CBAHI readiness for the non-clinical standards
The facility, safety, document and records evidence a CBAHI surveyor checks, prepared before your survey date.
- Licence tie
- Hospitals: accreditation tied to operating licence renewal
- Programmes
- Hospitals · primary care · ambulatory centres · dental · laboratories and blood banks · home care
- Our scope
- The non-clinical standards
- How a surveyor gathers evidence
- Document review · observation · staff interview
- Gap assessment
- On site, its length set at scoping
CBAHI is the Saudi accreditation body for healthcare facilities, under the Saudi Health Council. For hospitals, accreditation is tied to renewal of the operating licence; other facility types were brought in programme by programme. We prepare the non-clinical standards: facility management and safety, document control, quality management records, staff files and information management.
- 01 Enquiry
- 02 Survey
- 03 Scope
- 04 Plan
- 05 Execute
- 06 Evidence
- 07 Review
- 08 Next cycle
CBAHI readiness for the non-clinical standards sits at step 2 of the same eight steps, with health's names. You receive a survey record.
Points lost for reasons that have nothing to do with care
Most facilities that struggle with a CBAHI survey do not struggle with medicine. They struggle with paper, and with the building.
The fire suppression system is serviced, but the facility cannot produce the inspection record because the contractor kept it. Emergency lighting has never been tested with the mains off. The hazardous materials inventory lists chemicals the housekeeping store stopped buying two years ago, and the safety data sheets sit in a binder in the manager's office instead of at the point of use. Fire drills were run on the day shift only.
Policies carry review dates that passed last year, and an obsolete version of the evacuation policy is still in a folder at the nursing station.
None of that is a clinical failure. It is a records failure and a facility failure, and method fixes it, not recruitment. A national study of essential safety requirement surveys in hospitals between 2016 and 2018 found the fire suppression standard among the lowest-scoring requirements, in public and private hospitals alike. Sprinklers and extinguishers are building systems, and their evidence is an inspection record.
One survey, two kinds of standard
A survey covers clinical and non-clinical standards in the same visit. We work the non-clinical side: the building and its safety systems, the documents, the records, and the files on the people who keep them. Areas are named by function, because chapter names and numbering differ between programmes and editions. We map to the manual your facility is surveyed to.
| Area | What we prepare | Owner in your facility |
|---|---|---|
| Leadership and governance | Committee structure, terms of reference, the minute format and the register that tracks each plan. | Administration and the governing body |
| Quality management and patient safety | The machinery: the incident reporting flow, the risk register, and data collection and review for the indicators your clinicians choose. | The quality department |
| Facility management and safety | The management plans, inspection and test schedules, drills on every shift, and contractor records pulled into your own file. | Facilities and the safety officer |
| Infection prevention and control, environmental side | Environmental cleaning schedules and records, waste segregation records and construction containment sign-off, worked with your infection control lead. | The infection control lead |
| Management of information and records | Document control, the policy system and record retention procedures. | Health information management |
| Staff files | The personnel file structure, the licence and certification expiry register and orientation records, ready for the privileging decisions your medical staff make. | Human resources and the medical staff office |
| Medication, care, nursing, laboratory and radiology practice | Prepared by your clinical teams. Anything clinical we notice during our work goes onto the clinical referral list, addressed to the person who owns it. | Clinical leadership |
The documents you keep
The non-clinical gap report
Every measurable element in scope, marked met, partial, not met or not applicable, with the evidence seen and an owner.
The clinical referral list
Clinical points noticed during the work, each written up for the clinical lead who owns it.
The facility management and safety plans
Fire, hazardous materials, utilities, security, medical equipment and emergencies, each with its inspection and test schedule.
The policy register
Every policy with its owner, approval date and review date.
The mock survey report
Findings written the way a surveyor writes them: the requirement, the evidence seen, the gap.
The corrective action log
Each finding with its cause and the evidence that closed it.
The evidence index
Each standard mapped to the document and the record that prove it, and where they are kept.
How the preparation runs
The engagement duration and the timing of each step are set at scoping, taking your survey date into account.
- 01
Read the ground
Your programme, the edition you are surveyed to, your last survey report and your survey date. The plan is worked backwards from that date.
- 02
Gap assessment on site
A walk of the building, a sample of documents and records, and interviews with staff. A surveyor gathers evidence those three ways, so we look the same three ways.
