K.N.H.

CBAHI
ACCREDITATION:
Nurses Role in Maintaining
Standardized Care
 Purposes of Lecture
To create awareness among KNH nursing
staff about the different views and aspects
of Quality
To create an environment of professional
practice with the compliance with the
Dimensions of Quality in our routine duties
To promote culture of safety and best
state of knowledge about ideal, desirable
and according to the standards.
What is QUALITY?

Doing the right

thing RIGHT the
FIRST TIME, and
doing it BETTER
EVERY TIME .
 Definition of Quality
The correct implementation of health
interventions
according to established norms and
procedures,
which satisfy the health systems clients and
maximize health outcomes without creating
health
risks or unnecessary costs.

Rwanda MOH,
2012
 What is QUALITY?
The degree to which health services for
individual and population increase the
likelihood of desired health outcome
and are consistent with current
professional knowledge ( WHO )
 QUALITY CARE
Doing the RIGHT THINGS (What)
To the RIGHT PEOPLE (To Whom)
At the RIGHT TIME (When)
And doing things RIGHT FIRST
TIME!


KEY DIMENSIONS OF
QUALITY CARE
SAFE
TIMELY
EFFICACY
EFFECTIVE
EQUITABLE
PATIENT CENTERED
CONTINUITY
APPROPRIATE
AVAILABILITY
RESPECT AND CARING
EFFIECIENT
 SENTINEL EVENTS
Unexpected Death
Maternal Death
Wrong Patient, Wrong
Procedure, or Wrong Site.
Retained Instrument or
Sponge
Medication Error Leading
To Death or Major
Morbidity
Infant Abduction or Infant
Discharged to the Wrong
Family
Unexpected Loss of a Limb
or a Function
Hemolytic Blood
 What is Accreditation?
A comprehensive peer review
process to measure compliance
with a set standards by surveyors
from an authorized organization
 What is Accreditation?
Healthcare accreditation is an assessment process that
involves a rigorous, transparent, and comprehensive
evaluation by an external independent accreditation body.
The health care facility undergoes an examination of its
systems, processes, and performance by peer reviewers or
surveyors to ensure that all is conducted in a manner that
meets applicable predetermined and published national
standards.
The Saudi Central Board for Accreditation of
Healthcare Institutions (CBAHI) is the official
agency authorized to grant accreditation
certificates to all governmental and private
healthcare facilities operating today in Saudi
Arabia. CBAHI has emerged from the Saudi
Health Council as a non-profit organization.
The principal function of CBAHI is to set the
 The CBAHI Accreditation
Standards were developed by a
consensus process of health care
experts representing;
MOH
National Guards Hospitals
KFSH and RC
University Hospital
Private Hospitals
Security Forces Hospital
Saudi Council for Health
Specialties
 The Scoring Process
Accredited the overall compliance score
80% and no more that 2 chapters scores
<50%
Denied the hospital will be denied
accreditation if the overall score at is
less than 70% or more than 2 score
less that 50%
Resurveyed hospital scoring from 70% to
79% is required resurveyed within 90 day
 Accreditation Decision
3 Fully Met when 75%
compliance
2 Partially Met when 50% to
<75% compliance
1 Minimally Met when 25% to
<50% compliance
0 Not Met when <25% compliance
with the standard elements
Why do we need Accreditation?
Standardized Care
Clinical Practice Guidelines
Policies and Procedures
Safe Care
Better Resource Utilization
Good Reputation
Accountability
 Benefits of Accreditation
Patient
Continuity of Care
Focus on Patient Safety
Patient Satisfaction
Rights are Respected and Protected
Access to a Quality Focused Organization
High Quality of Care
Understandable Education and Communication
Benefits of Accreditation
Staf
Staf Development
Provides Education
Provides Leadership for Quality
Improvement
Increase Satisfaction with Continuous
Learning
Good Working Environment, Leadership
and Ownership
Benefits of Accreditation
Hospital
Improves Care
Continuous Improvement
Demonstrate Commitment to Quality
Care
Raise Community Confidence
Role of Nurses in Quality Improvement

To carry out interdisciplinary

processes to meet organizational
QI goals
To measure, improve, and control
nursing-sensitive indicators (NSI)
afecting patient outcomes
specific to nursing practices