist format that includes all standards arranged in chapters that
correspond to the respective CBAHI Standards. The SAT contains a number of sections:
• Standards Section - contains a list of standards and sub-standards in every chapter.
• Scoring Section - contains scoring points used for evaluating the level of compliance
for each sub-standard.
• Comments Section – free space for documenting the assessment findings i.e.
strengths, weaknesses and areas for improvement.
Frequency for the SAT

CBAHI accreditation policies require Ambulatory Care Centers to conduct a self-assessment
at different periods of time: during preparation for an initial survey and at the middle of the
accreditation cycle of an accredited Ambulatory Care Center, i.e., 18 months after being
awarded accreditation.
• Prior to Initial Survey – Conduct the SAT before the initial survey to evaluate the
Ambulatory Care Center’s readiness and preparation for the accreditation.
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• Mid-accreditation Cycle – Conduct the SAT during the three (3) month period prior to
the 18th month post accreditation award date. Each accredited Ambulatory Care
Center will receive CBAHI notification regarding its submission of SAT and action
plan for non-compliant standards.
CBAHI also recommends that the self-assessment be done more frequently (e.g., quarterly)
as part of an improvement process to ensure ongoing compliance, determining progress
overtime and sustaining quality and safe care.
How to Use the SAT

The SAT has a 3-point rating scale that corresponds to the level of compliance based on the
assessment per sub-standard. Each sub-standard is scored from 0 to 2; with 0 = insufficient
compliance, 1 = partial compliance, and 2 = satisfactory compliance. If the standard is not
applicable to the Ambulatory Care Center, mark “NA” = Not Applicable. The rating scale
shows the areas that require great improvement efforts. On-going self-assessment facilitates
monitoring the progress made over time.
Accessing the SAT

Using the Ambulatory Care Center’s username and password, download the SAT, an
internet-based program that provides features for:
• Entering self-assessment findings
• Sending surveys to respondents for completion
System Requirements
(Note: The instructions are based on a Microsoft XP environment. Appearance may differ in
other environments. If you require further assistance, contact the System Administrator at
[email protected].)
The online self-assessment system can run on Microsoft XP and Vista, and Macintosh OS X
environments. Minimal system requirements include:
• Access to the internet
• An internet browser (e.g., Internet Explorer)
To login:
• Open the web browser e.g., Internet Explorer.
• Type “www.cbahi.com.sa” in the address bar.
• Press “Enter”. The Web Page is displayed.
• Choose "Health Care Facility".
• Click “Login”.
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o Enter username number and password.
o Click “Login”.
• When successfully logged in, the self-assessment page is displayed.
• Click on "Self-Assessment".
• Click "Open CBAHI Self-Assessment".
• It will redirect you to a new web page.
• Click "Create New Self-Assessment Record".
• Choose one of the eleven (11) chapters from the drop-down list to begin filling the
scoring.
• Save the result. The result displays the total number of scorable items, number of
scored items, number of items that have not been scored yet, and the chapter score in
percentage based on the items that have been scored.
• Upon completion of scoring of standards, click "close."
• This will redirect you back to the previous page where a report has been generated
automatically that shows report date, submission date, number of scored items,
number of unscored items, and the Ambulatory Care Center’s percentage score.
• The generated report is automatically shared with CBAHI.
• If there is no activity for (5) five minutes, the session will go into a “timeout” with
directions to log in again to continue the session.
• If either username or password have been forgotten, contact the System Administrator
via [email protected].
1. Healthcare Facility Orientation Program (HOP)
CBAHI provides orientation programs in different regions of the Kingdom of Saudi Arabia.
The Ambulatory Care Center Standards orientation program includes an introduction to the
standards, their implementation, the accreditation policies, and survey process to achieve an
effective survey preparation. Dates and venues of the orientation programs are communicated
to the ambulatory care centers in a timely manner.
2. Mock Survey (optional)

