CBAHI National Hospital Standards
CBAHI National Hospital Standards for hospital accreditation across the Kingdom. Chapters span organizational leadership, clinical care, medication and infection safety, and critical services - scored on CBAHI's 0-5 compliance rubric with zero-tolerance Essential Safety Requirements (ESR) and a 75% accreditation threshold. Fully bilingual (English / Arabic).
Overview
CBAHI National Hospital Standards for hospital accreditation across the Kingdom. Chapters span organizational leadership, clinical care, medication and infection safety, and critical services - scored on CBAHI's 0-5 compliance rubric with zero-tolerance Essential Safety Requirements (ESR) and a 75% accreditation threshold. Fully bilingual (English / Arabic).
Framework Domains (16)
This framework is organized into 16 domain(s) covering 314 controls total.
Domain 1: LD - Leadership of the Organization
Addresses the hospital's governance structure, the roles and responsibilities of governing body and executive leadership, strategic and operational planning, service scope definition, ethical management, and leadership accountability for quality of care and patient safety across every department.
Domain 2: HRM - Human Resources Management
Covers credentialing and privileging, staffing plans, job descriptions, competency assessment, orientation and continuing education, performance evaluation, and personnel file management to ensure a qualified and competent workforce throughout the hospital.
Domain 3: QPS - Quality and Patient Safety
Defines the hospital-wide quality management and patient-safety program, including performance-improvement projects, key performance indicators, incident and sentinel-event reporting, root-cause analysis, risk management, and the National Patient Safety Goals.
Domain 4: PFR - Patient and Family Rights and Education
Protects patients' and families' rights and responsibilities, informed consent, privacy and confidentiality, complaint management, protection of vulnerable populations, and structured patient and family education throughout the care journey.
Domain 5: AOP - Assessment and Provision of Care
Governs patient registration, initial and ongoing assessment and reassessment, individualized plans of care, multidisciplinary coordination, consultations, resuscitation, transfer and referral, discharge planning, and continuity of care for inpatients and outpatients.
Domain 6: MS - Medical Staff
Addresses the organization of the medical staff, clinical privileges, medical staff bylaws, peer review, morbidity and mortality review, physician documentation requirements, and the ongoing evaluation of practitioner performance.
Domain 7: NR - Nursing Care
Covers the organization and leadership of nursing services, nursing assessment and care planning, nurse staffing and skill mix, clinical competency, nursing documentation, and the delivery of safe, evidence-based nursing care across all clinical units.
Domain 8: AN - Anesthesia and Surgical Care
Standards for pre-anesthesia and pre-sedation assessment, moderate and deep sedation, intra-operative and post-anesthesia monitoring, the surgical safety checklist, operating-room environment and workflow, and management of the peri-operative patient.
Domain 9: MM - Medication Management
Governs medication selection and procurement, safe storage, prescribing and transcribing, preparation and dispensing, administration and monitoring, high-alert and look-alike / sound-alike medications, narcotics control, and medication-error and adverse-drug-reaction management.
Domain 10: IPC - Infection Prevention and Control
Requires a hospital-wide infection prevention and control program covering hand hygiene, standard and transmission-based precautions, sterilization and disinfection, environmental cleaning, surveillance of healthcare-associated infections, and outbreak management.
Domain 11: ED - Emergency Department
Addresses emergency triage and prioritization, timely assessment and stabilization, management of high-risk and time-sensitive conditions, staffing and equipment readiness, and safe disposition, admission, or transfer of emergency patients.
Domain 12: LB - Laboratory and Blood Bank Services
Covers laboratory staffing and safety, specimen collection and handling, quality control and proficiency testing, critical-value reporting, point-of-care testing, and the safe management of the blood bank including donor screening, storage, and transfusion practices.
Domain 13: RAD - Radiology and Medical Imaging
Standards for diagnostic and interventional imaging, radiation safety and protection, staffing and credentialing, equipment maintenance and quality control, contrast-media management, and timely and accurate reporting of imaging results.
Domain 14: FMS - Facility Management and Safety
Ensures a safe and functional environment of care through management of safety and security, hazardous materials and waste, fire safety and life safety, medical equipment, utility systems, and emergency preparedness and disaster planning.
Domain 15: MOI - Management of Information
Governs the information management plan, the completeness and integrity of the unique medical record, data security and confidentiality, record retention, coding and documentation standards, and the use of aggregate data for decision support.
Domain 16: ICU - Intensive and Critical Care Services
Addresses admission and discharge criteria for critical-care units, intensity of monitoring, staffing and competency for critically ill patients, management of ventilated and unstable patients, and prevention of complications in the intensive-care environment.
Detailed control mapping and audit workflows are available in the Framework Browser demo.
Ready to audit?
Use ArabAudit to run structured assessments against this framework, map evidence automatically, and generate regulator-ready reports.