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Quality Assurance Center

Quality Assurance Center

Quality Assurance Center
Dr.Qamra Said Al Sariri
DG of Quality Assurance Center
The Ministry of Health (MOH) in the Sultanate of Oman is devoted to protecting the health of all citizens and residents. They address health and disease challenges, develop the health sector, ensure efficient resource use, and strive for a healthy society free of health risks and hazards. Their vision for 2024 is that "Health is the responsibility of all." The Quality Assurance Center at MOH is committed to the following: • Enhance long-term success by understanding and meeting the needs and expectations of all stakeholders to support and strengthen the quality of healthcare services. • Ensure the quality and safety of healthcare services by implementing Oman's national quality standards in alignment with statutory and regulatory requirements. • Build the capacity of healthcare workers in the field of quality and patient safety. • Promote Quality studies, research, and innovation that positively impact health services. • Reinforce patient and community engagement in different patient services • Support Strategic Direction and interested parties to provide advanced evidence-based practices through a process-based approach. • Collaborating with a diverse range of national and international organizations to ensure patients and the community receive evidence-based care.
Mission

The Quality Assurance Center (QAC) to be the national reference body in healthcare quality and patient safety that meets international standards

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Vision

The Quality Assurance Center (QAC) is working to raise the level of quality of healthcare services and patient safety in all Ministry of Health institutions in collaboration with these institutions through the application of international standards appropriate to the local realities.

Read More
History

In light of the significant growth of the Ministry of Health in terms of the number of healthcare institutions, employees, and the quality of services provided, it was necessary to establish a unit that focuses on assessing healthcare services, and resources, and enhancing performance at all levels. As a result, the decision to establish the Directorate General of Quality Assurance Center was made in 2014 to align with the Ministry's ambitious strategic plan for 2050. The Quality Assurance Center aims to become a global benchmark for healthcare quality and patient safety. It seeks to enhance the quality of healthcare services and patient safety in all Ministry of Health institutions by implementing national standards for healthcare in Oman.

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Services

Services Provided

Department of Accreditation and Standards Development

Department of Accreditation and Standards Development

The accreditation and standards development department under the National healthcare accreditation committee's supervision is dedicated to developing and sustaining the Oman healthcare Accreditation system to ensure the provision of people-centred and safe health services in all healthcare institutions in the Sultanate of Oman. The department has thoroughly reviewed the current approved standards, arranged for an international experts’ revision of the current standards and arranged and actively involved in the training of the national assessors, arranged and been actively engaged in the national standards piloting and evaluation in different hospitals in the country, arranged for national experts’ revision of the standards, and who contributed greatly to reach to this level of achievement. The current Omani standards are consequences of extensive work and effort by various expert stakeholders and competent professionals from different specialties in health sector in Oman. The accreditation and standards development department acknowledges the enormous and outstanding efforts made by the technical working teams; who developed the standards. The department also would like to express its sincere gratitude for the trained assessors who contributed in the evaluation and implementation of the national standards in different hospitals in Oman. The department is also delighted to extend its warm regards and great appreciations to all healthcare institutions, health authorities, the general public, governmental and non-governmental hospitals, and private hospitals for their valuable inputs, comments, and recommendations that were of considerable value for developing the current national standards. Last but not least, bearing in mind the fact that healthcare is dynamic and complex; the accreditation and standards development department under the supervision of the National Healthcare Accreditation Committee is committed to ensuring that the current standards will be regularly updated as per the international accrediting organization and as per the emerging needs and requirements.