Some Ambulatory Care Centers will prefer to conduct 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.
3. 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.
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4. 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
The survey team is composed of two certified CBAHI surveyors, a physician and a nurse, and
is based on the following factors as provided in the survey application:
• Size of the facility based on average daily census.
• Complexity of services offered, including surgical and anesthesia services.
• Presence of special care units.
All ambulatory care center surveys are done in one (1) day. Prior to the survey, the surveyors
review information related to the Ambulatory Care Center from the following sources:
• The Survey Application information.
• Offsite required documents.
• Any other relevant documents as decided by CBAHI.
• For reaccreditation: mid-term self-assessment and the related corrective action plan
(CAP).
These documents provide the surveyors an opportunity to verify whether the Ambulatory
Care Center documentation are consistent with the actual practice.
Survey Schedule and Survey Agenda
HAD manages all the scheduling and survey agenda arrangements in collaboration with the
Ambulatory Care Center’s survey visit coordinator. The survey agenda for the day reflects
the activities to take place during the survey. HAD communicates the survey agenda to the
Ambulatory Care Center at least three (3) days prior to the survey. (Please refer to Annex A for
more details.)
Offsite Survey Activities
Prior to the onsite survey, the assigned surveyors receive and review essential documents as
listed (Annex B - offsite). The list is submitted by the Ambulatory Care Center to HAD prior
to the survey visit through the CBAHI portal.
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On-Site Survey Activities
The onsite survey commences with an opening conference and leadership interview followed
by visits to patient care and support areas. The surveyors review relevant documents during
the unit visits. This is followed by review of closed medical records and staff files. The
surveyors conduct a closed session to document their findings and prepare for the exit report.
Finally, the surveyors meet with the Ambulatory Care Center’s leaders and a selected group
of staff to discuss the survey findings as presented in the exit report.
There should be no surprises in the survey report, as the surveyors have already raised any
issues during the unit visits, review of medical records and staff files. During the survey, the
surveyors maintain ongoing communication with their counterparts from the Ambulatory
Care Center. As questions arise, the surveyors present their findings to their counterparts,
providing an opportunity to clarify or explain possible discrepancies or compliance issues.
This enhances further consultation and staff education.
Survey Team Arrival

• The surveyors arrive to the Ambulatory Care Center early enough to start the survey
activities in a timely manner according to the survey agenda. Upon arrival, the
surveyors present their CBAHI identification.
• The surveyors meet in the designated room identified by the Ambulatory Care Center.
Opening Conference and Leadership Interview
Objectives
• Introduce CBAHI team to the Ambulatory Care Center’s leaders.
• Explain the scope of survey.
• Orient the surveyors about the Ambulatory Care Center’s structure, mission, vision,
scope of services, and staffing.
• Define the expectations on the Ambulatory Care Center staff and surveyors.
• Assess leadership compliance to the LD standards.
Participants
• CBAHI Surveyors
• Ambulatory Care Center staff: director, chiefs of services (medical/nursing/
administrative) and others at the discretion of the Ambulatory Care Center’s leaders.
Logistics
• A workroom that is large enough to hold all participants and allows interactive
discussions, e.g., a conference room equipped with audiovisual equipment.
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Procedure
• Surveyors’ greetings and staff introduction.
• Senior leader’s presentation regarding the Ambulatory Care Center’s mission, vision,
values, scope of services, staffing and workload statistics.
• Surveyors brief Ambulatory Care Center on the survey structure - survey agenda,
questions and answers, and any changes in the suggested agenda in consideration of
staff schedules and procedure observation.
• Surveyors identify staff required to attend other survey activities.
• Surveyors identify medical records and personnel files for review as per agreed time
schedule.
• Surveyors’ interview with the Ambulatory Care Center’s leaders focusing on
leadership standards, roles and responsibilities:
o Governance structure and function.
o Organizational structure.
o Strategic planning and budgeting.
o Human resource management.
o Patient and family rights.
o Quality improvement and patient safety program.
o Risk management program.
o Contracted services.
Outpatient Area Visit

Objectives
• Ensure the unit structure complies with safety, security and infection control
requirements.
• Observe and assess staffing ratios to ensure compliance with both the national
requirements and staffing plan.
• Observe and assess staff practices in patient care and medication management.
• Observe and assess compliance with patient and family rights.
• Observe and assess equipment management practices.
• Observe and assess the Ambulatory Care Center’s readiness for cardiopulmonary
resuscitation.
• Review relevant documents to the various practices in the outpatient area.
• Ensure compliance of available shops with safety requirements.
Participants
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• CBAHI Surveyors
• Ambulatory Care Center’s visit facilitator
• OPD director, nurse manager and staff in their specific locations
Logistics
• None
Procedure
• The surveyors and the visit facilitator go to the OPD area. The surveyors observe the
general layout for:
o General cleanliness and aesthetic appearance.
o Accessibility for patients.
o Waiting rooms.
o Availability of toilets, dirty utility, clean utility and housekeepers’ closets.
o Staff wearing ID badges.
o Crash cart availability.
o Periodic preventive maintenance of medical equipment.
o Medication storage and preparation.
o Availability and distribution of hand sanitizers.
o Availability and distribution of sharps containers.
o Availability of personal protective equipment.
o Availability of patient and family rights displayed or in brochures.
o Availability of services and working hours displayed or in brochures.
o Facilities for patients with disabilities.
o Fire detection and abatement devices and equipment.
o Safety exits.
o General security (availability and distribution of security staff).
o Storage of medical records for confidentiality and security.
o Ambulance accessibility and readiness for transporting patients.
• The surveyors observe the examination rooms for:

o Patient’s privacy during interview and examination.
o Hand washing facility.
o Additional safety features for specialized equipment.
• The surveyors interview the staff.

