CBAHI readiness checklist, non-clinical standards
The facility, safety, document and records evidence a CBAHI surveyor checks, set out to work through before your survey date.
This checklist covers the non-clinical side of a CBAHI survey: governance documents, policies and document control, facility management and safety plans, drills, the environment of care, staff files, quality programme records and survey-day logistics. Each row is marked met, partial, not met or not applicable. Clinical practice is prepared by your clinical teams and is not covered.
What is in the checklist
Leadership and governance
Committee structure, terms of reference, one minute format, the plan register, and your last survey report with its corrective action plan.
Policies and document control
The policy on policies, the policy register, recorded approval, withdrawal of old copies and staff acknowledgement.
Facility management and safety
The six plans with the record a surveyor asks for, and the contractor and landlord records brought into your own file.
Drills
The frequency written into the plan, drills spread across every shift including nights, a review after each one, and a drill log.
Environment of care
Cleaning schedules and records by room, verification, waste segregation, sign-off for works near clinical areas, water, air handling and pest control.
Staff files and competence records
Five sections in every file, one expiry register for licences and certificates, and orientation records for non-clinical staff.
Quality and patient-safety records
The incident reporting flow, the risk register, indicator data review, the corrective action log and the evidence index.
Survey-day logistics
Document, facility and staff file tracers to rehearse, and the checks that let a surveyor's question be answered in minutes.
Ask for the full checklist
Quality directors, facilities managers and accreditation coordinators at hospitals and clinics preparing for a CBAHI survey, first time or re-survey. It suits whoever has to answer for the building, the documents and the staff files on survey day.
Before you ask for it
Can I download it straight from this page?
No. It is not a public download: you ask for it with your name, company and work email, and a person at ITF reads the request and sends the PDF to you by email.
What format is it?
A PDF of seven A4 pages, made to be printed. The tick boxes and fill-in lines are drawn for a pen, so each row can be marked by hand.
Does it cover the clinical standards?
No. It covers the non-clinical standards: the building and its safety systems, the documents, the records and the staff files. Medication, care, nursing, laboratory and radiology practice are prepared by your clinical teams.
Which CBAHI programme is it written for?
It names areas by function rather than by chapter number, because chapter names and numbering differ between programmes and editions. Map each row to the manual your facility is surveyed to.
Will working through it get us accredited?
Nobody can promise that. CBAHI decides, and its survey covers clinical standards as well. The checklist helps you confirm that the non-clinical evidence exists, is current and can be found.
Read alongside
CBAHI readiness
The full non-clinical preparation, from the gap assessment to the evidence index.
Read moreCBAHIFacility management and safety
The plans, inspections, tests and drills, with every contractor's record brought into your file.
Read moreCBAHIPolicies and staff files
Document control for healthcare and an expiry register that warns before a date passes.
Read moreCBAHIThe mock survey
The survey rehearsed on your records, your building and your staff.
Read more