Beruflich Dokumente
Kultur Dokumente
2016-2017
Version (1)
Ministry of Public Health
Published ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Ministry of Public Health, Qatar P.O. Box 42 Doha, State of Qatar
www.MOPH.gov.qa
Printed in Qatar, ‐‐‐‐‐‐‐‐‐
Table of Contents
1.0 Introduction: ............................................................................................................................ 1
1.1 Overview of the National Healthcare Facilities Licensing and Accreditation Program ............... 1
1.2 Benefits of an Integrated National Healthcare Facilities Licensing and Accreditation: ............... 2
2.0 Overview of the Licensing Process: ........................................................................................... 2
2.1 Development of licensing Standards: .......................................................................................... 3
2.2 Core Bundles of Licensing Standards and Requirements according to the Facility type: ............ 3
2.3 Structure/Components of a Licensing standard: ......................................................................... 5
2.4 Licensing Process: ........................................................................................................................ 1
2.4.1 Registration ........................................................................................................................... 1
2.4.2 Initial licensing Assessment .................................................................................................. 1
2.4.3 Final licensing Assessment .................................................................................................... 2
2.4.4 Annual Licensing Renewal Assessment ................................................................................. 4
2.4.5 Ad‐Hoc Inspections ............................................................................................................... 5
2.5 Licensing Evaluation Process: ...................................................................................................... 6
2.6 Decision Process:.......................................................................................................................... 6
2.6.1 Decision Criteria for Initial, Final, Renewal and Ad‐Hoc Assessment ................................... 6
2.6.2 Risk Matrix Tool: ................................................................................................................... 7
2.7 Payment: ...................................................................................................................................... 9
3.0 Health Center Licensing Standards: ........................................................................................ 11
3.1 Initial Assessment: High Risk Licensing Standards ..................................................................... 13
3.2 Initial Assessment: Licensing Standards: ................................................................................... 27
3.3 Final Assessment: High Risk Licensing Standards: ..................................................................... 71
3.4 Final Assessment: Licensing Standards ...................................................................................... 81
3.5 Renewal and Ad‐Hoc Assessment: High Risk Licensing Standards .......................................... 110
3.6 Renewal and Ad‐Hoc Assessment Licensing Standards: .......................................................... 121
4.0 Glossary ............................................................................................................................... 158
5.0 References: .......................................................................................................................... 161
6.0 Attachments: ....................................................................................................................... 166
6.1: Facility Guidelines ................................................................................................................... 166
6.2: Healthcare Facilities Licensing Process Flow chart ................................................................. 171
6.3: Registration Application: ................................................................................................... 179
6.4: Role of Licensing Specialist ..................................................................................................... 183
6.5: Initial Assessment Application ................................................................................................ 184
6.6: Role of Inspector ..................................................................................................................... 185
6.7: Decision Committee (DC) Terms of Reference (TOR) ............................................................. 187
6.8: Final Assessment Application ................................................................................................. 190
6.9: Renewal Assessment Application ........................................................................................... 191
6.10: Fees for approved health services ........................................................................................ 192
7.0 Appendices: ......................................................................................................................... 193
7.1: Point of Care Testing Services ................................................................................................. 193
7.2: Crash Cart Check List ............................................................................................................... 194
7.3: Initial Assessment Guidelines ................................................................................................. 196
7.4: Dialysis Unit Design Guidelines ............................................................................................... 213
7.5: Rehabilitation Unit – Functional Relationship Diagram .......................................................... 216
Foreword
The new Licensing program has been integrated with the Accreditation Program. The Licensing
Program has developed a new set of basic requirements related to the regulatory standards in
planning, design, construction, and commissioning of capital projects. The standards apply to various
types and sizes of health care facilities, which will enhance the current licensing standards and
procedures and link them to the Accreditation standards for Healthcare facilities as a single program
for the state of Qatar. The licensing standards are interwoven and has been considered as a first stage
of the process. This will enable the healthcare facilities to achieve their licensed status and be ready
for the next step of accreditation process, which is higher level of continuous Quality Improvement.
These will be two distinct processes but owned by the same authority in an attempt to have a single
healthcare facility regulator. A unique program that stimulates Healthcare Quality Research is aligned
with International Society for Quality in Healthcare (ISQua) Accreditation principles.
The Licensing Standards Manual provides an overview of how the Healthcare Facilities can obtain a
license status from the Healthcare Facilities Licensing and Accreditation Department, Ministry of
public health. It is inclusive of the Licensing assessment process, Standards, and related Decision
Guidelines, which define whether a healthcare facility will receive a license to officially operate either
in the early establishment or existing premises.