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- Reception staff:
o Patient registration and appointment system.
o Helping patients to choose the right services, if needed.
o How to suspect communicable diseases.
o What to do in case of fire.
o What to do in case of electrical failure or computer outage.
- Nursing staff:
o Correct patient identification.
o Turnaround time for investigations.
o Reporting of critical values.
o Disinfection of patient equipment in-between patients.
o What to do in case of cardiopulmonary arrest.
o Crash cart management.
o Medication management: preparation and administration.
o Process for patient transfer.
o Process for staff sharps injury.
o Effectiveness of point of care testing.
- Physicians:
o Patient assessment and care planning.
o Consultation process between specialties.
o Safe prescribing of medications.
o Turnaround times for investigations.
o Informed consent.
o Patient and family education.
o Reporting of medication errors, allergic reactions and adverse events.
o Disclosure to patient and family following incidents.
o Knowledge on clinical practice guidelines.
- Housekeeping staff:
Page 22 of 54
o Orientation to the Ambulatory Care Center and educational topics
received.
o Chemicals used for cleaning.
o Chemicals used for disinfection.
o Cleaning schedules.
o What to do in chemical, blood/body fluid spills.
o Waste management.
• Document Review:
o Policy on patient assessment.
o List of surgery/procedures/interventions requiring informed consent.
o Policy on patient transfer for higher level care.
o Clinical practice guidelines.
o Infection control manual.
o Ambulance maintenance.
• Open Medical Records Review:

o Completed patient assessments.
o Care planning with measurable goals.
o Evidence of screening for pain, nutritional needs, and functional needs.
o Documentation of allergies and chronic infections.
o Consultations.
o Consent.
o Patient and family education.
o Lab and radiology results.
o Prescriptions.
• Policy on patient transfer for higher level care.
Day Procedure Unit Visit

