The Importance Of CBAHI Accreditation

The Importance of CBAHI AccreditationDr. Mohammed Ahmed Garout, MDAssistant Prof. of Public Health, Medical Faculty - UQU – MakkahIPC Specialty Team Leader - CBAHISaudi Arabia

Healthcare Accreditation: an overview2

Introduction Healthcare accreditation is a process of external peer reviewto assess the performance of a healthcare facility in relation toagreed healthcare accreditation standards. Accreditation in healthcare has existed for over 100 years(Brubakk et al, 2015). Accreditation has been widely adopted as an essential part ofhealthcare systems in more than 70 countries (Greenfield etal, 2013).3

Introduction Accreditation is a primary driver of quality and safetyinternationally (Braithwaite et al, 2006). Health service accreditation is an assessment of performanceagainst standards at a given point in time. It provides a snapshot of performance against standards (Swiers &Haddock, 2019).4

Introduction Accreditation is part of healthcare globally and is a reliable activity(Greenfield et al, 2010). It has been found to improve patient care and support a positive cultureand effective leadership in various countries and settings (Bogh et al,2016; Braithwaite et al, 2010; Shaw et al, 2014). It also contributes to continual and systematic quality improvementchanges, at a process and system level within hospitals (Greenfield et al,2019).

Accreditation’s value6

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Current literature is unable to consistentlyassess the effectiveness of accreditation(Brubakk et al, 2015). Argument that inconsistent andunconvincing evidence fails to demonstratethe value of accreditation (Hinchcliff et al,2012, Brubakk et al, 2015, Duckett et al,2018). Questioning if the investment inaccreditation delivers sufficient outcomeswith desired/expected patients’ safety(Øvretveit et al, 2000, Lam MB, 2018,Griffith JR, 2018). There was no statistically significantassociation between Lebaneseaccredited hospitals and patientsatisfaction (Haj-Ali et al, 2014). Considerable variation withinaccreditation categories in quality ofcare and mortality among surveyedhospitals, which indicates thataccreditation have limited usefulnessin distinguishing individualperformance among accreditedhospitals (Chen et al (2015).8

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Infection control performance ispositively associated with accreditedfacilities (Sekimoto et al, 2008). Supportive evidence was found forusing SAB rates to demonstrate theimpact of infection control programsembedded within the accreditationprogram (Mumford et al, 2015). For IPC KPIs (VAP, CAUTI, CLABSIand SSI), the healthcare accreditationacts as a catalyst for implementing andmonitoring positive changes (FatimaMS and Habibur Rahman M , 2017). Admissions at fully accreditedhospitals were associated with a lower30-day mortality risk than admissionsat partially accredited hospitals(Falstie-Jensen AM et al, 2015). Admissions at fully accreditedhospitals were associated with ashorter LOS compared withadmissions at partially accreditedhospitals (Falstie-Jensen AM et al,2015).10

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Contradicted views of published research about value andeffectiveness of healthcare accreditation are expected andcould be referred to: Different accreditation methods.Different healthcare systems.Different study designs.Measures of different outcomes.Inability to ascertain causal relationship.Studies sample sizes.Others

AccreditationCan not:Can: Guarantee absolute quality. Act for the best interests ofpatients and HCWs. Guarantee absolute safety. Be a commitment to minimisingrisks. Eliminate all risks. Be a commitment tomaximising quality and safety. Ensure/encourage the Guarantee that evidence basedcontinuous quality improvementbest practice is always provided.of the organisation.Therefore, accreditation provides a snapshot of performance against standards while theongoing maintenance and improvement of this performance is the responsibility of theaccredited facility (Swiers & Haddock, 2019)

Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI)14

The Saudi Central Board for Accreditation ofHealthcare Institutions (CBAHI) is the officialagency authorized to grant accreditationcertificates to all healthcare facilities operating inSaudi Arabia.CBAHI At A Glance CBAHI has emerged from the Saudi HealthCouncil as a non-profit organization. The principal function of CBAHI is to set thehealthcare quality and patient safety standardsagainst which all healthcare facilities areevaluated for evidence of compliance.

