.

An organization is

assessed by an

external body to determine its

performance compliance with agreed
standards and

.the impact of its services on the patients

- JCAHO

CCHSA

ACHS

ANAES

) (

CBAHI:
Central Board for
Accreditation
of Health care
Institutions

Std.

Statement
Std. Intent

Preparation
Tool (PT)
Teaching tools

Sample

What is The Survey

Process
It is a process of peer review by experts to
verify the compliance of practice with the
recognized standards

Medical
Infection

Nurse

Control
STD

LD &TQM

Teams

Pharmacy

Laboratory

FMS

1.
2.
3.

4.
5.

6.

Seven (7) members in the team

Core team: Admin/Physician/Nurse
Specialty team:
Pharmacy/Lab/Safety/Infection Control
Core team: three (3) or four (4) days
Specialty team: one (1) or two (2)
days
All seven will go together first day
during accreditation surveys and may
be on different day during mocks.

7.

Each standard is given equal weight.

8.

Each chapter is given equal weight.

9.

10.

Results has to be approved by the

Central Board before it is given to
the hospital.
The surveyors are not permitted to
provide hints to the hospital
regarding the accreditation status .

Review

Interview

View

Scoring Method
All CBAHI chapters have equal weight regardless of
standard contents.

All standards within a chapter weigh equally.

Each standard is assigned ONE point.
Standard may contain one or more evidences of
compliance.
The ONE point is divided equally between the
evidence of Compliances.
Each evidences of compliance could be scored as
MM

PM

FM

25% >

to 50% 25

to 74% 50

75%

NM

NA

Accreditation Decision
Rules
Accredited: greater than 80 percent with no
more than 2 chapters
less than 50% and no chapter less than 30%.
If the hospital scores 70-79%, CBAHI will re-visit
free within 90
days to perform a focus survey on the
chapters failed, then make the decision for
accreditation.
Not Accredited: If the hospital scores less than 70%,
the hospital is eligible for a full survey after 6 months.