Several types of internal audits have been used to promote quality improvement (QI) in healthcare facilities. However, government entities have their mechanisms and criteria for evaluating the effectiveness of audits according to their respective health regulatory bodies. CBA understands the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality in healthcare facilities.
A healthcare facility refers to any entity that has a licence or needs to obtain a licence under a health regulatory body, such as home care, clinics, medical centres, polyclinics, day care surgery centres, specialised medical centres, long-term care centres, general hospitals, specialised hospitals, pharmacies, first aid posts, drugstores, and medical stores.
CBA quality auditors are experts in government regulations, and our auditors attend multiple audits directly with the facility. These audits include new facility audits, range audits, adding specialities, change of type, change of location, temporary closure, and change of plan in DOH, DHA, MOH, and DHCC.
Since our auditors are experts in documentation, they systematically conduct audits, adhere to regulations, and synthesise the literature on audits. Documentation for individual facility types and specialities is synthesised by focusing on the scope of services, testing, and supplementing comprehensive programmes to refine them into a set of context mechanism outcomes.
Quality Assurance is an integral part of any process and requires continuous monitoring. Quality assurance in healthcare encompasses activities and measures designed to ensure continuous improvement in the quality of medical care. Quality assurance does more than provide an excellent experience for your patients and patient satisfaction; it also helps you achieve facility goals and measure success.
Our auditing support includes, but is not limited to, assisting in developing robust process monitoring mechanisms, enhancing existing processes, and issuing final audit licences from healthcare regulatory bodies.
Quality Assurance is an integral part of any process and requires continuous monitoring. Quality assurance in healthcare encompasses activities and measures designed to ensure continuous improvement in the quality of medical care. Quality assurance does more than provide an excellent experience for your patients and patient satisfaction; it also helps you achieve facility goals and measure success.
Our auditing support includes, but is not limited to, assisting in developing robust process monitoring mechanisms, enhancing existing processes, and issuing final audit licences from healthcare regulatory bodies.
HEALTHCARE FACILITY AUDIT | UAE
Each emirate has its own regulatory framework. We provide audit consultations, fulfil requirements, offer support services, handle documentation, review facility drawings, and provide orientation and awareness training to both healthcare professional staff and non-healthcare professional staff. The major healthcare regulatory bodies in the UAE responsible for issuing and processing licences for healthcare facilities are:
DOH Licensing or Ranking Audit
DHA Licensing Audit
MOHaP Licensing Audit
For continuous improvement with the Department of Health (DOH), facilities must fulfil JAWDA compliance and ADHICS compliance requirements. To meet these standards, CBA will assist with the completion process and attend audits with DOH auditors. These regulations not only demonstrate high medical ethics and quality assurance to customers, minimising the chances of medical errors, but also provide a sense of security when availing of the services of your facility.
For continuous improvement with the Department of Health (DOH), facilities must fulfil JAWDA compliance and ADHICS compliance requirements. To meet these standards, CBA will assist with the completion process and attend audits with DOH auditors. These regulations not only demonstrate high medical ethics and quality assurance to customers, minimising the chances of medical errors, but also provide a sense of security when availing of the services of your facility
UAE DOH LICENSING OR RANKING AUDIT
We assist and facilitate with the Department of Health (DOH) Abu Dhabi facility licensing audits for all types of facilities, including medical centres, hospitals, daycare surgery units, traditional medicine centres, primary healthcare facilities, homecare services, pharmacies, rehabilitation centres, optical stores, laboratories, teleconsultation facilities, first aid posts, ambulance services, and school clinics.
We help you with the process, from trade name reservation with the Department of Economics to final approval with DOH. This involves document preparation, engineering drawing approvals (DOH), staff training, inspection preparation, and presence during the permanent registration audit.
If you are looking at adding a new specialty to your existing facility, we help you with the engineering drawing approval process and inspection preparation with audit support.
If you are planning to modify an existing area within your facility or add rooms, we can process the application on your behalf and be a part of the entire approval process.
If you seek to upgrade your facility type based on the scope of services you plan to provide, we can help with the end-to-end process, from proposing the list of specialities to hiring the required professionals.
If you intend to change the location of your existing facility for insurance empanelment or better business prospects, we can handle the entire application process from the initial application to the final audit approval.
As part of the DOH’s initiative to ensure continuous improvement among healthcare facilities, yearly focused visits are conducted by DOH auditors to ensure compliance with all aspects of patient care. These are primarily categorised into organisation management, infection control requirements, facility requirements, medical documentation, and staff awareness.