Objectives:
• Ensure structure of DPU complies with the National and International requirements
for operating rooms and recovery rooms for day surgery/procedure.
• Ensure the availability of the essential equipment for patient safety during
sedation/anesthesia, procedures and recovery.
• Observe and assess staff practices in patient care and medication management.
Page 23 of 54
• Observe and assess compliance with patient and family rights.
• Observe and assess equipment management practices.
• Observe and assess the Ambulatory Care Center’s readiness for cardiopulmonary
resuscitation.
• Review relevant documents for the various practices in the DPU area.
• Review medical records documentation compliance in DPU.
• Observe infection prevention and control practices.
Participants
• CBAHI Surveyors
• DPU director, nurse manager, physicians and nurses in DPU.
Logistics
• None
Procedure
• The surveyors and the visit facilitator go to DPU. The surveyors observe the general
layout for:
o Unit design: staff changing area, receiving area, procedure room and
equipment medication preparation area, utility rooms (dirty, clean,
housekeepers), clean and dirty waste circulation.
o Procedure room and equipment.
o Difficult intubation equipment availability.
o Crash cart availability and readiness.
o Recovery room and equipment.
o Emergency exits.
o Recovery area has an ICU setup.
• Staff Interview:
- Nursing staff:
o Receiving patients (identification, pre-procedural checklist).
Page 24 of 54
o Daily checking of anesthesia machine operating room (anesthesia machine,
medications, air-conditioning requirements, crash cart).
o Time out procedure.
o Intra-procedure sedation monitoring.
o Recovery process from sedation/anesthesia.
o Discharge home from recovery.
o Periodic preventive maintenance for medical equipment.
o Medication management: preparation and administration.
- Physicians:
o Patient assessment and surgical plan.
o Consent for surgery.
o Procedural site marking.
o Time out procedure.
o Pre-sedation / anesthesia assessment.
o Consent for sedation / anesthesia.
o Recovery process from sedation/anesthesia.
o Discharge home from recovery.
- Housekeeping staff:
o Waste management.
o Disinfection of procedure room and equipment in between cases and at the end
of the list.
o DPU policies and procedures.
o Registry book for procedures.
Page 25 of 54
o Physicians’ privileges.
o Policy on managing patients who inadvertently require ICU care following
surgery/procedure.
• Open Medical Records Review:
o Physician assessment and procedural (“operational”) plan.
o Pre-procedure sedation / anesthesia assessment.
o Availability of laboratory and radiology results.
o Intra-operative/procedure monitoring.
o Operative report.
o Recovery and discharge home process.
o Patient / family education.
Laboratory Unit Visit
Objectives
• Ensure the laboratory structure complies with safety, security and infection control
requirements.
• Observe infection control and safety practices.
• Review equipment maintenance and quality control documents.
• Interview staff for their daily pre-analytical, analytical and post analytical practices
and reporting of test results.
Participants
• CBAHI Surveyors
• Laboratory director and technicians
Logistics
• None
Procedure
• Observe:
o Phlebotomy area (equipment, infection control).
o Receiving area (infection control).
o Process for receiving specimens.
o Adequacy of space, infection control practices (equipment area, utility rooms,
storage areas for reagents and specimen, and processing area).
Page 26 of 54
o Periodic preventive maintenance for equipment.
o Safety of equipment.
o Emergency exits.
• Lab Staff Interview:
o Patient identification before sample collection or receiving samples.
o Specimen labelling
o Specimen rejection.
o Turnaround times for results.
o Reporting of critical results.
o Quality control.
o Proficiency testing.
o Outsourced services.
o Effectiveness of Point of care testing.
o Periodic preventive maintenance for equipment.
o Waste management.
o Laboratory services and specimen manual.
o Contract for outsourced services.
o Policy for quality control.
o Policy for proficiency testing.
o Policy for reporting of results.
o Infection control program.
o Safety program.
Radiology Unit Visit
Objectives
• Ensure the radiology unit structure complies with safety, security and infection
control requirements.
Page 27 of 54
• Interview staff for daily equipment checks, quality control practices and reporting of
test results.
Participants
• CBAHI Surveyors
• Radiology director and technicians.
Logistics
• None
Procedure
• Observe:
o Layout, reception area, safety signs and warnings, aprons, emergency exits.
o Staff wearing ID badges and thermoluminescence dosimeters (TDL) cards.
o Storage of contrast media/hazardous material.
- Radiologist/Technician
o Outsourced services.
o Radiation safety program.
o Equipment testing and preventive maintenance.
o Scope of services.
o Contract for outsourced services.
o Radiology safety program.
o TLD cards’ results.
o Equipment operation and service manuals.
o Equipment periodic preventive maintenance.
Page 28 of 54
o Periodic testing of radiation protection aprons.
Dental Unit Visit
Objectives
• Ensure the dental unit structure complies with safety, security and infection control
requirements.
• Interview staff for daily infection prevention practices and disposal of dental waste.
Participants
• CBAHI Surveyors
• Dental director, dentists and dental assistants
Logistics
• None
Procedure
• Observe:
o Dental room layout for infection control.
o Availability of dental assistants.
o Infection control practices.
o Safety measures in dental lab.
o Emergency exits.
o Fire detection and abatement equipment.
o Availability of radiation protection aprons.
- Dentist/Dental Technician:
o Scope of services.
o Infection control practices.
Page 29 of 54
o Infection control program.
o Assessment and care planning.
• Medical Records Review:
o Patient assessment.
o Care planning.
o Patient / family education.
o Prescriptions.
Dermatology & Aesthetics Medicine Visit
Objectives
Participants
Logistics
Procedure
• Observe:
Medication Management Tour
Objectives
• Ensure the pharmacy structure complies with the safety and security of medications.
• Observe medication preparation areas comply with infection control requirements.
• Observe staff medication preparation practices.
• Interview staff for their role in medication safety practices, reporting of medication
errors and adverse drug reactions.
Participants
• CBAHI Surveyors
• Pharmacy director, medical and nursing staff
Logistics
Page 30 of 54
• None
Procedure
• Observe:
o Medication expiry dates including multi-dose vials.
o Medication storage and preparation.
o Storage of “LASA” and high alert medications.
o Storage of expired medications.
o Emergency exits.
- Pharmacist
o Managing incomplete and inappropriate prescriptions.
o Reporting of medication errors.
o Handling of narcotic medication.
o Evaluating the appropriateness of prescriptions before dispensing and
managing incomplete/inappropriate prescriptions.
o Drug formulary.
o Physicians’ signature list.
o Policy on handling medications when storage temperature is outside required
temperature range.
o Policy on handling and storage of LASA and concentrated electrolytes high
alert medications.
o Policy on dealing with expired medications.
o Medication errors, allergies and adverse drug reactions policies and reports.
o Guidelines on the use of multi-dose vials and vaccines.
Management of Information Tour

Objectives
• Ensure the unit structure complies with safety, confidentiality and security
requirements.
Page 31 of 54
• Observe functional distribution and storage of medical records.
• Interview staff for the daily pulling out of files, analysis and storage.
• Informational technology data center (safety, security and integrity of data).
Participants
• CBAHI Surveyors
• Medical records director and clerk
Logistics
• None
Procedure
• Observe:
o Functional distribution of medical records storage area.
o Records analysis area.
o Confidentiality, safety and security of medical records stored in the unit.
o Emergency exits.
- Medical Records Clerk:
o Standardized process for arranging medical records.
o File analysis upon return from clinical areas.
o Managing incomplete records.
o Managing duplicate files.
- Administrator/MOI Officer:
o Designing the MOI plan.
o Compliance with regulatory bodies’ required documents.
o MOI plan.
o Policy on writing in medical records.
o Policy on managing incomplete medical records.
Page 32 of 54
o Approved abbreviation list.
Closed Medical Records Review

