Bahrain Healthcare Accreditation Standards: quality and safety weighed ‘preciously’

Raj Pahuja - Head of Corporate Commercial - Bahrain - Corporate / Mergers and Acquisitions / Capital Markets / Commercial

November 2017

Bahrain’s National Health Regulatory Authority’s (‘NHRA’) directive to ensure safe and high quality delivery of healthcare has led the Supreme Council for Health to issue standards against which to evaluate each hospital facility in Bahrain. Such standards are set out in Decision No. 7 2016, setting out the required NHRA quality and safety standards, followed by Article No. 26 2016, regarding the accreditation of hospitals (together, ‘NHRA Licensing and Regulation Standards for Hospital Facilities’).

An NHRA survey team certified by the Saudi Central Board for Accreditation of Healthcare institutions (‘CBAHI’) will conduct the accreditation process in Bahrain for private hospitals. In Saudi, the International Society for Quality in Healthcare (‘ISQua’) has certified CBAHI, since 2012. ISQua defines accreditation as ‘a self-assessment and external peer review process used by healthcare organisations to carefully assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system’. With this in mind, NHRA requires evidence that the facility not only meets the standards at the time of survey but also is in a position to maintain during the period of accreditation acceptable standards and compliance with its legal obligations, including the NHRA Licensing and Regulation Standards for Hospital Facilities.

Visits conducted by the surveyors will assess all hospital facilities on 11 core elements, further considering three supporting elements and 13 facility specific elements when applicable. The lead surveyor will be responsible for producing the final facility report. Following this, the NHRA survey team will review and edit the report. The facility staff will be notified of the ratings and the comments of the survey team. However, based on the ratings and the comments of the survey team, specific recommendations and the final decision regarding the accreditation status of the facility will be given by an accreditation committee convened under NHRA. Based on the accreditation grade awarded, the facility will be categorised by NHRA as either

– Diamond: for facilities that achieve 95 per cent or more of standards evaluation;

– Platinum: for facilities that achieve not less than 90 per cent and not more than 95 per cent of standards evaluation;

– Gold: for facilities that achieve not less than 80 per cent and not more than 90 per cent of standards evaluation; and

– Silver: for facilities that achieve not less than 70 per cent and not more than 80 per cent of standards evaluation.

Following Bahrain’s 2030 vision for sustainable development, NHRA firmly believes that information management is necessary to support better decision making within a healthcare facility. NHRA believes that the hospital facility should have an information management process to meet the information needs of its clinical and managerial teams and to compare its performance with other databases, when relevant.

With regards to healthcare professional training, Dr. Mariam Aljalahma, Chief Executive Officerof NHRA, has explored opportunities for cooperation with Tamkeen (an organisation tasked with developing Bahrain’s private sector) in order to establish sponsored training schemes for health care professionals in the private sectors. The NHRA standards impose a mandatory number of Continuous Medical Education (‘CME’) and Continuous Professional Development (‘CPD’) credits in order to renew a caregiver’s licence to practice.

In the development and implementation of the NHRA Licensing and Regulation Standards for Hospital Facilities, NHRA has also resorted to experts in the field of hospital management and health policy to ensure effective oversight on the accreditation process.

The NHRA Licensing and Regulation Standards is an important step in setting minimum accreditation standards for private hospitals in Bahrain. The introduction of a certified survey team and report based process brings the accreditation process in line with similar practices set by other regulators in the region.