GAHAR scores each evidence of compliance met at 80% or more over the lookback period, partially met at 50% to under 80% and not met below 50%, then averages standards and chapters. Three-year accreditation needs 80% overall, every chapter at 70% or more and no GAHAR Safety Requirement standard unmet.
Three levels of scoring
Each evidence of compliance scores 2 when the facility shows 80% or more compliance during the lookback period, 1 at 50% to under 80%, and 0 below 50%, and anything outside the facility's scope is removed from both sides of the sum.1 A standard is met when the average of its applicable evidence is 80% or more, and each chapter scores the average of its standards.1 Some evidence depends on other evidence, so a policy that is missing can pull down the staff awareness and the practice that rest on it.1
The four decisions
| Decision | Overall | Chapters and standards | Validity |
|---|---|---|---|
| Accreditation | 80% or more | Every chapter 70% or more, one whole standard not met at most, no GSR not met | 3 years |
| Conditioned accreditation | 70% to under 80% | Chapters 60% or more, up to one standard not met per chapter, no GSR not met | 2 years |
| Conditioned accreditation | 60% to under 70% | Chapters 50% or more, up to two standards not met per chapter, no GSR not met | 1 year |
| Rejection | Under 60% | A chapter under 50%, more than two standards not met in a chapter, or any GSR not met | None |
A facility with unmet evidence sends GAHAR a corrective action plan within 90 days after the first decision, 60 days after the second and 30 days after the third, and a conditioned facility must pass a new survey within two years or one year.1 Provisional accreditation scores the same way, weights the safety requirements at 45%, the essential quality requirements at 45% and the operating manual at 10%, and needs 80% in each section for one year.2
- List the applicable standards. Mark what is out of scope, so it leaves the sum as it will on the day.
- Start with the 21 GSRs. Any GSR standard not met rules out every level of accreditation, so score them first.
- Sample the lookback period. Pull records from across the last four months, never only last week's.
- Score each evidence 2, 1 or 0. Use GAHAR's own thresholds of 80% and 50%.
- Average by standard and chapter. Find any chapter under 70% and any standard not met.
- Fix and rescore. Write the corrective action, give it an owner and a date, and score again a month later.
- Standard ______ Chapter ______ GSR ______
- Evidence of compliance ______
- Sample size ______ Compliant ______ Percentage ______
- Score 2, 1 or 0 ______ Not applicable ______
- Standard average ______ Chapter average ______
- Corrective action ______ Owner ______ Due ______
Questions
Can one safety requirement stop accreditation?
Yes, a single GAHAR Safety Requirement standard scored not met leads to rejection, whatever the overall score.
How long is conditioned accreditation?
Two years at 70% to under 80% overall and one year at 60% to under 70%, each with a new survey to pass in that time.
When is the corrective action plan due?
Within 90 days after the first decision, 60 days after the second and 30 days after the third, sent to GAHAR.
Does Law No. 2 of 2018 set how long accreditation lasts?
Article 30 of the law says accreditation certificates are valid for three years and can be renewed, suspended or cancelled.
Sources
- 1General Authority for Healthcare Accreditation and Regulation (GAHAR), 2025GAHAR Handbook for Primary Healthcare Accreditation Standards, 2025, second editionRead source
- 2General Authority for Healthcare Accreditation and Regulation (GAHAR), 2025GAHAR Handbook for Primary Healthcare Provisional Accreditation Standards, 2025Read source
- 3Universal Health Insurance Authority (UHIA), 2018Law No. 2 of 2018 issuing the Universal Health Insurance System Law, Official Gazette issue 2 continued (b), 11 January 2018Read source
Written by the wai team from General Authority for Healthcare Accreditation and Regulation guidance, checked on 16 October 2026. This is guidance, not legal advice. GAHAR does not endorse wai or any software.