Hospitals: the non-clinical side, at scale
Many contractors, many committees and a survey against the National Hospital Standards, with the non-clinical evidence held in one place.
A hospital is surveyed against CBAHI's National Hospital Standards, and for hospitals accreditation is tied to operating licence renewal. The non-clinical side is large: contractors, a biomedical team, kitchens, committees and a staff file for every employee. We hold that side together: CBAHI evidence, FM records, training registers and policy control.
Every contractor keeps its own file
A hospital building is run by several contractors at once. FM, fire systems, lifts, kitchens, laundry and security each keep records in their own format, and the surveyor asks the hospital, not the contractor. Committees meet, but fewer can show what a meeting decided and whether it happened. The staff files hold every licence, orientation and certification in the building, each with a date that expires. None of this is clinical. It is the part of a survey that can be fixed with method rather than recruitment.
- The generator load test log sits with the generator contractor, not in the hospital's file
- Fire drills are recorded for day shifts, and the night shift has no drill record
- Committee minutes record the discussion but not the decision, the owner or the follow-up
- Orientation records for housekeeping and security staff are incomplete
- A policy passes its review date while the obsolete version stays in a folder on the ward
The services a hospital uses most
We work the non-clinical standards. Clinical observations from our walks go to a separate referral list, addressed to the leader who owns them.
CBAHI readiness
The non-clinical evidence a survey reads, prepared against your re-survey date, with a gap report and an evidence index.
Read moreCBAHIFacility management and safety
Management plans, inspection and test schedules, drills per shift, and contractor records pulled into your file.
Read moreCBAHIPolicies and records
Document control for every policy, and one expiry register for the licences and certifications across the staff files.
Read moreCBAHIMock survey
The survey rehearsed on your records and your staff before CBAHI arrives, with time left to close what it finds.
Read moreWith ITF FMFacility management for healthcare
Water, air, fire and fabric in a building that treats patients, with the records written in your survey format.
Read moreWith ITF TrainingStaff training
Fire safety and first aid for non-clinical staff, run per shift, with a register you can split by shift.
Read moreWith ITF ConsultHACCP for the hospital kitchen
The food safety plan and the prerequisite records behind a hospital kitchen, built by ITF Consult.
Read moreWhat the survey measures
| Requirement | What it means on site |
|---|---|
| National Hospital Standards | Hospitals are surveyed against the third edition, published in 2016. We map against the manual your hospital is surveyed to. |
| Licence renewal | For hospitals, CBAHI accreditation is tied to renewal of the operating licence. |
| Measurable elements | Each standard carries an intent statement and numbered measurable elements, assessed by document review, observation and staff interview. |
| Essential safety requirements | Measured by a separate CBAHI programme. A national study of those surveys found the fire suppression standard among the lowest-scoring requirements, in public and private hospitals alike. |
| Records with history | A surveyor looks for compliance sustained over the months before the visit, so records need months of history. A folder assembled the week before shows. |
| After accreditation | CBAHI follows up corrective action plans. Each finding needs an owner, a date and the evidence that closed it. |
Questions from hospital administrators
Is CBAHI accreditation tied to our operating licence?
For hospitals, yes. The Ministry of Health ties accreditation to operating licence renewal, so a failed survey is an operating risk rather than a reputational one. The plan starts from your survey date.
Which standards do you work on?
The non-clinical ones: facility management and safety, document control, quality management records, staff files and information management. The measurable elements we treat as ours are listed in the gap report before work starts, so the line is agreed in writing. Clinical observations go to a separate referral list for the right leader.
Our contractors keep the test records. Is that enough?
A contractor's record counts once it is in your file, current and consistent with your facility plan. We set up a monthly transfer from each contractor into the hospital's file, in one format, so the surveyor sees one set of records rather than one per contractor.
What does a typical engagement look like?
A private general hospital in Riyadh has a re-survey in seven months, and two of the people who carried the last one have left. The gap assessment finds three contractors and an in-house biomedical team each keeping their own records, drills recorded for day shifts only, the generator load test log held by the contractor and a batch of policies past review. The facility plans are rewritten with the facilities manager, contractor records move into the hospital's file every month, night-shift drills are run and the mock survey comes in month five. The hospital ends up holding the gap report, a clinical referral list, the drill record by shift, the policy register, the mock survey report and an evidence index by standard.
Can the same supplier run the building services?
Yes. ITF FM runs facility services for healthcare buildings, and where it does, its records are written in your survey format. You can also keep your current contractors and buy only the evidence work.
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.
Count back from the re-survey date
Send the date and your last survey report. The gap assessment is planned backwards from them, and its report says what can be closed in the time.