Our team of experienced professionals will liaise with your staff on a regular basis to ensure that you achieve excellent scores.
Our team of experienced professionals will liaise with your staff regularly to ensure that you achieve excellent scores.
The process involves conducting an initial mock survey to understand the facility’s readiness, providing a gap analysis on pending requirements as per DOH standards, and offering guidance and support for implementing necessary controls to achieve compliance.
UAE DHA LICENSING AUDIT
We assist and facilitate the Dubai Health Authority (DHA) facility licensing audits for all types of facilities, which include medical centres, hospitals, day care surgery units, traditional medicine centres, homecare, pharmacies, rehabilitation centres, optical stores, laboratories, teleconsultation facility, first aid-post, ambulance services and school clinics
We help you with the process of trade name reservation with the Department of Economics, to the final approval with DHA. This involves document preparation, engineering drawing approvals (DHA), training to staff, inspection preparation and presence during the permanent registration audit.
If you are looking at adding a new speciality to your existing facility, we help you with the engineering drawing approval process and inspection preparation with audit support.
If you are planning to modify an existing area within your facility or add rooms into the existing facility, we can process the application on your behalf and be a part of the entire approval process.
If you are seeking to upgrade your facility type, based on the scope of services that you are planning to provide, we can help you with the end-to-end process from proposing the list of specialties to hiring the required professionals.
If you intend to change the location of your existing facility, in anticipation of an insurance empanelment or better business prospects, we can take care of the entire application process from the initial application to the final audit approval.
The process involves conducting an initial mock survey to understand the readiness of the facility and provide a gap analysis on the pending requirements as per the DHA requirements. Later provide guidance and support on implementation of the necessary controls to achieve compliance.
UAE MOHaP LICENSING AUDIT
We assist and facilitate the Ministry of Health and Prevention (MOHaP), facility licensing audits for all types of facilities, which include medical centres, hospitals, day care surgery units, traditional medicine centres, homes, pharmacies, rehabilitation centres, optical stores, laboratories, teleconsultation facility, first aid-post, ambulance services and school clinics
We help you with the process of trade name reservation with the Department of Economics, to the final approval with MOHaP. This involves document preparation, engineering drawing approvals (MOHaP), training to staff, inspection preparation and presence during the permanent registration audit.
If you are looking at adding a new speciality to your existing facility, we help you with the engineering drawing approval process and inspection preparation with audit support.
If you are planning to modify an existing area within your facility or add rooms to the existing facility, we can process the application on your behalf and be a part of the entire approval process.
If you are seeking to upgrade your facility type, based on the scope of services that you are planning to provide, we can help you with the end-to-end process, from proposing the list of specialties to hiring the required professionals.
If you intend to change the location of your existing facility, in anticipation of an insurance empanelment or better business prospects, we can take care of the entire application process from the initial application to the final audit approval.
The process involves conducting an initial mock survey to understand the facility’s readiness and to provide a gap analysis based on the pending requirements as per the MOHaP standards. Subsequently, we offer guidance and support for implementing the necessary controls to achieve compliance.
UAE DOH JAWDA COMPLIANCE AUDIT
JAWDA is the quality assurance initiative of the Department of Health, Abu Dhabi (DOH), and is implemented alongside the other quality and patient safety measures undertaken by DOH.
Healthcare facilities are required to monitor predefined Key Performance Indicators (KPIs) relevant to their scope of services. Additionally, facilities must ensure compliance with medical coding practices that align with DOH and international standards.
Third-party organisations appointed by the DOH conduct JAWDA audits across the KPI and coding domains.
We facilitate this by aiding in the interpretation of the KPIs defined by the Department of Health, Abu Dhabi (DOH) for hospitals, medical centres, dental centres, home care, teleconsultation facilities, rehabilitation centers, and primary health care facilities.
The process involves defining data collection practices, data cleansing and validation, providing submission guidance, and supporting audits.
According to a DOH circular regarding JAWDA: “Further to the subject and the mandatory Shafafiya system enrollment, all healthcare providers are required to abide by the circular (DG/02/18) published on January 10, 2018 regarding the updates on JAWDA Data Certification (JDC). All payers and TPAs must refer to the list of licensed facilities published on Shafafiya to confirm the compliance status prior to making the payments.
