Survey-ready records for healthcare facilities
Policy control, staff credential expiries and facility rounds for hospitals, polyclinics and laboratories working toward a CBAHI survey.
CBAHI surveys Saudi healthcare facilities against its standards, and for hospitals accreditation is tied to renewal of the operating licence. We build the non-clinical record layer a survey looks at: policies under revision control, staff credential and training expiries, facility rounds, and an index that maps each standard to its evidence.
Most standards are proven by a document
A CBAHI survey assesses a facility against clinical and non-clinical standards, and many of them are evidenced by a policy that exists, is approved, is current, and is known to the staff who must follow it. Policies drift across branches, review dates pass, and the proof that staff read the new revision sits on a signed sheet in a supervisor's drawer. Credentials drift the same way: a licence renewal date passes during annual leave, and it surfaces when the survey team asks for the staff file.
- Each branch keeps its own copy of the policy manual, and the copies drift apart
- Review dates pass without anyone being told they have
- Acknowledgement of a new revision is a signed sheet in a drawer
- Professional licence and life-support certification expiries are tracked by memory
- Facility and fire safety rounds are done on paper and filed by month rather than by finding
What we build for a quality team
Policy control and the credential register come first. Rounds and the survey index build on them.
Document control
One policy register with approval and review dates, branch variations recorded as variations, and read-and-acknowledge records per revision.
Read moreDigitalWorkflow automation
A credential register for professional licences and life-support certification that escalates to the department head ahead of an expiry.
Read moreDigitalAudit and inspection apps
Facility and fire safety rounds captured on a phone, each finding raised with an owner and a due date.
Read moreDigitalDocument assistants
An assistant that answers staff questions from your approved policies, citing the document, section and revision it read.
Read moreITF HealthCBAHI readiness
The facility, safety, document and records evidence a CBAHI surveyor checks, prepared by ITF Health against your survey date.
Read moreITF HealthPolicies and staff files
The policy set and the staff file structure themselves, written and organised by ITF Health to the standards.
Read moreITF HealthRegisters and dashboards for healthcare
The same registers seen from the Health side, with device traceability and revenue dashboards alongside.
Read moreRecords a survey looks at
Each of these is evidenced by a document or a register. The software keeps them current, and the people named in each row decide what they say.
| Requirement | What it means on site |
|---|---|
| Policies and procedures | Approved by your quality director, with review dates that raise their own task. Branch variations are approved and recorded as variations of one policy. |
| Read-and-acknowledge records | Staff acknowledge a new revision on their phones, and the record shows who has not yet. |
| Professional licences and life-support certification | Held per staff member with expiry dates, confirmed by the department head, and escalated ahead of a lapse. |
| Facility and fire safety rounds | Captured on a phone per area, with each finding tracked to closure. |
| Medical equipment maintenance | The register and its evidence sit here. The maintenance itself stays with biomedical engineering, who close each entry. |
| Facility and staff incident reports | Raised, investigated and closed with an owner. Where one relates to a clinical event, it carries the reference number from your clinical system. |
| The survey index | Each standard mapped to the documents and records that evidence it, so the survey team works from one index. |
Questions from quality directors
Who decides what a policy says?
Your quality director approves every revision and decides branch variations, and department heads confirm credential records. The software routes each revision to the quality director, records the approval and its date, and issues the approved revision to every branch for acknowledgement.
How does this sit next to our clinical system?
Side by side. Clinical records stay in your clinical system, and when a round or an incident needs to point at a clinical event, the record carries that system's reference number so the two stay linked.
Can laboratories use this for ISO 15189?
The document control and credential records apply to a laboratory as they do to a hospital, so a later ISO 15189 project finds them already running. ITF Health's laboratories page covers the facility, safety and staff-file side of a laboratory survey.
What does a typical engagement look like?
A polyclinic group in Riyadh with three branches has a CBAHI survey due, and each branch keeps its own copy of the policy manual, which have drifted apart. The policies are brought into one register, with approved branch variations recorded as variations rather than as separate documents, and the quality director approves each current revision. Staff acknowledge new revisions on their phones, and the record shows who has not. Licence and life-support certification expiries sit in one register that escalates to the department head. The group holds one policy register, acknowledgement records per revision, the credential register and an index mapping each standard to the documents that evidence it.
Part of one system
Every division keeps records to the same standard, so the second one you need works the way the first one did.
Start from your survey date
The systems audit maps the standards your survey will test against the documents and registers you hold today, and shows which ones would be hard to find on the day.