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Department of Document Development and Control

Department of Document Development and Control

This department works on: 1. Ensure the Health Care institutions follow the approved national guidelines to develop documents. 2. Adopting all types of documents used in healthcare institutions 3. Supervising the periodic updating of documents used in healthcare institutions to commensurate them with the new updates in the field of document management 4. Determining the principles and criteria to measure the progress and development of quality management system implementation in the healthcare services system in coordination with the concerned authorities

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Department of Patient Safety and Risk Management

Department of Patient Safety and Risk Management

This department works on: 1. Establishing programs of training and awareness for all employees in healthcare institutions in the field of patient safety, incident reporting and risk management 2. Establishing valid and reliable indicators to assess the level of patient safety and risk management in healthcare institutions 3. Establishing a national system for reporting of risks in all healthcare institutions 4. Supervising and following up the incident reporting system (AMAN) in collaboration with the departments of quality management and patient safety in healthcare institutions and directorate-general of health services in the governorates, and monitoring the implementation of corrective action plan. 5. Implementation of WHO Patient Safety Friendly Hospitals & Primary Health Care Institutions Framework, training of institutions and follow up in the Sultanate of Oman. 6. Conducting Research in the field of patient safety, incident reporting and risk management. 7. Supervising the activities and the Celebration of the annual National and International Patient Safety Day.

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Department of Quality of Health Services Assessment and Improvement

Department of Quality of Health Services Assessment and Improvement

This department works on: 1. Establishing valid and reliable indicators to assess the quality management system in collaboration with various sections 2. Using the indicators regularly to assess the application of the quality management system and evaluate the quality of healthcare services and patient safety 3. Following up continuously on the latest developments in the field of healthcare quality and sharing them with healthcare institutions 4. Evaluating and establishing modern and convenient pathways to deal with the obstacles that hinder the development of healthcare quality and patient safety 5. Evaluating the professional training needs in the area of healthcare quality and patient safety for employees in the healthcare institutions in cooperation with those institutions; to design a training plan that fits those needs

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Projects

Ongoing
Oman National Accreditation System

-Preparing the technical teams with their terms of reference who will carry out the implementation of the national accreditation standards. -Preparing for the Oman Healthcare Accreditation System awareness and training workshops. -Preparing for the Coaching training program for the nationally trained assessors. -Preparing for the implementation of the Oman Healthcare Accreditation System Standards. -Preparing an international contract with international accreditation organizations.

Ongoing
WHO-EMRO Patient Safety Friendly Hospital and Primary health Care Framework

Implementing the WHO framework for hospitals and primary health care institutions to enhance patient safety

Ongoing
Scientific researches

To improve the service provided to patients, ensure their safety and find opportunities for improvement, many kinds of research are currently being worked on. • Research on the results of the implementation of the WHO Patient Safety Friendly Hospital Initiative in the Sultanate of Oman • Research on health workers' knowledge and current practices on clinical risk management • Research on employee culture about patient safety • Research on the causes of medication errors reported in the AMAN system • Research on the causes of delays in procedures reported in the AMAN system.

Ongoing
Quality Documentation Audit

• To Audit the process of documentation ( Guideline for Document Development - Version 2 ) centrally, regional and hospitals

Ongoing
Health Services Assessment and Improvement

• Monitoring the implementation of the ISO 9001:2015 Quality Management System in central Directorates. The system has been fully implemented in the following Directorates: Directorate General of Administrative Affairs, Directorate General of Financial Affairs, Directorate General of Engineering and Projects, Directorate General of Pharmacy and Pharmaceutical Control, Directorate General of Medical Supplies, and Directorate General of Private Health Institutions. • Reduce waiting time in emergency departments in hospitals • Best utilization of outpatient department appointments by reducing defaulter rate in OPD in Hospitals

Future
Oman National Accreditation System

- Implementation of the Oman Healthcare Accreditation System by the end of 2024.

Future
Introducing the concept of patient engagement in healthcare service

Introducing the concept of patient engagement in healthcare service

Future
Implementation of the incident reporting system (AMAN) in private health institutions

The project aims to standardize the incident reporting system in all health institutions in the Sultanate of Oman (government and private).

