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NATIONAL HOSPITAL STANDARDS Third Edition 1436-2015 Effective 1 January 2016 1 The mission of the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) is to continuously improve the safety and quality of healthcare services in the Kingdom of Saudi Arabia by supporting the healthcare facilities to continuously comply with the accreditation standards. CBAHI does this through the provision of preparation, on-site assessment, monitoring, education, publications and consultation services. CBAHI is making every possible effort to separate its consultative and educational programs as well as all publications it produces from its accreditation activities. This manual is produced for the sole use of the individual healthcare facilities and healthcare professionals in Saudi Arabia. CBAHI provides supplementary educational sessions to explain the intent of this manual and its contents, and therefore, attendance at these activities is helpful in achieving compliance with the quality and safety standards followed by accreditation. Attendees at CBAHI training, orientation and educational programs and purchasers of its publications will not have a distinctive treatment by any CBAHI associates including CBAHI surveyors, nor receive any privilege regarding assessment scoring results or outcome. © 2015 Saudi Central Board for Accreditation of Healthcare Institutions. The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI), a not-for-profit governmental organization, has been required by its formation order to support all healthcare organizations in Saudi Arabia through different mechanisms, including the production of scientific peer reviewed standards, materials and publications. This is a copyright material. No part of this publication may be reproduced or stored in a retrieval system for usage outside the concerned organization, or transmitted for public use in any form or by any means- electronic, mechanical, photocopying, recording or otherwise- without prior permission of CBAHI which can be accessed on the following address: cbahi@cbahi.gov.sa Requests for copies or permission to make copies of any part of this work should be mailed to the above email address or otherwise to the following mailing address: Department of Public Relations The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) P.O. Box 55505, Jeddah, 21544, Kingdom of Saudi Arabia ISBN: 978-603-90504-3-8 Printed in the Kingdom of Saudi Arabia, Jeddah For more information about CBAHI publications, please visit: http://www.cbahi.gov.sa 2 ‫املركز السعودي‬ :‫العتماد املنشآت الصحية ( سباهي) هو‬ ‫اجلهة الر�سمية املخولة منح �شهادات اعتماد اجلودة لكافة املرافق ال�صحية احلكومية واخلا�صة التي تعمل يف اململكة‬ ‫ يتوىل ب�شكل‬،‫ ويعترب جهة غري هادفة للربح‬،‫ ينبثق املركز �أ�سا�س ًا عن املجل�س ال�صحي ال�سعودي‬.‫العربية ال�سعودية‬ ‫�أ�سا�سي تقييم املن�ش�آت ال�صحية بغر�ض حتديد مدى التزامها بتطبيق معايري اجلودة و�سالمة املر�ضى التي �صممها‬ ‫ بد�أ املركز عمله حتت م�سمى املجل�س املركزي العتماد املن�ش�آت ال�صحية بقرار معايل وزير ال�صحة‬.‫املركز لهذا الغر�ض‬ ‫ وا�ستمر يف ت�أدية املهام املناطة به حتى �صدور‬، ‫هـ‬1426-9-1 ‫) وتاريخ‬144187( ‫رئي�س جمل�س اخلدمات ال�صحية رقم‬ ‫ القا�ضي بتحويله �إىل املركز ال�سعودي العتماد املن�ش�آت‬، ‫هـ‬1434-11-24 ‫) وتاريخ‬371( ‫قرار جمل�س الوزراء املوقر رقم‬ ‫ وا�ستمراره يف و�ضع وتطبيق املعايري الوطنية للجودة و�سالمة املر�ضى يف كافة املرافق ال�صحية ومنح �شهادات‬، ‫ال�صحية‬ ‫ يعترب احل�صول على االعتماد الوطني من قبل املركز ال�سعودي �إلزامي ًا على كافة املرافق ال�صحية‬.‫االعتماداملتعلقة بذلك‬ -1-9 ‫ ) وتاريخ‬58 /8 ( ‫احلكومية واخلا�صة مبوجب القرار �سالف الذكر ومبوجب قرار املجل�س ال�صحي ال�سعودي رقم‬ ‫ كما ت�شرتط وزارة ال�صحة ال�سعودية تطبيق معايري االعتم

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