This document presents the different aspects of the program and outlines the process for each step
of Licensing for healthcare facilities, including different types of assessment and the application of
Licensing Standards and Requirements. This document considered as a “living” tool, annually updated
and modified to reflect best practice, lessons learned and the changing environment of healthcare in
Qatar, ensuring that citizens receive the best care possible.
Name
Title
Ministry of Public Health
Disclaimer
The Ministry of Public Health reserves the right to change any information or directives published in
this document, and the methods used to generate the content of this document. Any dispute arising
out of use of information included in this document shall be governed by the laws of the State of
Qatar.
Notice of Copyright
Except where expressly stated to the contrary, the copyright and any other rights in the contents of
the Licensing Process Manual, including any images and text, are owned by the Ministry of Public
Health. Permission is granted to download, display or print material for personal use or use within
an individual organization, and for a non‐commercial purpose. Requests for further authorization
regarding proposed usage of the information provided should be addressed to the MOPH.
Scope of National Healthcare Facilities Licensing & Accreditation Program
The scope of national program addresses facilities licensing under the National Healthcare Facilities
Licensing and Accreditation Program includes the Initial, Final and Renewal Licensing processes only.
Not included in the current scope of this document are functions and processes related to approval
of the followings:
List of services out of scope (Based on current approved types of MOPH healthcare service) of the
national program, which are:
Optic shops.
Wellness centers.
First aids units/clinics.
Medical storage.
Ambulance vehicle.
Nursing agency services.
Dental lab.
Dietitian.
Handicapped care.
INTRODUCTION
2016-2017
Version (1)
1.0 Introduction:
1.1 Overview of the National Healthcare Facilities Licensing and Accreditation
Program
The Ministry of Public Health has been tasked with carrying out the mission of the Qatar National
Vision 2030’s (QNV 2030) goals and outcomes. The objectives include creating a clear national
healthcare vision, mitigating gaps in the healthcare system, creating policies and best practices to
regulate the medical landscape, as well as developing an efficient monitoring and evaluation strategy.
As part of the National Healthcare Strategy (NHS), the Ministry of Public Health implemented a project
that aims to establish a unique integrated national healthcare facility licensing and accreditation
program for the entire continuum of healthcare in Qatar.
The National Healthcare Facilities Licensing and Accreditation Program include enhanced facilities
licensing requirements and accreditation standards based on objective international benchmarks that
are in line with the International Society of Quality in Healthcare (ISQua) principles. ISQua is
responsible for awarding an international accreditation status to national programs (accredits the
national accreditors).
In this integrated program, licensing component will provide a foundation of basic requirements that
organizations can build upon in order to gain an accreditation standing of different levels. The main
objective of the program is to build an effective system of continuous quality improvement starting
with foundational licensing requirements, and advancing to the highest levels of accreditation over
time. The result will be a more streamlined process for health care facilities that are undergoing the
licensing and accreditation process, allowing them to focus on what they do best, serving their
patients. Over time, it may be possible that this model would be accommodated to allow for
participation from other organizations within the health care sector in Qatar in a one‐stop shop
initiatives.
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1.2 Benefits of an Integrated National Healthcare Facilities Licensing and
Accreditation:
Previously, the licensing process within Qatar ran independently from any accreditation process
provided by different international accreditation bodies. With the Ministry of Public Health taking on
the role as the national accrediting body for Qatar, there was an opportunity to combine both the
licensing and accreditation processes into one streamline process as demonstrated in the Q Diagram
on page 7.
This Program enables the facility to build internal capacity by adopting the MOPH Peer Reviewer
model. This model uses healthcare experts to contribute to the national Program as part time
employee after completion of the certification program for Surveyors and Inspectors. The peer review
process by a number of Peer reviewers allows a diversity of opinions and getting benefits of up to
date clinical skills. It decreases bias in decisions and conflict of interest. Peer reviewers’ feedback used
to improve the standards as best practice knowledge. Facilities that have staff who are peer reviewers
will be able to use these staff in improving and developing their own licensing and accreditation
programs. Peer reviewers to all healthcare facilities can easily share success stories and best practice
models.
2.0 Overview of the Licensing Process:
The licensing process consists of multi‐steps, starting with Initial followed by Final Assessments that
leads to issue licenses to operate for new healthcare facilities, as well as license renewal on an annual
basis and inspections on an ad hoc basis. The facilities licensing program is implemented in alignment
with the Qatar Certificate of Needs (QCON) program, which evaluates significant infrastructure
projects against the Qatar Healthcare Facilities Master Plan (QHFMP), other policies, population needs
and financial sustainability.