Future
Create an electronic record for clinical risk management that contains

Create an electronic record for risk management containing a record of corrective plans and a form for analyzing the impact of failure situation

Future
Updating the Employee Culture Study Questionnaire on Patient Safety

The questionnaire will be updated and entered into the Ministry's electronic data collection system (E.Survey)

Future
Automation of WHO Patient Safety Framework Standards (A-E) for Hospitals and Primary Health Care

This is to facilitate the evaluation process and entering of the grades electronically

Future
Automation of the Plan of Implementation of WHO Patient Safety Framework 2021-2030

This will help to monitor the implementation of the plan in Sultanate of Oman

Future
Health Services Assessment and Improvement

Monitoring the implementation of the ISO 9001:2015 Quality Management System in central Directorates. Implementation of the system will be completed in the following Directorates: Directorate General of Internal Audit, Quality Assurance Center, and Directorate General of Information Technology. • Create automated KPIs through the dashboard • Launching patient engagement by studying defaulter rates in OPD at hospitals. • National standard of KPIs benchmarking.

About Us


Values

Our values at the Quality Assurance Center are: 1. Commitment to the improvement of the quality of healthcare and patient safety services. 2. Team spirit 3. Creativity and innovation in the field of healthcare quality and patient safety 4. Professionalism in dealing and cooperation 5. Mutual trust 6. Transparency in dealing and cooperation

Last updated on : 09 October 2024 - 12:32 PM

Mission

The Quality Assurance Center (QAC) to be the national reference body in healthcare quality and patient safety that meets international standards

Read More
Vision

The Quality Assurance Center (QAC) is working to raise the level of quality of healthcare services and patient safety in all Ministry of Health institutions in collaboration with these institutions through the application of international standards appropriate to the local realities.

Read More
History

In light of the significant growth of the Ministry of Health in terms of the number of healthcare institutions, employees, and the quality of services provided, it was necessary to establish a unit that focuses on assessing healthcare services, and resources, and enhancing performance at all levels. As a result, the decision to establish the Directorate General of Quality Assurance Center was made in 2014 to align with the Ministry's ambitious strategic plan for 2050. The Quality Assurance Center aims to become a global benchmark for healthcare quality and patient safety. It seeks to enhance the quality of healthcare services and patient safety in all Ministry of Health institutions by implementing national standards for healthcare in Oman.

Read More

Ongoing Projects


Oman National Accreditation System

-Preparing the technical teams with their terms of reference who will carry out the implementation of the national accreditation standards. -Preparing for the Oman Healthcare Accreditation System awareness and training workshops. -Preparing for the Coaching training program for the nationally trained assessors. -Preparing for the implementation of the Oman Healthcare Accreditation System Standards. -Preparing an international contract with international accreditation organizations.

WHO-EMRO Patient Safety Friendly Hospital and Primary health Care Framework

Implementing the WHO framework for hospitals and primary health care institutions to enhance patient safety

Scientific researches

To improve the service provided to patients, ensure their safety and find opportunities for improvement, many kinds of research are currently being worked on. • Research on the results of the implementation of the WHO Patient Safety Friendly Hospital Initiative in the Sultanate of Oman • Research on health workers' knowledge and current practices on clinical risk management • Research on employee culture about patient safety • Research on the causes of medication errors reported in the AMAN system • Research on the causes of delays in procedures reported in the AMAN system.

Quality Documentation Audit

• To Audit the process of documentation ( Guideline for Document Development - Version 2 ) centrally, regional and hospitals

Health Services Assessment and Improvement

• Monitoring the implementation of the ISO 9001:2015 Quality Management System in central Directorates. The system has been fully implemented in the following Directorates: Directorate General of Administrative Affairs, Directorate General of Financial Affairs, Directorate General of Engineering and Projects, Directorate General of Pharmacy and Pharmaceutical Control, Directorate General of Medical Supplies, and Directorate General of Private Health Institutions. • Reduce waiting time in emergency departments in hospitals • Best utilization of outpatient department appointments by reducing defaulter rate in OPD in Hospitals

Future Projects


Oman National Accreditation System

- Implementation of the Oman Healthcare Accreditation System by the end of 2024.

