Ambulatory Care Centers

Accreditation Guide
(2nd Edition)
10th Oct. 2021

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 Table of Contents

Introduction 4

Registration with CBAHI 4

Scope of Accreditation Survey 5

Goal of Accreditation Survey 6

Assessment of Compliance 6

Accreditation Decision Rules 7

Special Scoring Considerations 9

Ambulatory Care Centers’ Responsibilities 11

CBAHI Survey Process 14

Overview 14

Pre-Survey Activities 14

Enrollment for Survey 14

Application for Survey 14

Update of Application Information 15

Resources for Ambulatory Care Centers’ Accreditation 15

About the Self-Assessment Tool (SAT) 16

Survey Team Composition 19

Survey Scheduling and Survey Agenda 20

On-Site Survey Activities 20

Survey Team Arrival 21

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Opening Conference and Leadership Interview 21

Outpatient Area Visit 23

Day Procedure Unit Visit 27

Laboratory Unit Visit 30

Radiology Unit Visit 32

Dental Unit Visit 34

Dermatology & Aesthetics Medicine Visit 36

Medication Management Tour 38

Management of Information Tour 40

Closed Medical Records Review 42

Personnel Files Review 43

Surveyors’ Report Preparation 44

Closing Conference 45

Post Survey Activities 46

Accreditation Decision and plan for corrections 46

Survey Report 46

Survey Feedback 46

Accreditation Maintenance 46

Annex(A): Sample Survey Agenda 48

Annex (B): Required Survey Documents 50

Annex (C) : Medical Records Review Tool 55

Annex (D): Personnel File Review Tool 63

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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.

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 Scope of Accreditation Survey

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.

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 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.
• 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
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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
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 not scored less than 50%.

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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 or more of the core standards scored 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.
• 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.

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• 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.

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Conflict of Interest
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

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be granted, the afore mentioned observer(s) are not allowed to participate in the survey visit
activities.

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.

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 Update of Application Information
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.

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 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 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.

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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.
• 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].)

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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”.
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].

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 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.

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.

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 • 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.

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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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.
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.

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• 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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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
• 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.
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 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.

- 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.

Page 24 of 65
 o Process for patient transfer.
o What to do in case of fire.
o Process for staff sharps injury.
o Effectiveness of point of care testing.
- Physicians:
o Correct patient identification.
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 What to do in case of cardiopulmonary arrest.
o Reporting of medication errors, allergic reactions and adverse events.
o Disclosure to patient and family following incidents.
o What to do in case of fire.
o Effectiveness of point of care testing.
o Knowledge on clinical practice guidelines.
- Housekeeping staff:
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.
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 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.
o Policy on patient transfer for higher level care.

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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.
• 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
• 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.
Page 27 of 65
 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).
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.

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 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.
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.

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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).
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
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 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.

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Radiology Unit Visit
Objectives
• Ensure the radiology 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 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 .

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• 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.
o Periodic testing of radiation protection aprons.

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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.
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 o Correct patient identification.
o What to do in case of cardiopulmonary arrest.
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.

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Dermatology & Aesthetics Medicine Visit

Objectives
o Ensure the Dermatology & Aesthetics Medicine unit structure complies with
safety, security, and infection control requirements.

o Observe infection control and safety practices.

o Review equipment maintenance and quality control documents.

o Interview staff for daily equipment checks.

Participants
• CBAHI Surveyors
• Ambulatory Care Center’s visit facilitator
• Dermatology & Aesthetics Medicine unit director and staff.

Logistics
• None
Procedure
• Observe:
o Layout, reception area, safety signs and warnings, emergency exits.

o Laser safety signs.

o Storage and handling of liquid nitrogen.

o Storage of hazardous material.

• Staff Interview:
o Physicians and nurses

o Laser safety program.

o Equipment testing and preventive maintenance.

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 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 Weekly safety visits to all procedural rooms.

o List of the procedures performed.

o Dermatology and aesthetics practice guidelines.

o Assessment and care planning.

o Laser safety program.

o Equipment operation and service manuals.

o Equipment periodic preventive maintenance.

