Hospital Accreditation
GAHAR Accreditation Standards
In reference to Law no. 2 for the year 2018 for issuance of the Universal Health Insurance in Egypt, GAHAR should set quality standards for health services and apply them to medical care facilities, and accomplish the accreditation and registration of medical facilities and medical professionals, thus ensuring compliance with quality standards.
Accreditation Standards
GAHAR developed its standards for accreditation with inputs from multidisciplinary health care professionals, subject matter experts, Ministry of Health & Population representatives, international organizations, and private sector healthcare providers.
The accreditation standards development process is based on scientific literature and expert consensus. The process was reviewed both internally and externally, and underwent field testing and pilot testing before final approval by GAHAR’s board.
The accreditation standards handle healthcare delivery from two main perspectives, the patient-centered perspective and the organization-centered.
On the one hand, patient-centered standards adopt the Picker model for patient-centered care to ensure the responsiveness of organizations to patients’ and families’ needs.
On the other hand, organization-centered standards highlight many aspects needed for workplace suitability to provide a safe environment for staff, patients, and their families, by adopting the HealthWISE concepts.
JCI General Eligibility Requirements
Any hospital may apply for Joint Commission International (JCI) accreditation if it meets all the following criteria:
• The hospital is located outside of the United States and its territories.
• The hospital is currently operating as a health care provider in the country, is licensed to provide care and treatment as a hospital (if required), and, at minimum, does the following:
0 Provides a complete range of acute care clinical services—diagnostic, curative, and rehabilitative.
0 Provides services that are available 365 days per year; ensures all direct patient care services are operational 24 hours per day, 7 days per week; and provides ancillary and support services as needed for emergent, urgent, and/or emergency needs of patients 24 hours per day, 7 days per week (such as diagnostic testing, laboratory, and operating theatre, as appropriate to the type of acute care hospital).
0 In the case of a specialty hospital, provides a defined set of services, such as pediatric, eye, dental, and psychiatry, among others.
• The hospital provides services addressed by the current JCI accreditation standards for hospitals.
• The hospital assumes, or is willing to assume, responsibility for improving the quality of its care and services.
• The hospital is open and in full operation, admitting and discharging a volume of patients that will permit the complete evaluation of the implementation and sustained compliance with all current JCI accreditation standards for hospitals.
• The hospital meets the conditions described in the current “Accreditation Participation Requirements” (APRs) chapter. Academic medical center hospital applicants must meet each of the criteria above in addition to the following three criteria:
• The applicant hospital is organizationally or administratively integrated with a medical school.
• The applicant hospital is the principal site for the education of both
(1) Medical students (undergraduates)
(2) Postgraduate medical specialty trainees (for example, residents or interns) from such medical school.
• At the time of application, the applicant hospital is conducting medical research with approval and oversight by an Institutional Review Board (IRB) or research ethics committee.
Understanding Terms
Full operation
Criteria indicating the organization’s readiness for comprehensive on-site evaluation against all relevant JCI standards, based on identification of the of the following in the organization’s electronic application for survey (E-App):
• A list of all clinical services currently provided for inpatients and outpatients.
• Utilization statistics for clinical services showing consistent inpatient and outpatient activity levels and types of services provided for at least four months or more prior to submission of the organization’s electronic application.
• All inpatient and outpatient clinical services, units, and departments.
These locations must be available for a comprehensive evaluation against all relevant JCI standards for hospitals currently in effect, consistent with JCI’s normal survey process for the size and type of organization, such as the following:
o Patient tracer activities, including individual patient and system tracers
o Open and closed medical record review
o Direct observation of patient care processes o Interviews with patients
o Interviews with medical students/trainees Principal site The location at which the hospital provides the majority of medical specialty programs for postgraduate medical trainees (for example, residents or interns) and not just one specialty, as in a single-specialty organization
(for example, an ophthalmologic hospital, dental hospital, or orthopedic hospital).
Medical research
Basic, clinical, and health services research that includes many types of research studies, such as clinical trials, therapeutic interventions, development of new medical technologies, and outcomes research, among others.
