Illustration on how the CPGs Adaptation Program has helped in quality improvement through compliance with national and international accreditation standards.

1. Compliance with CPGs-related
accreditation standards
(ACI & CBAHI – 2016/2017)
Dr. Yasser S. Amer
Quality Management Department
Medical-City Wide CPGs Steering Committee
Research Chair for Evidence-Based Health Care & Knowledge Translation
With gratitude
Compiled by Mohammed Hussein, Accreditation Unit

2. Current Practice
Best Practice
Clinical Care Gap

3. PROVISION OF CARE
18. Clinical practice guidelines, pathways, and
protocols are developed or adopted to guide
priority care services (CBAHI Ref. PC. 18)
18.1. The hospital implements the national CPGs, pathways,
and protocols that are consistent with current EB practice.
18.2. CPGs, pathways, and protocols are updated at least
every two years and as required with emphasis on the most
common diagnosis.
18.3. CPGs, pathways, and protocols are documented in the
patient’s medical record.

4. CPGs standards in All
Accreditation Chapters
(PCC-15, ICU-13, Cancer-14, DEM-15, MED/PED-13,
OBSGYNE-16, PSYCH-16, OR-27, REHAB-14)
The team bases its services on (the
latest) research, EB-CPGs, and best
practice information to improve quality
of its services.

5. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• CPG Steering/ dept.
committees.
• Adapt/ adopt from
int’l CPGs
• Access: printed/ e-
(offline/online/eSiHi)
• ICity: Academic digital
library
The team has access to
EB-CPGs for _________
services.
(AC-Gold)

6. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Policy
• AGREE II Instrument
(QA) is a main part of
the ADAPTE
methods.
The team follows a
standardized process to
select EB-CPGs for
_________ services.
(AC-Platinum)

7. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Policy: (same) AGREE:
Domains #3
(methods), #5 (App).
• (Different)
(Cochrane)SR/
Evidence synthesis of
several specific CPGs?
The team has a detailed
process to select
between conflicting
EBCPGs, multiple Rs, or
the app of > CPG for
clients with comorbidities.
(AC-Diamond)

8. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Disease-specific
(Adapted CPG)
The team’s assessment
process is based on EB
CPGs.
(AC-Diamond)

9. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Or other CPG
implementation
tools (?)
• Detect/ justify
variation in practice +
link to clinical
outcomes.
The team has care
pathways for the
common diagnoses that
it manages .
(AC-Diamond)

10. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Access:
1. Printed: NSG, Drs.
2. Electronic:
(offline-PC, online-
ICity, eSiHi-
PowerPlans/Forms).
The team has access to
EB CPGs at the point of
care.
(AC-Platinum)

11. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Access:
1. Printed: NSG, Drs.
2. Electronic:
(offline-PC, online-
ICity, eSiHi-
PowerPlans/Forms).
The team has uses CPGs
(& CPs that are based on
CPGs) to standardize the
delivery of ____care
services.
(AC-Platinum)

12. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Adapted CPG:
section for update/
review.
• *2-5 years.
• CPG dept.
committee
The team regularly*
reviews its CPGs to
verify they are up-to-
date and reflect current
research and best
practice info. High priority
(AC-Platinum)

13. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Clinical audit, case
reviews, clinical
rounds &
discussions.
The team’s CPG review
process includes
seeking input from
team members about
CPG applicability &
ease of use .
(AC-Platinum)

14. CPGs’ Sub-standards (Non-CPG!)
EvidenceStandard/ sub-standard
• IRB Policy
• IRB Approvals for all
research activities
available.
The team’s research
activities for ____
services meet applicable
research and ethics
protocols and
standards. High priority
(AC-Diamond)

15. CPGs’ Sub-standards
EvidenceStandard/ sub-standard
• Conferences papers.
• Full-text publications.
• Saudi specialized
Assn's endorsement.
• Special collaboration/
communication (?Ext.
review)
The team shares
research, CPGs and
benchmark info with its
partners & other similar
organizations. Team’s
mandate/scope. High priority
(AC-Diamond)

16. INFECTION PREVENTION & CONTROL
(CBAHI Ref. IPC 39-43) * Area for improvement
• 13.2. The hospital implements EB interventions to prevent VAP*.
• 13.13. The hospital implements EB interventions to prevent SSI.
Two adapted CPGs by SURG SAP (ASHP-13) & NSG SSIP (NICE-11),
HW-QIP.
• 13.14. The hospital implements EB interventions to prevent
CAUTI*.
• 13.15. The hospital implements EB interventions to prevent
CLABSI. Adapted CPG by NSG (CDC-11, INA-11)
• 13.16. The hospital implements EB interventions to reduce the
burden of epidemiologically significant organism (MDROs)*

17. EMERGENCY STANDARDS
• 9.8. The team uses EB protocols to select diagnostic
imaging services for pediatric clients
(DEM/RADIOLOGY)*.
• 11.7. The team uses EB care protocols when providing
emergency department services to clients.

18. CRITICAL CARE
• 7.5. ROP The team identifies medical and surgical clients at risk of
VTE (DVT & PE) and provides appropriate thromboprophylaxis.
Adapted CPG by ICU VTEP (ACCP-12), HWPP, HW-QIP, …
OBGYNE section for pregnant women (obstetric) not CS*!
*MED VTE (T) CPG (ACCP-16) in progress
9.5. There are EB criteria for intubation, weaning off ventilator &
extubation.
9.6. The team follows a protocol when conducting a daily interruption
in sedation ICU CPG in progress.

19. QMD Priority topics:-
Process for Effective identification,
assessment & intervention for patients with:-
•Risk of Pressure ulcers.
•Risk of falling.
•Prevent catheter & tubing
misconnections.