The foundation of CBAHI dates back to 2001 as MakkahRegion Quality Program (MRQP).CBAHI AtA GlanceMRQP was an initiative aimed at improving quality ofhealthcare delivery in Makkah Region.In 2005, under a Ministerial Order, MRQP was developedand named as Central Board for Accreditation ofHealthcare Institutions (CBAHI) and its jurisdiction wasexpanded to the whole country.

2006CBAHI At A Glance With theassistance &collaborationof healthcarequalityexperts fromthe public andprivatesectors,CBAHIlaunched thefirst editionof nationalstandards forhospitals.2012 CBAHI’s2nd editionof nationalstandards forhospitals wascertified bytheInternationalSociety forQuality inHealthcare(ISQua).late 2013 Mandatorystatus ofCBAHIaccreditationwas declaredwhen a Cabinetof MinistersDecree calledfor changingCBAHI’sofficial name tothe “SaudiCentral BoardforAccreditationof HealthcareInstitutions”.17

In 2013, the national accreditation by CBAHI wasalso mandated on all healthcare facilities.CBAHI At A Glance In addition, CBAHI accreditation became aprerequisite for renewal of the operating license – astep towards encouraging more participation in thisambitious national initiative. Currently, it is mandatory for all public and privatehealthcare delivery facilities (hospitals, polyclinics,blood banks and medical laboratories) in SaudiArabia to comply with national standards set byCBAHI and obtain their accreditation through asurvey process set forth by the Center.

CBAHI’s Accreditation Achievements19

Total of 273 hospitals had undergoneCBAHI accreditation process (status tillOctober 2019): 212 hospitals had been accredited(78%). 50 hospitals had denied accreditation(18%). 9 hospitals with conditionalaccreditation (3%). 2 hospitals had their accreditationsuspended (1%).20

Out of 88 clinical laboratories, total of 56laboratories (64%) had been accredited(until September 2019).21

Total of 196 Primary Health CareCenters had undergone CBAHIaccreditation process (status untilOctober 2019): 165 PHC had been accredited(84.2%). 28 PHC had denied accreditation(14.3%). 3 PHC had conditionalaccreditation (1.5%).22

CBAHI Literature Review23

CBAHI standards need significant modifications to meet ISQua principles.New and developing accreditation programs should be encouraged to bepublished (Alkhenizan A, 2010). Limited number of hospitals has been accredited by CBAHI. Despite thegreat efforts to improve services in health sector, number of obstacles (suchas finance and qualified staff) have not yet been overcome to achieveeffective application of quality (Almasabi MH, 2013). CBAHI accreditation has positive impact on healthcare environmentprocesses, outcome and patient satisfaction (Al Shammari M, et al, 2015).24

Accreditation: Challenges25

Validity of standards. Reliability of assessments/surveys. Leadership and effective engagement of healthcare professionals. Transparency and accountability. Patient/care givers involvement. Quality of gathered data & proper analyses. Benchmarking and data share.

Summary27

Take home message: Accreditation is not about ‘passing an exam, it isabout commitment. Accreditation is not the goal Continuous QualityImprovement. Accreditation programs guide performance andinfluence organisational culture. Accreditation increases efficiency health systemsneed to become less accepting of errors.