(Hospitals that primarily conduct non–human subjects research and/or research exempt from review by an Institutional Review Board or research ethics committee, such as medical record review studies, case studies, and research involving data/specimens without individually identifiable information, do not meet criterion 3 of the academic medical center hospital eligibility criteria.)
HOSPITAL ACCREDITATION PROGRAM (3rd Version)
National Standards for Hospitals
This program was launched for all hospitals in the public and private sector in the Kingdom that provide secondary, tertiary, and Quaternary levels of healthcare services.
Currently in the Kingdom, hospitals of all types serve as a major line of defense and provide the main core of healthcare services for more than 31 million people. Because of their significant role with the high volume high risk implications, it was imperative that hospitals be the focus of the 3rd edition of CBAHI’s National Standards of Hospitals, issued in 2015.
Eligibility for Accreditation
All hospitals licensed to practice in the Kingdom of Saudi Arabia are eligible for CBAHI accreditation. However, eligibility for conduction of a survey visit is contingent upon fulfilling all of the following requirements:
The hospital meets all licensing requirements to operate (and therefore, has a valid license when applicable), as indicated by the statutes and regulations of the Ministry of Health.
The hospital meets any additional licensing requirements as indicated by other relevant authorities (particularly, valid certificate from the Civil Defense, and any radiation-related licensing requirements from King Abdul Aziz City for Science & Technology).
The hospital meets the legal definition of a hospital as per the regulations of the Ministry of Health and the international guidelines
in this regard :- Licensed as a hospital under the law governing healthcare institutions in Saudi Arabia.
- It has an organized medical staff (doctors and continuous nursing services under the supervision of registered nurses and technicians).
- Maintains permanent and full time facilities that include inpatient beds for the care of overnight resident patients, i.e. bed and board.
- Provides diagnosis (has laboratory and radiology services) and medical or surgical treatment primarily for, but not limited to, acutely sick and injured patients.
(This manual is not for facilities providing treatment for patients with mental illness or providing treatment in special inpatient care facilities e.g. long term care facilities).
- It provides emergency and intensive care services.
The hospital provides healthcare services addressed by the CBAHI’s National Hospital Standards.
The hospital has been in operation for at least (12) months before the on-site survey.
Accreditation Pathway
CBAHI is committed to its mission of promoting healthcare quality and patient safety by supporting healthcare facilities to continually comply with accreditation standards. There are several activities a healthcare facility will go through to obtain CBAHI accreditation.
Hospital Orientation Program (HOP)
CBAHI provides ongoing HOPs at different locations throughout the year. Hospitals are highly encouraged to attend at one of HOPs offered by CBAHI, free of charge. Although any hospital can attend, the priority goes for hospitals selected for the current year accreditation program. During these orientation sessions, standards, accreditation policies, and survey process are all explained in detail. This is a good opportunity for the hospital representatives to enquire about the intent of a standard and how it will be implemented. Dates and venues of the orientation programs will be communicated to the hospitals in a timely manner.
Self-Assessment Tool (SAT)
All hospitals enrolled in accreditation are required to conduct a comprehensive self-assessment using the SAT provided by CBAHI. This tool is intended to support the hospital in assessing how close it is to a satisfactory compliance with the standards and requirements. It also gives an idea of how much preparation and time the hospital needs before it can request a survey visit. Usually, SAT is for the internal use of the healthcare facility but it might be required by CBAHI to help deciding on the preparedness of the facility prior to conducting a survey.
Self-assessment is utilized by several other accreditation organizations to help them –if properly and objectively conducted- to have a better insight on the baseline situation of each hospital and provides for a common communication tool between the hospital seeking accreditation and the accrediting body. When both parties reach a compromise about the level of preparedness for a survey visit based on the self-assessment findings, a survey can be scheduled at a tentative date suitable for both.
Mock Survey
Upon reaching a satisfactory level of compliance with all applicable standards, a mutual agreement is made concerning the exact date of a Mock Survey, which is recommended but not mandatory. Some hospitals