Oman MOH four-monthly self assessment procedure template

1Purpose

1. 1.1This procedure sets out how [Clinic name] runs the DHA self inspection checklists every three months, and closes what they find.

2Before each self inspection

1. 2.1[Name, role] owns the self inspection for the quarter, and books the date in [month] of each quarter.
2. 2.2The owner downloads the current DHA checklists for the facility type, so the clinic always inspects against the latest version.

3Running it

1. 3.1The owner walks each checklist item with the person responsible for that area, and records the finding and the evidence seen.
2. 3.2Five patient files are read cold for completeness, signature, consent and results.
3. 3.3Every professional's DHA licence and privileges are checked against the work they did this quarter.

4After it

1. 4.1Each gap gets an action, an owner and a date, and the checklist is signed and kept.
2. 4.2Gaps from the previous quarter are checked as closed before the new checklist is signed.
3. 4.3The medical director reviews the result and signs it off.

5Review

1. 5.1The medical director reviews this document every [12] months, and sooner after an incident, a complaint or a change in the regulator's requirements.
2. 5.2Each review is recorded with the date, the reviewer and what changed, and the previous version is kept.
3. 5.3Staff are told of each change, and their acknowledgement is recorded.

6Where this sits in the Oman MOH framework

• Supervision and inspectionSelf assessment by the establishment every four months
  Periodic assessment