- 03
Gap report
Every non-clinical measurable element marked met, partial, not met or not applicable, with the evidence seen and an owner.
- 04
Build
Plans, policies, registers and record forms, written with the people who will keep them and issued under your document control.
- 05
Records run
Your staff keep real records. A surveyor looks for compliance sustained over months, not a folder assembled the week before.
- 06
Mock survey
The survey rehearsed on your records, your building and your staff.
- 07
Close out
Findings closed with evidence, and the evidence filed where the index says it is.
- 08
Hand over
Everything indexed the way a surveyor reads it: standard, document, record, location.
A re-survey in seven months
A private general hospital in Riyadh has a re-survey in seven months. It was accredited last cycle, on late nights rather than a system, and two of the people who carried that survey have since left.
The facility side is spread across three contractors, for FM, fire systems and lifts, plus an in-house biomedical team, and each keeps its own records. Fire drills are recorded for day shifts only. The emergency generator's load test log is held by the generator contractor, not by the hospital. The hazardous materials inventory is two years old. Orientation records for housekeeping and security staff are incomplete, and a batch of policies is past its review date.
During the walk we also see look-alike medications stored side by side on one ward. That goes onto the clinical referral list, addressed to the pharmacy director.
The facility management and safety plans are rewritten with the facilities manager. Each contractor's records are pulled into the hospital's own file every month, in one format. Night-shift drills are scheduled and run. The policy batch goes through document control with a named owner per policy. The mock survey and the closure of its findings follow the timing set at scoping.
The hospital ends up holding a non-clinical gap report, a clinical referral list, the facility management and safety plans, a contractor record file, the drill record by shift, the policy register with review dates, the mock survey report, a corrective action log and an evidence index by standard.
Start from the date and count backwards
The survey date sets the plan, not our availability. The time to write and approve documents is set at scoping. Records take months to build a history, and the drill schedule follows the frequency your programme and your facility plan set. A surveyor counts the drills on file.
Everything in the preparation fits
Documents are written and approved early, records run for months before the mock survey, and the mock survey leaves time for its findings to close with new records.
- Gap assessment before any writing starts
- Records running well before the rehearsal
- Mock survey findings closed with fresh evidence
Documents first, then records
We fix the documents first, then start the records on the timing set at scoping. The gap report names the areas that will show a short history on the day, so it surprises nobody.
- Record start date set at scoping
- Short-history areas named in writing
Fix what the time allows, and say plainly what remains
The document corrections and their timing are agreed at scoping. A history of records cannot be grown in weeks. We close what the time allows and tell you which findings will remain on the day. A record carries the date it was made.
Asked before the gap assessment
Can you promise we will be accredited?
No, and be careful with anyone who does. CBAHI decides, and its survey covers clinical standards as well. Our part is that the non-clinical evidence exists, is current and can be found in minutes.
Is accreditation tied to our licence?
For hospitals, yes: accreditation is tied to renewal of the operating licence. Other facility types were brought into mandatory accreditation programme by programme, so check where your programme stands before you plan around a date.
Which standards count as non-clinical?
It depends on the programme and the edition, and some areas are shared, infection prevention and control among them. The gap report lists every measurable element we treat as ours before any work starts, so the line is agreed in writing.
We have a few weeks, not months. Is it worth starting?
Sometimes. The document corrections and their timing are agreed at scoping; a history of records cannot be grown in weeks. The gap assessment tells you which findings you can close in the time and which will show a short history on the day.
What happens to our clinical policies?
They go under the same document control as every other policy: format, approval route, review date and staff acknowledgement. Their content comes from your clinical leadership.
Our FM contractor keeps the records. Do those count?
They count when they are in your file, current, and consistent with your own facility plan. We set up a monthly transfer so that they are.
Where to read next
Facility 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 a licence expiry register that warns before a date passes.
Read moreCBAHIThe mock survey
The survey rehearsed on your records, building and staff, with timing set at scoping around the actual survey date.
Read moreSectorHospitals
CBAHI, the facility chapter and the building services behind it, for a hospital.
Read moreWith ITF FMFacility management for healthcare buildings
The maintenance behind the facility plans, run with ITF FM.
Read moreITF ConsultInternal audit
An audit programme and findings in three parts, so your own team audits between surveys.
Read morePart 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 with the survey date
Bring your survey date and your last survey report to the first call. The gap assessment is planned from them, and every document after it is built against the manual you are surveyed to.