Hospital Orientation Program

1. CBAHI Standards and Survey
Process Orientation – SSPO
October, 2015

2. Outline
• Introduction to CBAHI
• NHS 3rd Edition Standards Structure
• Essential Safety Requirements (ESRs)
• Survey Process Changes
• CBAHI scoring system
• Accreditation polices and decision rules
• Appeal policy
• Accreditation Maintenance
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3. CBAHI
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4. .
Mission
“To promote quality and safety by supporting
healthcare facilities to continuously comply
with accreditation standards.”
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5. Vision
“To become the regional leader in
improving healthcare quality and safety.”
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6. Values
Commitment To
Excellence
Team Spirit
Integrity
Professionalism
TIPE
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7. The Logo
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8. The Main Pillars of CBAHI
Standards Surveyors
Survey
Process
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9. NHS 3rd Edition Standards &
Survey Process
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10. 1. Leadership
2. Human Resources
3. Medical Staff
4. Provision of Care
5. Nursing
6. Quality Management and Patient safety
7. Critical Care Services
8. Labor and Delivery
9. Emergency Care
10. Hemodialysis
11. Anesthesia
12. Patient and Family Rights
13. Operating Room
14. Radiology Services
15. Burn Care
16. Oncology and Radiotherapy
17. Specialized Care Services
18. Management of Information
19. Medical Records
20. Infection Prevention and Control
21. Medication Management
22. Laboratory
23. Facility Management and Safety
CBAHI –NHS 3rd Edition Chapters

11. • Standards related to HR in the former “LD” chapter have been
moved to a new separate chapter “HR”.
• “Medical Staff and Provision of Care” has been divided into
two chapters:
– Medical Staff: describes structure and organization of the
medical staff.
– Provision of Care: addresses the quality and safety of the
actual clinical care processes.
CBAHI –NHS 3rd Edition Major Changes

12. • Ambulatory Care” and the “Psychiatry” chapters have been
merged with the “Provision of Care” chapter to emphasize the
continuum of care.
CBAHI –NHS 3rd Edition Major Changes

13. • The CBAHI accreditation standards for hospitals
underwent an extensive review based on the past
experience.
• The changes in this new edition include:
– Chapters,
– Standards,
– Survey process,
– Essential Safety Requirements (ESRs),
– Scoring Guidelines,
– Accreditation Decision Rules, and
– Introduction of Tracers
CBAHI –NHS 3rd Edition Major Changes

14. Essential Safety Requirements (ESRs)
• Selected standards have been assigned as Essential Safety
Requirements. ESR
• ESRs are selected based on:
– Proximity of risk,
– Probability of harm,
– Severity of harm, and
– Number of patients at risk.
– Score will be the same as the other sub- standards

15. Examples Essential Safety Requirements (ESRs)
• HR.5 The hospital has a process for proper credentialing of
staff members licensed to provide patient care.
• MS.6 The hospital has clearly defined and documented
processes used to credential, appoint, and grant clinical
privileges to medical staff.
• MS.9 Medical staff leaders make use of the data and
information resulting from the medical staff performance
review.
• PC.26 Patients at risk for developing venous
thromboembolism are identified and managed.
• PC.28 Policies and procedures guide the care of psychiatric
patients.

16. Survey Process Changes
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17. • Support CBAHI Surveyors in the accreditation process .
• It is the operational manual for the CBAHI surveyors
• It covers the technical protocols, sample agenda, activity
requirements as well as the forms used during the
execution of surveys.
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Hospital Accreditation Guide - HAG

18. Hospital Accreditation Guide - HAG
All the resources that hospitals need for
preparing for Accreditation are available
online.
SUPPORT: hospital preparation for accreditation surveys
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19. New Survey Process
Design
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20. On-Site Survey Activities
Opening
Conference
Closed Medical
Record Review
Personnel File
Review
Formal/committee
Interviews
Medical Exec
P&T
Infection Control
Safety
Quality & Data session
Contracted Services
Building tour
Unit visit
Staff interview
Observation
Open medical record
Documented Evidence
Exit Conference
Leadership Interview
Document
Review
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21. New Survey Process Statistics
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21%
5%
10%
59%
5%
0%
Document Review
Closed Medical Record
Review
Personnel File Review
Unit Visit
Formal/Committees
Interviews
Leadership Interview