Objective
• Ensure compliance with medical records documentation requirements.
Participants
• CBAHI Surveyors
• Medical and nursing staff
Logistics
• A quiet room with table and chairs to accommodate attendees.
• Medical records of patients in the Ambulatory Care Center from the previous (4) four
months for a new survey; and the previous (1) one year for triennial surveys (at least
five from different specialties).
Procedure
• The selection of closed medical records for review is guided by the services provided
by the Ambulatory Care Center and any available source of information during the
period prior to the survey such as the top diagnoses and procedures.
• Surveyors utilize the tool as in Annex C.
• The review focuses on:
o The completion of records in terms of assessment, care planning, consents,
patient and family education, consultations, referrals and transfer
documentation.
o Timeliness, use of abbreviations and symbols.
• Personnel Files Review

Objective
• Evaluate standards related to human resources such as recruitment, qualifications, job
descriptions, orientation, education, and staff performance evaluation.
Participants
• CBAHI Surveyors
• Ambulatory Care Center staff familiar with the contents of personnel files.
Logistics
• A quiet room with table and chairs to accommodate attendees.
Page 33 of 54
Procedure
• Surveyors provide the Ambulatory Care Center with a list of personnel files required
to be reviewed during the survey. The list includes but is not limited to chief medical
and administrative staff, new hires, physicians, nurses, technicians, and others.
• The requested personnel files must be ready prior to the review session.
• Personnel file documents for review are:
o Staff credentials (education, training, experience)
o Licensure and registration
o Credentialing of all staff
o Job description
o Privileging of medical staff
o Orientation (general and departmental)
o Continuous education
o Performance evaluation
• The surveyor shall utilize an evaluation template as in Annex D.
Surveyors’ Report Preparation

Objectives
• Integrate findings from areas visited into the corresponding chapter standards.
• Prepare an initial report that can be shared with the Ambulatory Care Center at the
end of the on-site survey.
• Provide the Ambulatory Care Center with the possible challenges and areas for
improvement.
• Provide the Ambulatory Care Center with the list of non-compliant core standards that
need immediate leadership attention.
Participants
• CBAHI Surveyors
Logistics
• A workroom that accommodates the surveyors and Ambulatory Care Center staff.
Procedure
• The surveyor completes the scoring of all the sub-standards during the on-site
assessment. If there are two surveyors, they must integrate their findings into one
report that will be shared with the Ambulatory Care Center at the end of the on-site
survey.
Page 34 of 54
• The survey Visit Team Leader (VTL) integrates and delivers the final report.
Closing Conference
Objectives
• To provide the Ambulatory Care Center with an initial overview on the outcome of
the survey.
• To allow the Ambulatory Care Center to clarify and explain possible discrepancies or
compliance issues.
• To provide the Ambulatory Care Center’s leaders with the strengths and areas for
improvements.
Participants
• CBAHI Surveyors
• Ambulatory Care Center’s chief medical and administrative staff, and staff in
supervisory levels
Logistics
• A workroom/auditorium that is large enough to accommodate all the attendees.
Procedure
• At the conclusion of the on-site survey; the surveyors hold a closing conference to
present key findings, strengths and areas for improvement. The Ambulatory Care
Center is informed on how to access the detailed report and possible follow-up
activities and/or decisions. During the exit conference, the surveyors do not declare
any accreditation awards.
• Members of the leadership group take the 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.
Page 35 of 54
Post Survey Activities
Accreditation Decision and Plan for Corrections

Following completion of the survey, CBAHI renders an accreditation decision and delivers a
report. Types of possible accreditation decisions, follow up activities, and required
accreditation maintenance activities are fully explained in part two of the standards manual.
The surveyed Ambulatory Care Center receives official documents from CBAHI detailing the
accreditation decision, and any required follow-up activities, within thirty days after the
conclusion of the survey. The Ambulatory Care Center will be able to access the survey
report with the use of their username and password through the Ambulatory Care Center
portal.
Survey Report
CBAHI provides a survey report to the Ambulatory Care Center 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 welcomes and appreciates each
surveyed Ambulatory Care Center’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 Ambulatory Care Center’s survey coordinator after the survey visit has been completed
requesting their feedback about CBAHI standards, survey process and surveyors’
performance.
Accreditation Maintenance
The maintenance of the accreditation process pertains only to hospitals already accredited.
When an Ambulatory Care Center receives accreditation, the Ambulatory Care Center 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 an
Ambulatory Care Center has achieved accreditation, a process of continuous improvement
maintains the accreditation status. The maintenance of accreditation procedures are fully
Page 36 of 54
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 an Ambulatory Care Center to engage in a process of rigorous
self-review and improvement against CBAHI standards.
Page 37 of 54
Annexes
Annex (A)
Sample Survey Agenda
Ambulatory Care Center Agenda (Two Surveyors)
Surveyor 1
SN Topic Time Duration
1. Document Review 01:10pm – 02:20pm 1 hour 10 mins
2. Leadership Interview 02:20pm – 03:05pm 45 mins
Break Time 03:05pm – 03:30pm
3. Medical Record Visit 03:30pm – 04:15pm 45 mins
4. Observation & Interview