Introducing the concept of patient engagement in healthcare service

Introducing the concept of patient engagement in healthcare service

Implementation of the incident reporting system (AMAN) in private health institutions

The project aims to standardize the incident reporting system in all health institutions in the Sultanate of Oman (government and private).

Create an electronic record for clinical risk management that contains

Create an electronic record for risk management containing a record of corrective plans and a form for analyzing the impact of failure situation

Updating the Employee Culture Study Questionnaire on Patient Safety

The questionnaire will be updated and entered into the Ministry's electronic data collection system (E.Survey)

Automation of WHO Patient Safety Framework Standards (A-E) for Hospitals and Primary Health Care

This is to facilitate the evaluation process and entering of the grades electronically

Automation of the Plan of Implementation of WHO Patient Safety Framework 2021-2030

This will help to monitor the implementation of the plan in Sultanate of Oman

Health Services Assessment and Improvement

Monitoring the implementation of the ISO 9001:2015 Quality Management System in central Directorates. Implementation of the system will be completed in the following Directorates: Directorate General of Internal Audit, Quality Assurance Center, and Directorate General of Information Technology. • Create automated KPIs through the dashboard • Launching patient engagement by studying defaulter rates in OPD at hospitals. • National standard of KPIs benchmarking.

Services List


Department of Accreditation and Standards Development

Department of Accreditation and Standards Development

The accreditation and standards development department under the National healthcare accreditation committee's supervision is dedicated to developing and sustaining the Oman healthcare Accreditation system to ensure the provision of people-centred and safe health services in all healthcare institutions in the Sultanate of Oman. The department has thoroughly reviewed the current approved standards, arranged for an international experts’ revision of the current standards and arranged and actively involved in the training of the national assessors, arranged and been actively engaged in the national standards piloting and evaluation in different hospitals in the country, arranged for national experts’ revision of the standards, and who contributed greatly to reach to this level of achievement. The current Omani standards are consequences of extensive work and effort by various expert stakeholders and competent professionals from different specialties in health sector in Oman. The accreditation and standards development department acknowledges the enormous and outstanding efforts made by the technical working teams; who developed the standards. The department also would like to express its sincere gratitude for the trained assessors who contributed in the evaluation and implementation of the national standards in different hospitals in Oman. The department is also delighted to extend its warm regards and great appreciations to all healthcare institutions, health authorities, the general public, governmental and non-governmental hospitals, and private hospitals for their valuable inputs, comments, and recommendations that were of considerable value for developing the current national standards. Last but not least, bearing in mind the fact that healthcare is dynamic and complex; the accreditation and standards development department under the supervision of the National Healthcare Accreditation Committee is committed to ensuring that the current standards will be regularly updated as per the international accrediting organization and as per the emerging needs and requirements.

Read More

Department of Document Development and Control

Department of Document Development and Control

This department works on: 1. Ensure the Health Care institutions follow the approved national guidelines to develop documents. 2. Adopting all types of documents used in healthcare institutions 3. Supervising the periodic updating of documents used in healthcare institutions to commensurate them with the new updates in the field of document management 4. Determining the principles and criteria to measure the progress and development of quality management system implementation in the healthcare services system in coordination with the concerned authorities

Read More

Department of Patient Safety and Risk Management

Department of Patient Safety and Risk Management

This department works on: 1. Establishing programs of training and awareness for all employees in healthcare institutions in the field of patient safety, incident reporting and risk management 2. Establishing valid and reliable indicators to assess the level of patient safety and risk management in healthcare institutions 3. Establishing a national system for reporting of risks in all healthcare institutions 4. Supervising and following up the incident reporting system (AMAN) in collaboration with the departments of quality management and patient safety in healthcare institutions and directorate-general of health services in the governorates, and monitoring the implementation of corrective action plan. 5. Implementation of WHO Patient Safety Friendly Hospitals & Primary Health Care Institutions Framework, training of institutions and follow up in the Sultanate of Oman. 6. Conducting Research in the field of patient safety, incident reporting and risk management. 7. Supervising the activities and the Celebration of the annual National and International Patient Safety Day.

