Ambulatory Care Centers Accreditation Guide
Ambulatory Care Centers Accreditation Guide
Ambulatory Care Centers Accreditation Guide
Accreditation Guide
(First Edition)
1st June 2021
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Table of Contents
Introduction
Assessment of Compliance
Overview
Pre-Survey Activities
Closing Conference
Survey Report
Survey Feedback
Accreditation Maintenance
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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.
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.
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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 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:
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:
Denial of Accreditation
• 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.
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Ambulatory Care Centers’ Responsibilities
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.
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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.
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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.
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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.
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.
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.
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.
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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.
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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.
o What to do in case of fire.
• 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.
Participants
• CBAHI Surveyors
• Ambulatory Care Center’s visit facilitator
• 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 Staff wearing ID badges.
o Fire detection and abatement devices and equipment.
o Recovery area has an ICU setup.
• Staff Interview:
- Nursing staff:
o Receiving patients (identification, pre-procedural checklist).
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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 Effectiveness of point of care testing.
o Periodic preventive maintenance for medical equipment.
o Medication management: preparation and administration.
o What to do in case of cardiopulmonary arrest.
o What to do in case of fire.
- 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.
o Effectiveness of point of care testing.
o What to do in case of cardiopulmonary arrest.
o What to do in case of fire.
- Housekeeping staff:
o Waste management.
o Disinfection of procedure room and equipment in between cases and at the end
of the list.
o What to do in case of fire.
• Document Review:
o DPU policies and procedures.
o Registry book for procedures.
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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
• Ambulatory Care Center’s visit facilitator
• 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).
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o Periodic preventive maintenance for equipment.
o Safety of equipment.
o Staff wearing ID badges.
o Emergency exits.
o Fire detection and abatement devices and equipment.
• 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 What to do in case of fire.
o Disinfection of patient equipment in-between patients.
o What to do in case of cardiopulmonary arrest.
o Crash cart management.
• Document Review:
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.
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• Observe infection control and safety practices.
• Review equipment maintenance and quality control documents.
• Interview staff for daily equipment checks, quality control practices and reporting of
test results.
Participants
• CBAHI Surveyors
• Ambulatory Care Center’s visit facilitator
• 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.
• Staff Interview:
- Radiologist/Technician
o Outsourced services.
o Radiation safety program.
o Equipment testing and preventive maintenance.
o What to do in case of fire.
o Correct patient identification.
o Disinfection of patient equipment in-between patients.
o What to do in case of cardiopulmonary arrest.
o Crash cart management.
• Document Review:
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.
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o Periodic testing of radiation protection aprons.
Dental Unit Visit
Objectives
• Ensure the dental unit 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 daily infection prevention practices and disposal of dental waste.
Participants
• CBAHI Surveyors
• Ambulatory Care Center’s visit facilitator
• 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 Staff wearing ID badges.
o Safety measures in dental lab.
o Emergency exits.
o Fire detection and abatement equipment.
o Availability of radiation protection aprons.
• Staff Interview:
- Dentist/Dental Technician:
o Scope of services.
o Infection control practices.
o What to do in case of fire.
o Correct patient identification.
o What to do in case of cardiopulmonary arrest.
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o Crash cart management.
• Document Review:
o Infection control program.
o Assessment and care planning.
• Medical Records Review:
o Patient assessment.
o Care planning.
o Patient / family education.
o Prescriptions.
Objectives
Participants
Logistics
Procedure
• Observe:
• Staff Interview:
• Document Review:
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
• Ambulatory Care Center’s visit facilitator
• Pharmacy director, medical and nursing staff
Logistics
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• 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 Staff wearing ID badges.
o Emergency exits.
o Fire detection and abatement equipment.
• Staff Interview:
- 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 What to do in case of fire.
• Document Review:
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.
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• 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.
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Post Survey Activities
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
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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.
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Annexes
Annex (A)
Sample Survey Agenda
Ambulatory Care Center Agenda (Two Surveyors)
Surveyor 1
SN Topic Time Duration
4 hours 45 min
Total Time Hours
approximately # 5
hours
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Surveyor 2
SN Topic Time Duration
4. ER (Interview &
04:15pm – 04:30pm 15 mins
Observation, MR review)
4 hours 30 min
Total Time Hours
approximately # 5
hours
Annex (B)
Required Survey Documents
Offsite Documents:
# Documents Standard
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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
Onsite Documents:
# Documents Standard
1 Budget plan LD.8
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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
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Annex (C) Medical Records Review Tool
File 1 File 2 File 3 File 4 File 5
# # # # #
# # # # #
DPU.6.1 Pre-sedation/anesthesia
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File 1 File 2 File 3 File 4 File 5
# # # # #
assessment
DPU.6.3 Pre-sedation/anesthesia
plan
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File 1 File 2 File 3 File 4 File 5
# # # # #
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File 1 File 2 File 3 File 4 File 5
# # # # #
complications, if any.
DPU.12.2 Post-procedure
instructions are written
in the patient medical
record
DN.2 Documentation of
dental chief complaint
DN.2 Documentation of
chronic illnesses
DN.2 Documentation of
medication history
DN.2 Documentation of
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File 1 File 2 File 3 File 4 File 5
# # # # #
allergy status
DN.3.1 Radiological
investigation(s) needed
Page 49 of 54
File 1 File 2 File 3 File 4 File 5
# # # # #
the file
Page 50 of 54
File 1 File 2 File 3 File 4 File 5
# # # # #
medical records
Page 51 of 54
Annex (D) Personnel File Review Tool
File 1 File 2 File 3 File 4 File 5
Standard Measurement Y N NA Y N NA Y N NA Y N NA Y N NA
LD.13.4 Registration of
healthcare
professionals with
the Saudi
Commission for
Health Specialties
LD.13.5 Evidence of
credentialing process
in employee file
Page 52 of 54
File 1 File 2 File 3 File 4 File 5
Standard Measurement Y N NA Y N NA Y N NA Y N NA Y N NA
LD.15.1 Attendance at
general orientation
LD.15.2 Attendance at
department specific
orientation
LD.18.3 Evidence of
continuous
education
Page 53 of 54
File 1 File 2 File 3 File 4 File 5
Standard Measurement Y N NA Y N NA Y N NA Y N NA Y N NA
Page 54 of 54