04:15pm – 04:30pm 15 mins
(Laser room)

04:30pm – 04:45pm 15 mins
(OPD, Procedure room)

04:45pm – 05:00pm 15 mins
(CSSD)

05:00pm – 05:15pm 15 mins
(FMS)
8. Personnel File Review 05:45pm – 06:30pm 45 mins
4 hours 45 min
Total Time Hours
approximately # 5
hours
Page 38 of 54
Surveyor 2
SN Topic Time Duration
1. OPD (Interview &

01:10pm – 02:10pm 1 hour
Observation)
2. DSC (Interview &

02:10pm – 03:20pm 45 mins
Observation, MR review)
3. Dental (Interview &

03:30pm – 04:00pm 30 mins
4. ER (Interview &
04:15pm – 04:30pm 15 mins
5. Derma & Laser (Interview

04:30pm – 04:50pm 20 mins
& Observation, MR review)
6. Laboratory (Interview &

04:50pm – 05:40pm 45 mins
7. Personnel File Review 05:45pm – 06:30pm 45 mins
4 hours 30 min
Total Time Hours
approximately # 5
hours
Annex (B)
Required Survey Documents
Offsite Documents:
# Documents Standard
Page 39 of 54
1 Organizational structure LD.3
2 Structure and function of the governing body LD.1
3 Delegation of authority LD.1
4 Governmental licensure (Civil Defense, MOH, municipality) LD.4
5 Scope of services LD.5
6 Strategic and operational plans LD.6/7
7 Staffing plan LD.10
8 Recruitment policy and procedure LD.11
9 Credentialing and privileging of medical staff policy and procedure LD.13/14

10 General orientation program LD.15
11 Cardiopulmonary resuscitation policy and procedure PC.12
12 Ethical framework LD.26
13 Document control policy and procedure LD.28
14 Quality improvement and patient safety program LD.29
15 Risk management program LD.31
16 Management of information plan MOI.1
17 Prevention and control of infection program IPC.1
18 Waste collection contract IPC.11
19 Hand hygiene program IPC.6
20 Facility management and safety program FMS.1
Onsite Documents:
# Documents Standard
1 Budget plan LD.8
2 Competency assessment policy and procedure LD.16
3 Safe operation of equipment policy and procedure LD.17

Page 40 of 54
4 Educational calendar LD.18
5 Performance evaluation process LD.20
6 Staff health and safety program LD.21
7 Patient/family rights LD.22/23
8 Patient/family complaint process LD.24
9 Performance improvement project (sample) LD.29
10 Key performance indicators LD.30

11 Occurrence variance reports with analysis LD.32
12 Patient registration process PC.1
13 Patient identification process PC.2
14 Patient assessment policy and procedure PC.3
15 Process of reporting of critical test results PC.5
16 List of procedures/interventions requiring consent PC.10
17 Informed consent policy and procedure PC.11
18 Transfer of critical patient policy and procedure PC.13
19 Laboratory specimen manual LB.1
20 Laboratory safety program LB.3
21 Laboratory infection control program LB.4
22 Process for selecting and evaluating reference laboratories LB.5
23 Laboratory instrument and equipment management process LB.6
24 Receipt and inspection of specimen policy and procedure LB.7
25 Laboratory quality control policy and procedure LB.8
26 Proficiency testing policy and procedure LB.9
27 Process for correcting or amending reported laboratory results LB.11
28 Process for point of care testing LB.12
29 Radiation safety program RD.2
30 Radiology equipment management process RD.3
Page 41 of 54
31 Dental infection control guidelines DN.4
32 Dental lab safety and infection control guidelines DN.4/5
33 Physicians’ signature list MM.1
34 Medication formulary MM.2
35 Process for medication storage MM.3
36 Process for ensuring stability of multi-dose vials MM.4
37 Process for managing expired medications MM.5
38 Safe prescribing of medications policy and procedure MM.6
39 Guidelines for prescribing antibiotics MM.7
40 Process for managing controlled medications MM.8
41 Process for managing high alert and look alike/sound alike

MM.9
(LASA) medications
42 Process for verifying of prescriptions MM.10
43 Medication errors reporting policy and procedure MM.12
44 Process for medication allergy reporting MM.13
45 Adverse drug reaction reporting policy and procedure MM.14
46 Crash cart standardization policy and procedure PC.12
47 Process for diagnosis and procedure coding MOI.2
48 Approved and non-approved abbreviations policy and
MOI.2
procedure
49 Medical records content policy and procedure MOI.3
50 Rules and regulations for writing in medical records policy and

MOI.4
procedure
51 Process for completion and storage of medical records MOI.5
52 Use of information technology in healthcare policy and