Read More

Department of Quality of Health Services Assessment and Improvement

Department of Quality of Health Services Assessment and Improvement

This department works on: 1. Establishing valid and reliable indicators to assess the quality management system in collaboration with various sections 2. Using the indicators regularly to assess the application of the quality management system and evaluate the quality of healthcare services and patient safety 3. Following up continuously on the latest developments in the field of healthcare quality and sharing them with healthcare institutions 4. Evaluating and establishing modern and convenient pathways to deal with the obstacles that hinder the development of healthcare quality and patient safety 5. Evaluating the professional training needs in the area of healthcare quality and patient safety for employees in the healthcare institutions in cooperation with those institutions; to design a training plan that fits those needs

Read More

Content Resources


Patient Safety Assessment Manual for Primary Care

The Patient Safety Assessment Manual for Primary Care explains how to apply the Patient Safety Friendly Primary Care Framework, which consists of 19 standards based on international research and evidence-based practices. The WHO Regional Office developed the framework for the Eastern Mediterranean to assess patient safety at a system level and promote safer care. It provides a way to determine the patient safety level and initiate a patient safety or quality improvement program. The evaluation is voluntary and is conducted through self-assessment and an external peer review survey.

WHO-EMRO Patient Safety Friendly Hospital Assessment Manual 3rd edition

The Patient Safety Assessment manual was first published in 2011, revised in 2015, and the second edition was published in 2016. It includes a set of standards that cover different domains of patient safety. The information on the standards is continuously collected and reflects current healthcare practices and evidence-based interventions. The corresponding criteria are revised every three to four years. In the third edition, the total number of assessment criteria is 134, compared to 139 in the second edition. Similar requirements have been combined into single standards and the wording of some standards has been modified. Other standards have been added based on their importance for patient outcomes and aligned with WHO initiatives to promote patient safety. This manual is the result of collaborative work between the WHO Regional Office for the Eastern Mediterranean and regional experts.

National Document of Patient Rights and Responsibilities (Poster)

National document of patient rights and responsibilities posters.

National Document of Patient Rights and Responsibilities (Booklet)

National document of patient rights and responsibilities booklet.

Rejection of Assault of Healthcare Workers (Poster)

Rejection of assault of healthcare workers poster. ( Stop Violence against Health Works)

Leadership Walk-Round Guideline

Leadership Walk-Rounds is an improvement tool designed to assist healthcare institution leaders in implementing mechanisms for promoting safety, learning about and hearing the concerns of front-line providers, supporting appropriate accountability concepts, and allocating resources to areas of greatest risk. It is also used to engage senior managers and frontline staff together to have quality conversations with a purpose to prevent, detect and mitigate patient/staff harm. It helps to build a culture of safety and trust within the organization

Management Review Procedure

The healthcare system must balance customer needs and available resources. The Management Review (MR) meeting is a global tool for cost-effective quality management, ensuring that all levels of management are informed about quality-related functions.

Policy and procedures of Informed Consent

This policy is compulsory and the MOH mandates all healthcare providers to ensure compliance with the legal and ethical standards outlined within this policy, in obtaining Informed Consent from patient/legally authorized representatives.

Policy and Procedures of Patient of Patient Identification

The success of many treatments and activities within the healthcare institution depends on ensuring that correct patient identity has been established. Patient identification is an essential stage in care processes as there could be significant consequences if an error is made.

Policy and procedures of Safe Surgery: Pre- Operative communication

Ensuring that all pre-operative criteria are met for each patient before undergoing a surgical procedure and patient information are communicated correctly when transfer to Operating Room

Policy and Procedure of Safe Surgery: Ensure Correct Patient, Procedure, and Site for Invasive/ Surgical procedure

A national guideline for verification of correct site, correct procedure, and correct patient for invasive/surgical procedures(s).

