Updates on Accreditation Procedures

• In the event of a serious incident occurring at the healthcare facility or suspicion of it being a serious incident, the General Authority for Healthcare Accreditation and Regulation (GAHAR) must be notified within 48 hours at most from the occurrence of the event or its notification, via the email Sentinel.Event@gahar.gov.eg

• A review of the counterparts should be conducted in cases where required after notifying GAHAR.

• GAHAR must be provided with a root cause analysis of the reasons for the occurrence of the serious incident within 45 days from the date of the error or its notification.

• The application for the facility to register for preliminary licensing is accepted only.

• The request for the remaining essential requirements is postponed until the facility obtains registration with GAHAR and completes the procedures for obtaining final licensing from the Central Administration for Non-Governmental Therapeutic Institutions and Licensing.

• The facility is required to provide the final license as soon as it is obtained from the Central Administration for Non-Governmental Therapeutic Institutions and Licensing.

• A grace period of six months is granted to the facility from the date of obtaining the final license to provide the remaining essential requirements.

It is necessary to provide the following requirements according to Article (3) of the Executive Regulations of the Comprehensive Health Insurance Law No. (2) of 2018, issued by the Prime Minister's Decision No. (909) of 2018:

1. Provision of examination, treatment, and follow-up by a general practitioner or family physician.

2. Referral to specialist doctors and consultants, including those related to dentistry, chronic diseases, and their complications when needed.

3. Examination, treatment, follow-up, and healthcare related to pregnancy, childbirth, newborns, infants, and children before school age.

4. If there is no laboratory in the facility, a contract must be made with an accredited laboratory, providing a room for sample collection. (The contract must be presented during the evaluation visit).

5. If there is no radiology and ultrasound device in the facility, a contract must be made with an accredited radiology center (the contract must be presented during the evaluation visit).

6. Healthcare programs for the disabled and individuals with special needs.

7. There must be a documented referral system with relevant entities for the following services:

   • Referral to specialist doctors and consultants, including those related to dentistry, chronic diseases, and their complications when needed.

   • Rehabilitation services and physical therapy.

External quality control of laboratories is conducted through proficiency testing.

or

Comparing the laboratory under evaluation with an accredited laboratory (Lab To Lab), provided that the accredited laboratory has been accredited according to international or national accreditation standards.

Health facilities applying for provisional accreditation must operate for 3 months prior to accreditation, and health facilities applying for full accreditation must operate for six months prior to accreditation.

When non-governmental / governmental facilities not affiliated with the Ministry of Health and Population or the General Authority for Healthcare Accreditation submit for providing primary healthcare services, the following should be taken into consideration:

1. Combined clinics can apply for primary healthcare standards after providing the following services as a minimum according to Law No. (2) of 2018:

   • Examination, treatment, and follow-up by a general practitioner or family physician.

   • Examination, treatment, and follow-up by doctors, including dentistry and chronic diseases and their complications.

   • Healthcare related to pregnancy and childbirth, newborns, infants, and children before school age.

   • If some other primary healthcare services stipulated by law are not available, it is required:

     • To clarify alternative linking places in the referral system.

     • These entities must be accredited.

     • To provide a document proving this when applying for accreditation.

     • The service provider must have specialized training in primary healthcare services from an accredited entity, according to the Primary Healthcare Facility Standards Guide issued by GAHAR.

When a healthcare facility requests to postpone the evaluation visit from the scheduled date:

• 10% of the accreditation or preliminary accreditation fees will be added for each month of postponement.

• The maximum postponement period is three months.

• This does not apply to the first visit for accreditation.

  8. Request for Professional Practice License for Clinical Technologist for Laboratory Directors in Government Laboratories and University Facilities

  • The professional practice license for medicine is accepted without the requirement to present a professional practice license for medical analyses.

  • It is sufficient to present the assignment decision as a laboratory manager issued by the facility management.

  9. تقديم صورة من التعاقد مع مقدمي الخدمة بالمراكز الطبية المتخصصة والصيدليات والعيادات الخاصة

  • يتم تقديم صورة التعاقد بدون القيمة المالية.

  10. Addition of Standards for Basic Requirements and Conditions (APCs)

  Standards (APCs) have been added to the Provisional Accreditation Standards, becoming part of the facility's evaluation during the assessment visit.

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  11. Scope of Services and Standards Included in the Evaluation Process during Assessment Visits

  All services contracted within the healthcare facility and following external entities are subject to evaluation by the reviewers.