MOI.6
procedure
53 Clinical documentation improvement (CDI) policy and
MOI.7
procedure
54 Laundry and linen management policy and procedure IPC.3
55 Renovation projects policy and procedure IPC.3
Page 42 of 54
56 Process for reporting communicable diseases IPC.4
57 Healthcare-associated infections prevention policy and
procedure IPC.5
58 Hand hygiene program IPC.6
59 Disinfection and sterilization policy and procedure IPC.7
60 Safe reprocessing of single-use items policy and procedure IPC.7
61 Isolation precautions policy and procedure IPC.8
62 Appropriate use of PPE policy and procedure IPC.9
63 Decontamination and disinfection in all patient care areas

IPC.10
policy and procedure
64 Infectious material and waste disposal policy and procedure IPC.11
65 Prevention and management of sharps injury program IPC.12
66 Housekeeping policies and procedures IPC.14
67 Interdisciplinary facility round document (sample) FMS.2
68 Utilities plan FMS.3
69 Fire prevention and abatement program FMS.4
70 Medical equipment periodic preventive maintenance program FMS.6
71 Emergency preparedness plan FMS.7
72 Hazardous material and waste plan FMS.8
73 Safe use of medical gases policy and procedure FMS.9
74 Care of patients in the day procedure unit policy and procedure DPU.2
75 Prevention of wrong patient, wrong site, wrong
procedure/surgery policy and procedure DPU.7
76 Monitoring of patients during and after procedure/surgery

process DPU.8
77 Discharge from recovery process DPU.12
78 Dermatology and aesthetics practice guidelines DA.6
Page 43 of 54
Annex (C) Medical Records Review Tool
File 1 File 2 File 3 File 4 File 5
# # # # #
Standard Document Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA
PC.3.2 Vital signs taken in each

visit
PC.3.2 Comprehensive H&P in

1st visit
PC.3.3 Nutritional screening

documented
PC.3.3 Functional screening

documented
PC.3.3 Pain screening

documented
PC.3.3 Social screening

documented
PC.3.3 Risk of fall documented
PC.3.4 Pain assessment

completed
PC.3.4 Patient referred to

nutritionist
PC.3.4 Patient referred to

physical therapist
PC.5.3 Read back documented

for critical test results
PC.6.1 Plan of care

documented
PC.6.3 Plan of care reviewed

every visit
PC.7.1 Consultation to other

services states the
Page 44 of 54
# # # # #
reason and urgency of

the request
PC.7.2 Reply to consultation

documented
PC.9 Patient and family

education
documentation
PC.11.1 Informed consent for

surgery/procedure
documentation
PC.11.1 Informed consent for

sedation/anesthesia
documentation
PC.13.3 Reason for urgent

transfer and
documentation of
necessary information to
accepting hospital
PC.13.4 Documentation of the

patient’s condition
during the transfer
process
PC.13.5 Evidence of handover to

transferring facility
DPU.3.3 Pre-operative patient

assessment
DPU.3.5 Relevant laboratory and

radiology results are
available
DPU.6.1 Pre-sedation/anesthesia
Page 45 of 54
# # # # #
assessment
DPU.6.3 Pre-sedation/anesthesia
plan
DPU.6.4 Immediate pre-induction

assessment
DPU.7.3 “Time out”

documentation
DPU.8.1 The patient’s vital signs,

oxygen saturation, and
ECG findings are
recorded by the
anesthesiologist.
DPU.8.2 The anesthetic

technique is recorded by
the anesthesiologist
DPU.8.3 The anesthetic or

sedation agent, IV
medications and other
medications, including
dosage and the timing of
administration are
recorded
DPU.8.4 Any unusual events are

recorded
DPU.8.5 Any investigations

carried out are recorded
DPU.8.6 The status of the patient

at the end of the
procedure is recorded
Page 46 of 54
# # # # #
DPU.10.1 Date and time of

admission to day
procedure
DPU.10.1 Date and time of

admission to recovery
DPU.10.2 Vital signs, oxygen

saturation, and level of
consciousness are
recorded.
DPU.10.3 The pain score is

recorded
DPU.10.4 Fluid output including

urine and drains is
recorded
DPU.10.5 Tolerance to oral fluid is

recorded
DPU.11.1 Operation report

highlights the pre- and
post-operative diagnosis
DPU.11.2 Operative report

documents the name of
the surgeon,
anesthesiologist, and
assistants.

documents the
operation or procedure
performed

includes a description of
the surgery or
procedure, findings, and
Page 47 of 54
# # # # #
complications, if any.
DPU.11.5 The amount of blood

loss is documented
DPU.11.6 Operative report flags

any drains or packs left,
the type of wound
closure, and the type of
dressing used, with
instructions on how and
when to remove.