22. CBAHI scoring system
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23. Scoring Guidelines
• Each sub-standard has equal weight and is scored on a three
point scale as follows:
0 = < 50% Compliance
1 = >= 50% - < 80% Compliance
2 = >= 80% Compliance
N/A = Not Applicable
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24. Accreditation Polices and
Decision Rules
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25. Accreditation Policies
• Accreditation decisions are communicated to the
hospital within (30) days after the conclusion of the
survey visit.
• Accreditation decision making process is basically
based on:
• The findings of the survey team members as recorded in
the survey report.
• Discussions regarding the survey findings between the
surveyor and the specialty team leader (STL).
• Review of the draft report by the participating hospital
for feedback.
• Review/discussion during the meeting of the
Accreditation Decision Committee (ADC).
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26. Accreditation Policies
• Other factors are:
• Criticality of the non-compliant standard(s), i.e.
the degree of severity and immediacy of risk to
patients, visitors or staff safety.
• Any concerns regarding the compliance of the
hospital with the Essential Safety Requirements
(ESRs).
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27. Accreditation Decision Rules
• Accredited:
• Overall score 85% or above and
• All essential safety requirements are in
satisfactory compliance and
• No other issues of concern related to the safety
of patients, visitors or staff.
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28. Accreditation Decision Rules
• Conditional Accreditation:
• Overall score 75% or above and less than 85%
and/or
• Some of the essential safety requirements (but
not exceeding 25% of them) are not in
satisfactory compliance.
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29. Accreditation Decision Rules
• Preliminary Denial of Accreditation (PDA):
• Presence of an immediate threat to the safety that is observed
during the on-site survey.
• Significant noncompliance with the accreditation standards at the
time of the on-site survey.
• Failure of timely submission of the post survey requirements after
conditional accreditation.
• The hospital has received conditional accreditation and was
subjected to a follow up focused survey but still could not meet the
requirements for accreditation.
• Reasonable evidence exists of fraud, plagiarism, or falsified
information related to the accreditation process
• Refusal by the hospital to receive the survey team and conduct a
survey.
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30. Accreditation Decision Rules
• Denial of Accreditation:
• Overall score less than 75% and/or
• More than 25% of the essential safety
requirements are not in satisfactory compliance.
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31. Appeal against Accreditation Decision
• A surveyed healthcare facility can appeal against the
following accreditation outcomes:
• Preliminary Denial of Accreditation (provided it is not
due to failure of timely submission of the post survey
requirements after granting accreditation or after
conditional accreditation, or due to the facility remains
conditionally accredited after a follow up focused
survey).
• Suspension/Revocation of Accreditation.
• All appeals shall be made within maximum of (15)
calendar days from receiving the official survey
report
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32. Appeal against Accreditation Decision
• Grounds for appeals
• Relevant and significant information which was available
to the survey team was not considered in the making of
the accreditation decision.
• The report of the surveyors(s) was inconsistent with the
information presented to the survey team.
• Perceived bias of a surveyor(s).
• Information provided by the survey team was not duly
considered in the survey report.
• The outcome of the appeal –if comes in favor of the
appealer- will result in changing the accreditation status.
• Appeals that will not result in changing the status of
accreditation will not be considered by CBAHI.
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33. 33
Accreditation Maintenance

34. Standing Requirements for Accreditation Maintenance
• Corrective Action Plan (CAP)
• When accreditation is awarded, a (CAP) addressing all standards
that were not in satisfactory compliance should be received within
(120) days from the date of the accreditation decision
• Standards Compliance Progress Report (SPR)
• When a hospital is conditionally accredited, an (SPR) should be
received within (60) days from the date of the accreditation
decision.
• The hospital compliance is going to be validated through a follow up
focused survey within (30) days from the date of receiving the SPR.
• Midterm Self-Assessment
• Accredited hospitals are required to participate in a mid-cycle self-
evaluation of standards compliance, Fifteen months from the date
of accreditation awarding.
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35. Questions?
Thank you
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