As part of the licensing application process, the Licensing Specialists will assess whether the facility or
project to build a facility is QCON reviewable. If applicable, a Certificate of Need (CON) will need to be
granted before the licensing stages can proceed. (Attachment 1: Types of healthcare facilities defined
by the Qatar Healthcare Facility Master plan)
During the Licensing process, a team of Inspectors undertakes a number of activities to complete an
evaluation of pre‐defined risk indicators. The various licensing activities include a combination of
documentation reviews, observations and interviews with staff, and an assessment of the evidence
against the licensing requirements.
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There are five key steps in the licensing program:
1. Registration
2. Initial Assessment
3. Final Assessment
4. License Renewal
5. Ad Hoc Inspections
(Attachment 2: Healthcare Facilities Licensing Process Flow chart)
Inspectors use the Licensing Standards to guide their evaluation and document their findings.
Licensing Standards ensure the evaluators’ framework applied consistently across all healthcare
facilities.
In contrast to the prior Licensing program, which focused on licensing a type of service, the Licensing
process under the National Healthcare Facilities Licensing and Accreditation Program evaluates the
facility as a whole against applicable requirements within the Licensing Standards.
2.1 Development of licensing Standards:
An Internationally recognized Accreditation body contracted to carry out this Project. The support
organization along with the MOPH Accreditation team conducted the Inception mission in 2013. They
reviewed and understood the existing Licensing Process, engaged major stakeholders that included
external Ministries, Major Public and Private Healthcare Facilities in Qatar and reviewed all Emiri Laws,
codes and regulations and incorporating these into the licensing standards and by reviewing
International Best Practices (For Example, from Facilities Guidelines Institute, other International
codes, WHO recommendations etc..). The Licensing Standard Working Group (LSWG) formulated
involving members from the various Ministries, major Public and Private Healthcare facilities, and the
interdependent departments within MOPH. Various feedback gathered, reviewed and the Standards
revised and updated accordingly.
Piloting was done during project Implementation (2014‐2016) both for the Licensing and
Accreditation Standards and to test the Program’s readiness. All categories of Healthcare facilities
were involved in the pilots. Inspectors, surveyors and peer reviewers asked to provide input and
feedback on the standards. Facilities undergoing inspections also asked to complete a survey for
feedback on the standards and the licensing/accreditation process. Licensing and Accreditation
Standards shared among the Interdependent stakeholders for their final review and approval. The
Program integrated all of the feedback into the Licensing and Accreditation Standards booklet in 2016.
2.2 Core Bundles of Licensing Standards and Requirements according to the Facility
type:
The applicable Standards and the specific requirements covered in each inspection will vary, based on
where the facility situated in the licensing process, the type of facility, and status of the particular
facility. The healthcare facility expected to adhere to the requirements set out in the applicable
Licensing Standards. (Refer to Attachment 1: Types of healthcare facilities defined by the Qatar
Healthcare Facility Master plan)
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Core Bundles of Licensing Standards and Requirements
Initial Final Renewal
1. Planning and Pre‐Design of 1. Commissioning 1. Leadership
Capital Project 2. Physical Environment : Compliance and Accountability
2. Design Considerations Compliance and Accountability Staffing Standards
3. Construction Entrances, Exits and Navigation Policies and Procedures
4. Commissioning Architectural Details Financial Management
5. Initial Assessment Specific Environment Emergency Preparedness and
Requirements Housekeeping and Waste Response
Entrances, Exits and management Workplace Health and Safety
Navigation Emergency Preparedness 2. Physical Environment
Parking and Land Reception Compliance and Accountability
Requirements Facility and Equipment Maintenance Reception
Architectural Details Client Care Areas Facility and Equipment
Environment Food Preparation Maintenance
House Keeping and 3. Service Specific Content Housekeeping and Waste
Waste Management Diagnostic Imaging management
Workplace Health and Endoscopy Service Food Preparation and Cafeteria
Safety Laboratory Service
Emergency Preparedness Point of care testing 3. Infection Prevention and Control
Client Care Areas Surgical Service Compliance and Accountability
Food Preparation Assisted Reproduction IPAC Program
Residential Healthcare Nursery Unit Client Care
Facilities Oncology Nursing Unit General Reprocessing
Staff Accommodation Urgent Care/Emergency Service Endoscope Reprocessing
6. Service Specific Content 4. Leadership Outbreaks and Pandemics
Critical Care Unit Compliance and Accountability 4. Medication Management
Endoscopy Service Staffing Compliance and Accountability
Intermediate Care Unit Staff Accommodation Oversight of Pharmacy Service
Laboratory Policies and Procedures Receiving and Storing
Surgical Service Financial Management Medication
Newborn Intensive Care Workplace Health and Safety Prescribing and Dispensing
Unit 5. Infection Prevention and Control Medication
Nursery Unit Compliance and Accountability Administering Medication
Obstetrical Unit IPAC Program 5. Diagnostic Services
Oncology Nursing Unit Outbreaks and Pandemics Compliance and Accountability
Pharmacy service General Reprocessing Diagnostic Imaging
Diagnostic Imaging 6. Medication Management Biomedical Laboratory Services
Assisted Reproduction Compliance and Accountability Point of Care Testing
Dialysis Unit Pharmacy Service Assisted Reproduction
Rehabilitation Unit Oversight of Pharmacy Service laboratory
Receiving and Storing Medication
Prescribing and Dispensing Medication
Administering Medication
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2.3 Structure/Components of a Licensing standard:
Each Standard is composed of various components.