Integrated Risk Management guideline

Risk management in healthcare involves a complex set of clinical and administrative systems, processes, procedures, and reporting structures. It is designed to detect, monitor, assess, mitigate, and prevent risks to patients.

Policy and Procedures of Employees Satisfaction Survey

The satisfaction of healthcare providers is crucial for addressing inefficient policies and procedures that can lead to employee dissatisfaction. The Ministry of Health has designed a satisfaction program to obtain feedback from health providers and employees through surveys. The surveys cover overall satisfaction, respect and fairness, leadership, supervision, management, work environment, and likelihood to recommend, as well as providing an opportunity for narrative comments.

Policy and Procedures of Patients Satisfaction Survey

Satisfaction is a subjective feeling that encompasses individual perceptions, expectations, and experiences. It is a crucial measure of healthcare quality, influencing the delivery of patient-centered care. The healthcare system aims to provide equitable, effective, and accessible services to improve patient satisfaction levels. Understanding patient satisfaction and factors contributing to dissatisfaction can guide the Ministry of Health and the healthcare sector in addressing system gaps and enhancing overall population health.

Policy and Procedures of Workplace Violence Prevention

Workplace violence is a growing concern, especially for healthcare workers. It includes verbal abuse, physical assault, and threats of assault. Types of workplace violence include physical violence, such as assault, as well as psychological violence like bullying, harassment, and threats.

Patient Engagement Framework

Involving patients and families in decision-making, policies, and quality improvement projects can help create a more responsive and innovative care system. This can lead to improved health outcomes, reduced safety incidents, shared accountability, better patient management, increased participation in studies, and lower per capita costs."mprove health outcomes, reduce safety incidents, and lower costs.

General Behavior Regulation within Health Institutions ( Poster)

A Poster Highlighting the General Behavior Regulation of the Public within Health Institutions

Oman Healthcare Accreditation Standards

The Oman Healthcare Accreditation System (OHAS) is a national system that promotes safe and quality care in healthcare institutions. It supports institutions in implementing and adhering to national standards through activities such as developing the accreditation manual, conducting awareness sessions, facilitating self-assessment, and performing on-site assessments. OHAS also provides consultation, guidance, and continuous education for accreditation, along with updating policies and guidelines.

Key Performance Indicators ( KPIs) Guidelines

The Quality Assurance Centre ensures patient safety and enhances quality management in healthcare. It monitors performance using performance indicators to identify areas for improvement. This document guides using this information to promote safety and quality improvements.

The Guideline for Document Development Version 2

The Quality Assurance Center (QAC) has issued this guideline to standardize document development across all levels of healthcare at the Ministry of Health. Changes in this version include the addition of chapters, the use of different templates, and the introduction of a pre-implementation piloting phase for selected national documents to assess practicality before final approval.

Policy & Procedure of Incident Reporting & Learning System (IRLS) for Aman System

The Incident Report and Learning System (IRLS) promotes safety in healthcare institutions by reporting and learning from all types of incidents. The Ministry of Health supports it and aims to minimize the impact on patient care and hospital operations. The IRLS policy emphasizes the importance of reporting incidents and guides the process of investigating and learning from them. Purpose To provide a systematic and standardized mechanism for identifying potential and actual safety incidents, and to develop strategies to minimize their occurrence, establish effective actions, and facilitate communication, response, learning, and system improvement. Scope This document applies to all healthcare institutions in Oman, including both government and private sectors.

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World and National Patient Safety Days


The 7th National Month and the 6th World Patient Safety Day 2024

Contact Numbers and Locations


Address

The QAC offices located in the Ministry of Health main building in the AL Khuwair

Office Numbers
22357206 - 22357207
dgqac-office@moh.gov.om
Opening Hours
Closed - Show working hours
Monday
7:30 AM-2:30 PM
Tuesday
7:30 AM-2:30 PM
Wednesday
7:30 AM-2:30 PM
Thursday
7:30 AM-2:30 PM
Sunday
7:30 AM-2:30 PM
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