The Accreditation Unit provides guidance to ensure KFHU is continuously compliance to the highest level of quality care and patient safety standards as set by the Joint Commission International (JCI), CBAHI and other regulatory agencies.
At the center of all JCI accreditation activities is the need to focus on safety. All accreditation standards support quality and safety efforts, whether a person is seeking services from a CBAHI / JCI accredited hospital and ambulatory care organization. More specifically, standards related to safety and reducing adverse events, provide a framework to reduce the risk and ensure the safety of individuals who receive care, treatment, and services in a health care organization.

Goals & Objectives

The following are the goals and objectives of the Accreditation Unit:

  • Perform as a facilitating unit for KFHU organization to maintain accreditation certification.
  • Meet with the chapter team to review the current forms, policies and procedures to continuously compliance on CBAHI and JCIA standards.
  • Assist the chapter team that require continuous improvement either in structures, processes and outcomes.
  • Assist each JCIA Chapter team leaders and members to do re-assessment for each chapter, prepare the list of lacking requirements for the chapter.
  • Performing regular unit visits, tracers, staff interview, and open chart review to test the implementation of policies and procedures and assess the degree of compliance with the specific standards
  • Facilitate and provide to CBAHI and JCIA Chapter team leaders any necessary resources (policies, forms, etc…) in collaborative with policy and procedure unit for standard compliance.
  • Track and report Re-accreditation Process plans and implementation schedules and consultants reports and action plan.
  • Coordinate with education and training unit for educational events in relation to the re-accreditation process.
  • Coordinate with the Chairperson of every department to monitor KFHU compliance to JCI / CBAHI standards through tracer activity
  • Prepare the survey agenda in coordination with accreditation surveyor team- in coordination with DQS Director.


  • Analyzing Survey Report
  • Education and communication
  • Updating the Accreditation Standards Database
  • Tracers

Continuous Improvement

  • Developed complete, patient-centered processes throughout King Fahd Hospital of the University
  • Launched a structured and transparent process to monitor continuous compliance to JCI /CBAHI standards
  • Improved interdisciplinary communication
  • Upgrade documentation of processes to ensure care continuity, patient safety and continuous improvement

Patient Safety

  • Adhered to the IPSGs to generate a culture of safety for staff and patients
  • Implement a comprehensive approach to involve patients, families, staff, and visitors
  • Established a transparent reporting system for complaints and suggestions from employees, patients and families.
Published on: 22 January 2017
Last update on: 22 January 2017
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