High‐Risk Requirements (HRR): An HRR is an essential practice that healthcare facilities must
comply to enhance patient and client safety, and minimize risk. The HRR in the Licensing Standards
denoted with a yellow caution sign next to the criteria statement ( ). A facility must be
compliant with an HRR to successfully receive and maintain a License. If a facility is not compliant,
the Inspector must indicate in the comments explaining how the facility is not compliant. Many of
the HRR requirements based on legal requirements of Qatar and are mandatory to fulfill.
Accreditation Standards, those requirements identified with an A next to the requirement
statement.
Short Forms: The first two letters of the standard are related to the section title, e.g. “PP” = “Planning
and Pre‐Design”
The last two letters related to the phase of licensing as follows:
IH = Initial Assessment, Hospitals.
IO = Initial Assessment, Outpatient;
FH = Final Assessment, Hospitals;
FO = Final Assessment, Outpatient the categories
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Facilities Licensing
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2.4 Licensing Process:
2.4.1 Registration
The licensing process begins with registration process from the prospective healthcare facility, which is the
entry point to the Licensing Process. All healthcare facilities, whether new, undergoing renovations or existing
and subject for license renewal, or adding any new scope of service, will have to complete the registration form
and submit all the applicable documents. (Attachment 3: Registration Application.)
Once submitted, a Licensing Specialist reviews the registration form. (Attachment 4: Role of Licensing
Specialist). During the registration process, if it is determined that the that the healthcare facility is Qatar
Certificate of Needs (QCON) reviewable, the specialist will direct the facility registration form to the Health
Care Planning and Assessment Department to proceed with the requirements. Once the Healthcare Facilities
Master Plan (HFMP) assessment is completed, the healthcare facility will proceed with the next step based on
the HFMP decision & recommendations. After thorough review and study, the healthcare facility provided with
a No Objection Letter and notified by e‐mail to receive the letter from MOPH. (If the facility is Hospital, after
the Registration process, the request forwarded to the Advisory Committee for their decision and
recommendations.). After the successful Registration, MOPH will offer an orientation session regarding
licensing program and process.
2.4.2 Initial licensing Assessment
The Initial Assessment focuses primarily on the structural plans of the healthcare facility and some foundational
operational elements. The Licensing Specialist will ensure that the facility submits all the relevant documents
related to the Initial assessment standards and assign team of Inspectors as per their area of expertise to
conduct documentation review and followed by planned onsite visit. (Attachment 5: Initial Assessment
Application)
The inspectors (Attachment 6: Role of the Inspectors) will assess all standards for compliance. When a standard
rated as unmet, the inspectors will provide comments on why the standard is rated as unmet. The inspectors
are also required to do a risk assessment for each unmet standard using the Risk Matrix Tool. The Team lead
(Attachment 5: Role of the Team Lead Inspector) will complete a preliminary report and submit team
recommendations to the Decision Committee (DC) for their review and decision. (Attachment 7: Terms of
Reference of Decision Committee.
If the facility assessed as unmet for some requirements that rated as low to medium scores as per the risk
matrix tool, the facility needs to submit an action plan report and proceed for Final assessment. Period for the
action plan depends on the types of risk and associated mitigation plans. (Refer to the Decision Process).