includes specimens
removed and the need
for histopathological
examination
DPU.12.1 Examination of the

patient to ensure the
patient’s suitability and
stability for home
discharge from recovery
DPU.12.2 Post-procedure
instructions are written
in the patient medical
record
DN.2 Documentation of
dental chief complaint
chronic illnesses
medication history
Page 48 of 54
# # # # #
allergy status
DN.3 Dental treatment plan

documented
DN.3.1 Radiological
investigation(s) needed
DN.3.2 Antibiotic prophylaxis

required
DN.3.3 Name of procedure

performed
DN.3.4 Type and dose of local

anesthetic or moderate
sedation
DN.3.5 Material used for filling

documented
DN.3.6 Informed consent

documented
MM.6.1 All prescriptions are

identified by accurate
patient demographics
including name, age and
medical record number
MM.6.2 Allergy status is clearly

identified on the
prescription
MM.6.3. Pediatric prescriptions

have patient’s weight
MM.6.4 Abbreviations are not

used in prescriptions.
MM.6.5 Copy of prescription in
Page 49 of 54
# # # # #
the file
MM.6.6 Narcotics prescription

follows MOH regulations
MOI.2.1 All diagnoses and

procedures are coded
MOI.3.4 Medical record contains

the required patient
demographics
MOI.3.5 Medical record contains

updated medical
information sufficient to
safely manage the
patient and promote
continuity of medical
care.
MOI.3.6 Allergies, adverse drug

reactions and chronic
infections are
confidentially displayed
in the patient’s file
MOI.4.2 All entries are legible,

dated, timed, and signed
by the author
MOI.4.3 Entries written in error

are not deleted or
erased. Instead, a line is
passed through the
error text and dated,
timed, and signed by the
author
MOI.4.4 Only standardized and

approved abbreviations
and symbols are used in
Page 50 of 54
# # # # #
medical records
Page 51 of 54
Annex (D) Personnel File Review Tool
Standard Measurement Y N NA Y N NA Y N NA Y N NA Y N NA
LD.12.4 The job description is

discussed with and
signed by the
employee upon
his/her hiring
LD.13.3 Credentials are

verified from their
original source
LD.13.4 Registration of
healthcare
professionals with
the Saudi
Commission for
Health Specialties
LD.13.4 The center ensures

the licensing of
healthcare
professionals by the
Ministry of Health
LD.13.5 Evidence of
credentialing process
in employee file
LD.13.5 Evidence of re-

credentialing process
in employee file
LD.14.3 Clinical privilege

signed by the
medical director
Page 52 of 54
LD.14.4 Evidence of re-

privileging
LD.15.1 Attendance at
general orientation
LD.15.2 Attendance at
department specific
orientation
LD.16.2 Initial competency

assessment in
employee file
LD.16.3 Annual competency

assessment in
employee file
LD.17.3 Evidence of training

on specialized
equipment
LD.18.3 Evidence of
continuous
education
LD.19.1 Basic life support

education and
training
LD.19.2 Advanced life

support education
and training
LD.20.2 Probationary staff

evaluation
Page 53 of 54
LD.20.2 Annual staff

evaluation
LD.20.4 Evaluations include

personal goals to
achieve for the next
year that the
employee will carry
out
Page 54 of 54

Ambulatory Care Centers Accreditation Guide

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Ambulatory Care Centers

Registration with CBAHI

Scope of Accreditation Survey

Goal of Accreditation Survey

Accreditation Decision Rules

Special Scoring Considerations

Ambulatory Care Centers’ Responsibilities

CBAHI Survey Process

Enrollment for Survey

Application for Survey

Update of Application Information

Resources for Ambulatory Care Centers’ Accreditation

About the Self-Assessment Tool (SAT)

Survey Team Composition

Survey Scheduling and Survey Agenda

On-Site Survey Activities

Survey Team Arrival

Opening Conference and Leadership Interview

Outpatient Area Visit

Laboratory Unit Visit

Radiology Unit Visit

Dental Unit Visit

Dermatology & Aesthetics Medicine Visit

Medication Management Tour

Management of Information Tour

Closed Medical Records Review

Personnel Files Review

Surveyors’ Report Preparation

Post Survey Activities

Accreditation Decision and plan for corrections

Annex(A): Sample Survey Agenda

Annex (B): Required Survey Documents

Annex (C) : Medical Records Review Tool

Annex (D): Personnel File Review Tool

Registration with CBAHI

Scope of Accreditation Survey

Accreditation Decision Rules

0 = Insufficient Compliance (less than 50% compliance with the standard).

• Overall score 75% or above.

Denial of accreditation results when significant noncompliance is demonstrated with the

Accreditation may be denied as a result of one or more of the following issues:

Special Scoring Considerations

• Criticality of a non-compliant standard (the degree of severity and immediacy of risk)

o A Healthcare provider is entering an isolation room without proper Personal

Survey Visit Coordinator

Application for Survey

Update of Application Information

Resources for Ambulatory Care Centers’ Accreditation

1. National Standards for Ambulatory Care Centers First Edition

2. Ambulatory Care Centers Accreditation Guide

3. Self-Assessment Tool (SAT)

About the Self-Assessment Tool (SAT)

Design of the SAT

Frequency for the SAT

How to Use the SAT

Accessing the SAT

2. Mock Survey (optional)

Survey Team Composition