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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
• Ambulatory Care Center’s visit facilitator
• Pharmacy director, medical and nursing staff
Logistics
• 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.
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• 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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Management of Information Tour
Objectives
• Ensure the unit structure complies with safety, confidentiality and security
requirements.
• 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
• Ambulatory Care Center’s visit facilitator
• 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 Fire detection and abatement equipment.
o Emergency exits.
o Staff wearing ID badges.
• Staff Interview:
- 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.
o What to do in case of fire.

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 - Administrator/MOI Officer:
o Designing the MOI plan.
o Compliance with regulatory bodies’ required documents.
• Document Review:
o MOI plan.
o Policy on writing in medical records.
o Policy on managing incomplete medical records.
o Approved abbreviation list.

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Closed Medical Records Review
Objective
• Ensure compliance with medical records documentation requirements.
Participants
• CBAHI Surveyors
• Ambulatory Care Center’s visit facilitator
• 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.

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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.
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.

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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.
• The survey Visit Team Leader (VTL) integrates and delivers the final report.

Page 44 of 65
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 45 of 65
 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
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status. The maintenance of accreditation procedures are fully 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 47 of 65
 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)

5. Observation & Interview

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

6. Observation & Interview

04:45pm – 05:00pm 15 mins
(CSSD)

7. Observation & Interview

05:00pm – 05:15pm 15 mins
(FMS)

Break Time 05:15pm – 05:45pm

8. Personnel File Review 05:45pm – 06:30pm 45 mins

4 hours 45 min
Total Time Hours
approximately # 5
hours

Page 48 of 65
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)

Break Time 03:20pm – 03:30pm

3. Dental (Interview &

03:30pm – 04:00pm 30 mins
Observation, MR review)

4. ER (Interview &
04:15pm – 04:30pm 15 mins
Observation, MR review)

5. Derma & Laser (Interview

04:30pm – 04:50pm 20 mins
& Observation, MR review)

6. Laboratory (Interview &

04:50pm – 05:40pm 45 mins
Observation, MR review)

Break Time 05:40pm – 05:45pm

7. Personnel File Review 05:45pm – 06:30pm 45 mins

4 hours 30 min
Total Time Hours
approximately # 5
hours

Page 49 of 65
Annex (B)
Required Survey Documents
Offsite Documents:
# Documents Standard
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
Page 50 of 65
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

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

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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
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

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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
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

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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
Prevention of wrong patient, wrong site, wrong
75 DPU.7
procedure/surgery policy and procedure
Monitoring of patients during and after procedure/surgery
76 DPU.8
process
77 Discharge from recovery process DPU.12
78 Dermatology and aesthetics practice guidelines DA.6

Page 54 of 65
 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

Page 55 of 65
 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.6.3 Plan of care reviewed

every visit

PC.7.1 Consultation to other

services states the
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

Page 56 of 65
 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

DPU.3.3 Pre-operative patient

assessment

DPU.3.5 Relevant laboratory and

radiology results are
available

DPU.6.1 Pre-sedation/anesthesia
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

Page 57 of 65
 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

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

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

Page 58 of 65
 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

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.

DPU.11.3 Operative report

documents the
operation or procedure
performed

DPU.11.4 Operative report

includes a description of
the surgery or
procedure, findings, and
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.

DPU.11.7 Operative report

includes specimens
removed and the need

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# # # # #

Standard Document Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA

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

DN.2 Documentation of
chronic illnesses

DN.2 Documentation of
medication history

DN.2 Documentation of
allergy status

DN.3 Dental treatment plan

documented

DN.3.1 Radiological
investigation(s) needed

DN.3.2 Antibiotic prophylaxis

required

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# # # # #

Standard Document Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA

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

the file

MM.6.6 Narcotics prescription

follows MOH regulations

MOI.2.1 All diagnoses and

procedures are coded

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# # # # #

Standard Document Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA

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
medical records

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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.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

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Standard Measurement Y N NA Y N NA Y N NA Y N NA Y N NA

process in
employee file

LD.14.3 Clinical privilege

signed by the
medical director

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

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 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.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

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 65 of 65