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References: Brubakk K, Vist GE, Bukholm G, Barach P, and Tjomsland O. (2015). A systematic review of hospital accreditation: the challengesof measuring complex intervention effects. BMC Health Services Research. 15:280. Chen, L. W., Nguyen, A., Jacobson, J. J., Gupta, N., Bekmuratova, S., & Palm, D. (2015): Relationship between quality improvementimplementation and accreditation seeking in local health departments. Duckett S, Jorm C, Moran G and Parsonage H. (2018). Safer care saves money: How to improve patient care and save public moneyat the same time. Grattan Institute. Viewed 3 March 2019. Safer-care-savesmoney.pdf Duckett S, Jorm C, Danks L and Moran G. (2018). All complications should count: Using our data to make hospitals safer. GrattanInstitute. Viewed 3 March 2019. 897-All-complications-should-count.pdf. Greenfield D, Pawsey M, Naylor J, Braithwaite J. (2013). Researching the Reliability of Accreditation Survey Teams: Lessons LearntWhen Things Went Awry. Health Information Management Journal, 42(1), 4–10. Greenfield D, Pawsey M, Naylor J and Braithwaite, J. (2009). Are accreditation surveys reliable? International Journal of healthcarequality assurance. 22(2):105-16 Greenfield D, Moldovan M, Westbrook M, Jones, D, Low L, Johnston, B, . Braithwaite, J. (2012). An empirical test of short noticesurveys in two accreditation programmes. International Journal for Quality in Health Care. 24(1), 65-71. Greenfield D, Lawrence SA, Kellner A, Townsend K, Wilkinson A. (2019) Health service accreditation stimulating change in clinicalcare and human resource management processes: a study of 311 Australian hospitals, Health policy (2019). Viewed 6 May 06. Griffith JR. (2018). Is It Time to Abandon Hospital Accreditation? American Journal Of Medical Quality. 33(1): 30–36.30

Hinchcliff R, Greenfield D, Moldovan M, Westbrook J, Pawsey M, Mumford V, Braithwaite J. (2012). Narrative synthesis of health serviceaccreditation literature. BMJ Quality and Safety. 21(12): 979–91. Miranda B Lam, Jose F Figueroa, Yevgeniy Feyman,2 Kimberly E Reimold, E John Orav, Ashish K Jha (2018): Association between patientoutcomes and accreditation in US hospitals: observational study Mumford V, Reeve R, Greenfield D, Forde K, Westbrook J and Braithwaite J. (2015). Is accreditation linked to hospital infection rates? A 4year, data linkage study of Staphylococcus aureus rates and accreditation scores in 77 Australian acute hospitals. International Journal forQuality in Health Care. 27 (6): 479–485. Sekimoto M, Imanaka Y, Kobayashi H, Okubo T, Kizu J, Kobuse H, Mihara H, Tsuji N, Yamaguchi A. (2008). Impact of hospitalaccreditation on infection control programs in teaching hospitals in Japan. American Journal of Infection Control. 36:212–19. MS Fatima and Habibur Rahman M (2017): The Impact of Joint Commission International Healthcare Accreditation on Infection ControlPerformance: A Study in Dubai Hospital. Falstie-Jensen AM, Larsson H, ERIK HOLLNAGEL Hollnagel E, Norgaard M, Svendsen MLO, and Johnsen SP (2015): Compliance withhospital accreditation and patient mortality: a Danish nationwide population-based study. Falstie-Jensen AM, Larsson H, ERIK HOLLNAGEL Hollnagel E, Norgaard M, Svendsen MLO, and Johnsen SP (2015): Is compliance withhospital accreditation associated with length of stay and acute readmission? A Danish nationwide population-based study Haj-Ali, W., Bou Karroum, L., Natafgi, N., & Kassak, K. (2014). Exploring the relationship between accreditation and patient satisfaction –the case of selected Lebanese hospitals. https://portal.cbahi.gov.sa/english/home31

Alkhenizan A and Shaw C (2010): Assessment of the accreditationstandards of the Central Board for Accreditation of HealthcareInstitutions in Saudi Arabia against the principles of the InternationalSociety for Quality in Health Care (ISQua). Almasabi MH (2013): An Overview of Quality and Accreditation inthe Health Sector within Saudi Arabia. Al Shammari M, Al Habib S, Al Shubrami D, Al Rashidi M (2015):Impact of Hospital‘s Accreditation on Patient Safety in Hail City,Saudi Arabia: Nurses‘Perspective.32

Healthcare accreditation is a process of external peer review to assess the performance of a healthcare facility in relation to agreed healthcare accreditation standards. Accreditation in healthcare has existed for over 100 years (Brubakket al, 2015). Accreditation has been widely adopted as an essential part of