Assessment of the accreditation standards of the Central Board for Accreditation of Healthcare Institutions in Saudi Arabia against the principles of the International Society for Quality in Health Care (ISQua)

BACKGROUND AND OBJECTIVES: Accreditation is usually a voluntary program, in which trained external peer reviewers evaluate health care organization’s compliance with pre-established performance standards. Interest in accreditation is growing in developing countries, but there is little published information on the challenges faced by new programs. In Saudi Arabia, the Central Board for Accreditation of Healthcare Institutions (CBAHI) was established to formulate and implement quality standards in all health sectors across the country. The objective of this study was to assess a developing accreditation program (CBAHI standards) against the International Society for Quality in Health Care (ISQua) principles to identify opportunities for improvement of the CBAHI standards. METHODS: A qualitative appraisal and assessment of CBAHI standards was conducted using the published ISQua principles for accreditation standards. RESULTS: The CBAHI standards did not describe the process of development, evaluation or revision of the standards. Several standards are repetitive and ambiguous. CBAHI standards lack measurable elements for each standard. CBAHI standards met only one criterion (11.1%) of the Quality Improvement principle, two criteria (22.2%) of Patient/Service User Focus principle, four criteria (40%) of the Organizational Planning and Performance principle, the majority (70%) of the criteria for the safety principle, only one criteria (7.1%) for the Standards Development principle, and two criteria (50%) of the Standards Measurement principle. CONCLUSIONS: CBAHI standards need significant modifications to meet ISQua principles. New and developing accreditation programs should be encouraged to publish and share their experience in order to promote learning and improvement of local accreditation programs worldwide.

creased world trade in manufactured goods led to the creation of the International Standards Organization (ISO) in 1947. 2 Accreditation formally started in the United States with the formulation of Joint Commission on Accreditation of Healthcare Organizations ( JCAHO) in 1951. This model was exported to Canada and Australia in the 1960s and 1970s and reached Europe in the 1980s. Accreditation programs interest is growing rapidly among developing countries. 3 There are other Abdullah AlKhenizan, a Charles Shaw b forms of systems used worldwide to regulate, improve and market health care providers and organizations including Certification and Licensure. Certification involve formal recognition of compliance with set standards (e.g. ISO 9000 standards) validated by external evaluation by an authorized auditor. Licensure involves a process by which a government authority grants permission, usually following inspection against minimal standards, to an individual practitioner or healthcare organization to operate in an occupation or profession. 1 Although the terms accreditation and certification are often used interchangeably, accreditation usually applies only to organizations, while certification may apply to individuals, as well as to organizations. 2 The Central Board for Accreditation of Healthcare Institutions (CBAHI) in Saudi Arabia was formed in 2005 based on the recommendation of the Council of Health Services in Saudi Arabia. CBAHI was established to formulate and implement quality Standards in all health sectors all over the Kingdom of Saudi Arabia. 4 ISQua, The International Society for Quality in Health Care is a not-for-profit organization that was established in 1985 to drive continuous improvement in the quality and safety of healthcare worldwide through education, research, collaboration and the dissemination of evidence-based knowledge. ISQua provides internationally recognized principles for healthcare standards. 5 Several sets of healthcare standards used in Australia, Canada, Egypt, England and the standards of the Joint Commission International, USA, have already been successfully accredited by ISQua. 6 In 1994, Saudi Aramco established the Saudi Medical Services Organization Standards. Private and governmental hospitals had to meet Aramco standards to be accepted as referral health care institutions for Aramco' s employees. In 2001, The Council for the development of health services in the Makkah region was established. One of the main products of this council was the establishment of the Makkah Region Quality Program (MRQP) in 2003, which involved written standards to be met by governmental and private hospitals working in the Makkah region (57 hospitals). These standards were based on JCAHO, and ARAMCO standards. In October 2005, the minister of health established the CBAHI in Saudi Arabia. CBAHI plans to start the accreditation process in the year 2010. 6 Several private and governmental hospitals obtained accreditation from different international accreditation bodies including the Joint Commission International ( JCI), Accreditation Canada, and The Australian Council on Healthcare Standards (ACHS). The first hospital in Saudi Arabia to obtain international accreditation was King Faisal Specialist Hospital and Research Centre in the year 2001.
The objective of this study was to assess a developing country accreditation standards (CBAHI standards) against the ISQua principles in order to identify opportunities for improvement of the CBAHI standards

METHODS
This was a qualitative analysis and assessment of the Saudi accreditation standards using the published ISQua principles for accreditation standards. ISQua principles were chosen because they are a well-respected international organization accepted by many international accreditation bodies including JACHO, ACHS and the Healthcare Accreditation Quality Unit, UK.
ISQua international principles for healthcare standards were developed as a guide for accreditation bodies to develop accreditation standards. ISQua principles consists of six principles, each of which consists of 4-14 sub-principles. ISQua produces guidance and a sample of standards assessment to assist in the interpretation and application of ISQua principle. The principles and sub-principles are rated on a three-point scale of Met, Partially Met and Not Met ( Table 1). As shown in Appendix A (available online at www.saudiannals.net) sub-principle 1.8 was rated as Met because CBAHI standards included all areas covered in the explanatory guidance of this sub-principle, including establishing systems for adverse events, medication errors and patients complaints. Sub-principle 2.3 was rated as Partially Met because CBAHI standards addressed the informed consent and patient involvement in the process of care; however, there were deficiencies in covering end-of-life care and patients' rights to be treated or not to be treated. Sub-principle 3.6 was rated as Not Met because CBAHI standards did not encourage active participation of patients and the community in the planning for the provision of health care services.

Assessment of CBAHI standards against ISQua principles
The assessment of accreditation standard of accrediting bodies using ISQua principles is an important process to assure accreditation bodies that their accreditation standards meet international principles and to assure their customers and sponsors about the quality of accreditation services they provide. ISQua established seven principles, including fifty-six sub-principles. The detailed assessment is shown in Appendix A. A summary of the assessment is shown in Table 2.

Quality Improvement
There is evidence of focus on quality improvement thoughout the standards. A statement of how the standards will contribute to improvements in the health system of Saudi Arabia would be useful to achieve CBAHI aim to improve the quality of health services in Saudi Arabia.

Patient/Service User Focus
Several standards focus on patients/service users. There is a need to encourage coordination of care and communication from the institution to the general practitioner, or referring hospitals. Evidence-based clinical pathways and guidelines need to be encouraged. There is a need for more standards to consider access for individuals with disabilities and special needs.

Organizational Planning and Performance
Standards encourage staff to follow evidence based clinical practice guidelines, protocols, and pathways. There are no standards encouraging active participation of patients, consumers and community leaders as partners, in the development of plans for the institution. There is a need for more explicit standards to set long and short term plans and goals considering environmental and financial factors with the monitoring of the progress in achieving these plans and goals and objectives through defined activities being measured and reported on a regular basis. Coordination with external services should be encouraged.

Safety
Several standards cover important aspects of safety. There is a need for more explicit standards that emphasize the need to have a risk management plan and to coordinate and plan risk management activities. There is also a need for standards for workload monitoring, stress management and waste handling.

Standards Development
Standards development was not explicitly described.
Membership of the CBAHI board includes different governmental health organizations and a representative of the private sector. Patient input was not incorporated. There is no clear process for revision and feedback of the standards. The structure of the standards is based on the different clinical services rather than having a patient-focused or managementfocused structure. They are poorly organized, with no subheadings, and there is significant repetition, complexity and ambiguity. The standards lack notes to explain the intent of each standard, and there is a lack of measurable elements for the different standards.