Abstract
Background MNGHA facilities have been accredited by the Joint Commission International (JCI) since 2006. Leaders in MNGHA believe that the accreditation process is a tool to improve the quality and patient safety in the hospital, applying evidence-based standards in performance with focus on the outcomes. A decision was made by the leadership to attain a national accreditation certificate (Central Board for Accreditation of Healthcare Institutions, CBAHI). In 2016, MNGHA facilities had the first experience with CBAHI through the ESR program. All facilities were visited by two surveyors to evaluate the compliance of MNGHA hospitals with 20 Essential Safety Requirements, as this was a national project to improve patient safety in all healthcare facilities in the Kingdom of Saudi Arabia. After this experience, MNGHA leaders were interested to submit all MNGHA facilities for a national accreditation represented by CBAHI in addition to international accreditation represented by JCI. All MNGHA facilities were scheduled for CBAHI accreditation in 2018, the Central Region in April 2018, Western Region in May, Al Ahsa in July, Dammam in August, and Madina in October, which was postponed to February 2019.
Methods A team consisting of 18 certified CBAHI surveyors was scheduled to conduct the mock survey for all regions at least 3 months prior to the real survey. MNGHA leadership fully supported the project by providing the required resources to achieve the desired outcome from the project.
Results All MNGHA facilities had their mock survey by the MNGHA’s surveyors with excellent feedback with the following outcomes: tremendous learning opportunities were created during the mock survey, improve the intraregional interaction by sharing experiences, create a resource team in the system from different specialties for CBAHI accreditation. Common findings were identified among all MNGHA Regions, which led to some changes at the corporate level of MNGHA. Moreover, the impact of the project on the real survey of all hospitals was remarkable; the MNGHA’s hospital scores were considered as extraordinary results:
Facility Score
KAMC - Central Region 96.40%
KAMC - Western Region 92.27%
KAH- Al Ahsa 94.66%
IABFH Dammam 96.75%.
Conclusion Building capacity is crucial in improving the system and process, utilizing local resources and appreciating staff skills and knowledge is the way to achieve the culture of a learning organization, connecting people from different systems and settings will create a culture of learning, sharing successful experiences of overcoming challenges standard with the same resources will highly impact a positive outcome in the real survey.
