CBAHI/JCI Assessment

Central Board for Accreditation of Healthcare Institutions (CBAHI) has introduced a national standard for hospitals. Facility Management and safety (FMS) sections covers the following sections.
  • Safety of the Building
  • Security
  • Hazardous materials and waste disposals
  • Emergencies (Internal & External)
  • Fire Safety
  • Medical Equipment
  • Utility System
  • Joint Commission International (JCI) Accreditation Standards for Hospitals. Safety Management Program based on JCI standard requirements that cover the following sections
  • Leadership and Planning
  • Safety and Security
  • Hazardous Materials
  • Disaster Preparedness
  • Fire Safety
  • Medical Technology
  • Utility Systems
  • Facility Management Program Monitoring
  • Staff Education


Total Safety Quality Center (TSQC) offers business management consulting services to organizations of all nature and size.&!&&!& Total Safety Quality Center (TSQC) specialist consultants provides Quality, Health & Safety, Environment, and Food Safety consulting, training, auditing, and related management consultancy services designed for the unique personality of any organization.&!&&!& The aim here is to generate procedures, protocols and documentation for Facility Management & Safety (FMS) based on CBAHI/JCI standard requirements and that that accurately reflect the hospital and its activities and to ensure that the requirements of the said standards are implemented and properly embedded in the hospital and in the minds and attitudes of its employees

Scope of Work

Total Safety Quality Center (TSQC) specialist consultants shall provide Facility Management & Safety (FMS) Consultancy based on CBAHI/JCI standard

Project Kick-off Meeting: An initial kick of meeting will be conducted with the organization detailing the steps of achieving the CBAHI/JCI standard Certification, its benefits and expectations.

Core Team Formation: A FMS core team shall be formed for the project execution. Consultants will assist the management in the selection process of the FMS Team Leader and other core team members.

Gap Analysis: Consultants shall conduct a comprehensive assessment-Health Safety and Environment Inspection of the hospital facility – to identify the strength and weakness of the client’s work activities and facility by assessing and analyzing the current status of the client’s work activities/facility to ensure compliance to applicable CBAHI/JCI Standard requirements. Inspection will cover facility safety requirement such as alarm systems, fire-extinguishing systems, firefighting system etc... The Inspection will identify the part of the system that can be considered for FMS development as well not complying areas.

System Development: TSQC consultant will design and develop the necessary required documents as per the gap analysis and review of Client’s existing system and documents. This involves providing assistance in preparing and developing the Facility Management & Safety (FMS) Program based on the CBAHI /JCI standard requirements. The documents shall be subjected to the client for review and approval.

Training: TSQC consultant provide FMS awareness training to the staff for enhancing the staff’s awareness and effectiveness of system implementation

System Implementation: TSQC Consultants shall assist the client in the system implementation.

Evaluation and Monitoring – Advice & Guidance: The client organisation may encounter problems if the staff or the contractors do not follow safety standards. The consultants shall provide assistance in evaluating the contractor safety requirement and providing advice and guidance for the new projects with respect to safety requirements.

Emergency Preparedness and Response: Consultant shall assist in the emergency response team formation and also in conducting the mock drills at defined intervals.

FMS Management Review Assistance: TSQC Consultancy shall support and guide the core team during the management review to enable proper conduct of meeting covering all required agenda items and management reporting.

Time Requirement

The time required to complete such projects are subjected to the resources that the client will provide in terms of commitment and participation, the size of organization and type of activities, the complexity of processes and their interactions, and the competence of personnel

Time requirement for project completion will be agreed once the determining factors have been assessed. Normally a small project can be completed within 6-12 month.

CONSULTANCY STEPS - Hospital Project

Project Kick Off Meeting
Formation of FMS Committee
Gap Analysis / Facility Inspection
FMS Development
Training & Awarness
Implementation Assistance
Emergency Response Preparation / Mock Drills
Committee Review Meeting