Listing on Shafafiya and following JDC requirements is applicable to all healthcare facilities, including home healthcare and long-term facilities operating exclusively as self-pay, proforma, or service codes, and shall be monitored by DoH and any non-compliance is applicable for sanctions.” published by the Department of Health.
UAE DOH ADHICS COMPLIANCE AUDIT
ADHICS compliance primarily addresses data security and patient information. As a facility can not hire full-time IT engineers to fulfil the requirement, CBA has its own well-trained team of IT engineers. Our IT team will prepare complete guidelines and policies as per ADHICS standards and provide training to your staff for ongoing implementation.
As per the DOH health information and cyber security standard, 1.3 Overview says that; “the requirements of this standard are based on governmental and industrial demands, and information security and cyber security international best practices. DOH has invested time and effort to understand the demands, define Abu Dhabi Health Sector-specific information and cyber security requirements, and define timelines for compliance. The standard focuses on the specifics of protecting and/or securing personal health information. It defines the controls applicable to healthcare entities based on their capability, maturity, and risk environment. Compliance with this standard increases the level of information assurance between healthcare entities, the public (citizens, residents, and visitors), and governmental bodies.”
Our team collaborates closely with your EMR provider and IT technicians or external IT support to manage patient information securely and ensure quarterly submissions to the Aamen portal. Our services include:
- Reviewing and updating ADHICS policies and guidelines
- Conducting documentation orientation for staff, including healthcare professionals
- Providing information security training for necessary employees
- Completing ADHICS self-assessment checklists
- Conducting ADHICS documentation and staff orientation sessions
- Offering consultations on system, networking, and EMR-related issues
- Developing corrective action plans for audits if needed
HEALTHCARE FACILITY AUDIT | SAUDI ARABIA
While we currently lack a physical office in Saudi Arabia, our team possesses extensive knowledge of regulatory requirements and can provide comprehensive online support to meet your needs. We are also preparing to establish a new office in KSA. Our audit support includes:
CBAHI COMPLIANCE AUDITCBAHI COMPLIANCE AUDIT
CBA provides crucial support for healthcare institutions undergoing audits by the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI), encompassing hospitals, primary healthcare centres, laboratories, blood banks, and ambulatory centres. Our approach begins with an initial mock survey to evaluate the facility’s preparedness and identify any gaps in compliance with CBAHI standards. We then offer comprehensive guidance and assistance to implement necessary controls and procedures, ensuring the institution meets regulatory requirements effectively.
MOH – LICENSING AUDIT
We assist private healthcare providers in obtaining final approval for health facility licensing by conducting an initial mock survey to assess the facility’s readiness. This involves providing a gap analysis based on the Ministry of Health (MOH) requirements. Following this, we offer guidance and support to implement the necessary controls to achieve full compliance.
HEALTHCARE FACILITY AUDIT | QATAR
We do not have a physical office in Saudi Arabia; however, our team has enough knowledge on the regulatory requirement, we are able to support online to fulfil the requirement. Our new office in KSA will be here soon. The audit support for MOPH-Licensing Audit
We assist private healthcare providers in complying with the SCH and MOPH requirements by conducting an initial mock survey to understand the readiness of the facility and provide gap analysis on the pending requirements as per the SCH and MOPH requirements. Later provide guidance and support on implementation of the necessary controls to achieve compliance.
Healthcare facilities play a crucial role in maintaining a healthy society. Audits help identify facility risks and ensure regulatory compliance according to KPIs. Our audit process, designed to mirror actual regulatory audits, includes mock audits to prepare healthcare facilities for real inspections and required documentation. The process flows as follows:
Patient safety, satisfaction, waiting time, and quality of service provided in a facility are measured using KPIs defined by regulatory or internationally recognized accrediting bodies. During the audit process, our auditors evaluate healthcare professional files, patient files, and EMRs to ensure that facilities maintain medical ethics, quality assurance, and legal practices, thus avoiding malpractice, unnecessary patient claims, and fines from regulatory authorities.
Regulatory bodies such as DOH, DHA, MOH, CBAHI, MOPH, and others require healthcare facilities to adhere to defined standards, regularly practice, and fulfil KPIs during audits to ensure compliance.
In summary, the expert team of quality auditors at CBA will work with your facility team to ensure compliance with these audits. We conduct mock audits that mirror actual regulatory body inspections, providing updated policies, guidelines, scope of services, scope of practice, privileges, and KPIs, as well as training for medical and non-medical staff to ensure readiness for official inspections.