The CBAHI National Hospital Standards are the requirements Saudi Arabia's national accreditation body uses to survey public and private hospitals, and a 2013 Cabinet decree made CBAHI accreditation mandatory for all healthcare facilities. CBAHI's hospital programme page, last archived in April 2025, names the 3rd edition, issued in 2015, so confirm with CBAHI which edition your survey will use.
This guide is for hospital quality directors, accreditation coordinators and the medical and nursing leaders who prepare for the survey.
Which edition of the CBAHI hospital standards applies?
CBAHI, the Saudi Central Board for Accreditation of Healthcare Institutions, began in 2001 as the Makkah Region Quality Program. A ministerial order in 2005 renamed it and gave it national scope. It published its first national standards for hospitals in 2006, and its 2nd edition received ISQua accreditation in 2012.
The latest edition CBAHI's own site shows is the 3rd edition of the National Standards for Hospitals. CBAHI's hospital accreditation programme page (archived copy, April 2025) calls it the Hospital Accreditation Program, 3rd version, and says the edition was issued in 2015. Secondary sources report that it took effect on 1 January 2016, which is why some pages call it the 2016 edition.
CBAHI's standards page also lists a set of 2016 modified standards for the 3rd edition. They change individual standards rather than starting a new edition. Check that your copy of the manual includes them.
We could not reach cbahi.gov.sa to confirm the position after April 2025. Ask CBAHI which edition and which modifications apply before you start a gap analysis.
Which hospitals can apply for CBAHI accreditation?
Every hospital licensed in Saudi Arabia is eligible. A hospital can only book a survey visit once it meets all of CBAHI's conditions. The main ones are listed below in our own words.
- A valid Ministry of Health licence, a valid Civil Defense certificate, and any radiation licence required by King Abdulaziz City for Science and Technology.
- Inpatient beds for overnight patients, an organised medical staff and continuous nursing under registered nurses.
- Laboratory and radiology services, plus emergency and intensive care.
- At least 12 months of operation before the on-site survey.
The hospital manual does not cover mental health hospitals or long-term care facilities. Our guide to the CBAHI mental health hospital standards covers that sector.
What are the Essential Safety Requirements?
The Essential Safety Requirements (ESRs) are a list of 20 national standards for hospitals. CBAHI also calls them the Essential National Requirements for Patient Safety. A hospital cannot receive accreditation unless it shows full compliance with every one of them at the survey visit, according to CBAHI's patient safety page (archived copy, April 2025).
CBAHI says the list is not final. It draws on earlier hospital evaluations, serious medical errors reported to the Ministry of Health and international patient safety research. Get the current list from CBAHI rather than from an old training slide.
In practice, treat the ESRs as a pass or fail gate. A hospital that scores well across the chapters but misses one ESR is not accredited. A sensible order is to audit the ESRs first, then work through the remaining chapters.
How does a hospital get from registration to survey?
CBAHI describes the pathway on its hospital programme page. The table summarises each step and the evidence a hospital usually keeps for it. The last column is AGS's practical interpretation, not CBAHI's wording.
| Step | What CBAHI asks for | What to have ready |
|---|---|---|
| Registration | The Healthcare Facility Registration Form. CBAHI then sends the National Standards for Hospitals and the Hospital Accreditation Guide | A named accreditation coordinator and a controlled copy of the manual |
| Orientation | Attendance at a free Hospital Orientation Program, strongly encouraged | Attendance records and notes shared with department heads |
| Self-assessment | A self-assessment with CBAHI's Self-Assessment Tool, required for every enrolled hospital | Completed tool, gap list, action plan with owners and dates |
| Mock survey | Recommended but not mandatory | Mock findings and the corrective actions closed since |
| Survey request | Signed service agreement, survey application form and proof of fee payment | Signed copies filed with the application |
| Real survey | Full compliance with all ESRs. At least six months between two real surveys | Policies, records and staff who can explain practice on the day |
The number of attempts is limited. Real surveys must be at least six months apart, and a hospital that uses up its permitted real surveys without accreditation can be excluded from the programme and referred to the relevant authorities.
What do surveyors check in the records?
Surveyors test whether daily practice matches the written policy. The 2016 modified standards, as listed on CBAHI's site in 2017, show the level of detail they look for. Here are four of them, explained in our words.
HR.4 expects a complete, confidential personnel file for every employee, including temporary, visiting, part-time and volunteer staff. Files hold current licensure, the job description, references, training records, performance evaluations and leave records. Check temporary and visiting staff files as carefully as permanent ones.
IPC.15.3.3 sets how often a negative pressure isolation room is validated. It is daily while a patient is isolated and weekly when the room is empty, with at least 12 air changes per hour tested and documented. A surveyor will ask for the validation log, not the design drawing.
FMS.27 expects staff to be trained and tested on the equipment and medical devices they operate, including new devices. LD.8.4 expects leaders to have a process for resolving ethical dilemmas within a reasonable time. Both need records: training sign-offs for FMS.27, and minutes or case logs for LD.8.4.
If your hospital also holds or is seeking JCI accreditation, map the two sets of records once rather than twice. Our guide to JCI hospital accreditation covers the international programme.
Is a new edition of the hospital standards coming?
CBAHI has posted a draft set of hospital standards, titled National Healthcare Priorities, on Istitlaa, the Saudi government's public consultation platform. The draft we read in an archived copy from November 2025 has chapters such as Effective Leadership, Safe Staffing Levels, Stroke Readiness, Acute Coronary Syndrome Readiness and Rapid Response System.
A consultation draft is not in force. Do not build your system on it until CBAHI announces an edition and an effective date. Track it, though, because chapters such as safe staffing would need new records.
How AGS can help
The CBAHI National Hospital (QMS) kit contains 54 editable Microsoft Word documents. It includes a quality manual and 18 procedures, from document control and credentialing to medication management, infection prevention and emergency management. It also has 12 forms, such as an occurrence variance report and an FMEA risk assessment, and 12 checklists, including the WHO surgical safety checklist and a readiness check focused on the ESRs.
Frequently asked questions
Is CBAHI accreditation mandatory for private hospitals?
Yes. CBAHI states that the 2013 Cabinet decree applies to all public and private healthcare facilities. It also says the Ministry of Health makes CBAHI accreditation a prerequisite for renewing an operating licence.
Can a new hospital be surveyed in its first year?
No. CBAHI requires at least 12 months of operation before the on-site survey. A new hospital can register and run its self-assessment during that time.
Where do we get the standards manual?
From CBAHI. Registered hospitals receive the National Standards for Hospitals and the Hospital Accreditation Guide, and CBAHI's overview page explains its role. AGS does not supply the standards text.
Does buying documentation mean the hospital will be accredited?
No. Documents are a starting point. Accreditation depends on how the system is implemented and on CBAHI's survey findings.
AGS provides independent documentation toolkits. This guide and the referenced kit are prepared to support CBAHI requirements. They are not affiliated with, endorsed by or approved by the Saudi Central Board for Accreditation of Healthcare Institutions, and they do not guarantee any survey or accreditation outcome.
Reviewed October 2026. Facts checked against the sources current at publication.