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The Initial Assessment is comprised of the following sections:
Initial Assessment for Inpatient Facilities Initial Assessment for Outpatient Facilities
1. PPIH: Planning and Pre‐Design of Capital Projects 1. PPIO: Planning and Pre‐Design of Capital
(Initial assessment Hospital) Project
2. DSIH: Design (including considerations and specific 2. DSIO: Design Considerations
requirements) 3. CSIO: Construction
3. CSIH: Construction 4. CMIO: Commissioning
4. CMIH: Commissioning 5. Initial Assessment Specific Requirements
5. Initial Assessment Specific Requirements: EEIO: Entrances, Exits and Navigation
• EEIH: Entrances, Exits and Navigation PLIO: Parking and Land
• PLIH: Parking and Land Requirements Requirements
• ADIH: Architectural Details ADIO: Architectural Details
• EVIH: Environment EVIO: Environment
• HWIH: House Keeping and Waste Management HWIO: House Keeping and Waste
• WSIH: Workplace Health and Safety Management
• EPIH: Emergency Preparedness WSIO: Workplace Health and Safety
• CCIH: Client Care Areas RPIO: Reprocessing Areas
• FPIH: Support Services: Food Preparation CCIO: Client Care Areas
• RPIH: Support Services: Re Processing FPIO: Support Areas‐ Food
• RCIH: Residential Healthcare Facilities Preparation
• SAIH: Staff Accommodation 6. Service Specific Content
6. Service Specific Content
LBIO: Laboratory
• CRIH: Critical Care Unit/Coronary
DIIO: Diagnostic Imaging
Critical care unit
EDIO: Endoscopy Service
• EDIH: Endoscopy Service
SSIO: Surgical Service
• ICIH: Intermediate Care Unit
• LBIH: Laboratory PCIO: Primary Care
• SSIH: Surgical Service UCIO: Urgent Care
• NIIH: Newborn Intensive Care Unit ARIO: Assisted Reproduction
• NUIH: Nursery Unit DIUO: Dialysis Unit
• OBIH: Obstetrical Unit RUIO: Rehabilitation Unit
• ONIH: Oncology Nursing Unit
• PSIH: Pharmacy service
• DIIH: Diagnostic Imaging
Following a successful Initial Assessment, the Licensing Specialist will send the facility an email about the Initial
assessment report/ decision and informing them to proceed with the Final Licensing Assessment.
2.4.3 Final licensing Assessment
The facility will inform the Licensing Specialist when they are ready to proceed to the onsite final assessment,
upon notification; the Licensing Specialist will assign a team of Inspectors as per their expertise to conduct the
onsite final licensing assessment and inspection. (Attachment 8: Final Assessment Application)
The Inspectors will evaluate the applicable requirements and Standards, and provide comments in areas
of non‐compliance along with a risk rating. Inspectors will also comment on areas of excellence. At least
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one of the assigned Inspectors to the Final Assessment should have been involved in the process of Initial
Assessment for the purpose of the continuous assessment process.
The results and recommendations of the Final Assessment is submitted by the Inspection team lead to the
assigned Licensing Specialist who will prepare the report for the Decision Committee (DC) to review the
Inspection report and to make a decision whether to grant the License to the facility or not.
If the facility does not meet some of requirements that are rated low to medium scores as per the risk
matrix tool the facility will be asked to submit the action plan, which will be followed by a re‐inspection,
conducted to validate compliance of unmet requirements.
The Final Assessment is comprised of the following sections:
Final Assessment for Inpatient Facilities Final Assessment for Outpatient Facilities
1. Commissioning 1. Physical Environment Specific
2. Physical Environment Specific Requirements Requirements
• CAFH: Compliance and Accountability CAFO: Compliance and Accountability
• EEFH: Entrances, Exits and Navigation EEFO: Entrances, Exits, and Navigation
• ADFH: Architectural Details ADFO: Architectural Details
• EVFH: Environment EVFO: Environment
• HWFH: Housekeeping and Waste HWFO: Housekeeping and Waste
management Management
• EPFH: Emergency Preparedness EPFO: Emergency Preparedness
• RCFH: Reception RCFO: Reception
• FEFH: Facility and Equipment Maintenance FEFO: Facility and Equipment Maintenance
• CCFH: Client Care Areas CCFO: Client Care Areas
• FPFH: Food Preparation
FPFO: Support Areas – Reprocessing
3. Service Specific Content
2 Service‐Specific Requirements (as applicable)
• DIFH: Diagnostic Imaging
DIFO: Diagnostic Imaging
• EDFH: Endoscopy Service
EDFO: Endoscopy Service
• LBFH: Laboratory
LBFO: Laboratory
• PTFH: Point of care testing
• SSFH: Surgical Service PTFO: Point – of – Care – Testing
• NUFH: Nursery Unit SUFO: Surgical Service
• ONFH: Oncology Nursing Unit ARFO: Assisted Reproduction
• UCFH: Urgent Care/Emergency Service PCFO: Primary Care
4. Leadership 3 Leadership
• CLFH: Compliance and Accountability CLFO: Compliance and Accountability
• SFFH: Staffing SFFO: Staffing
• SAFH: Staff Accommodation PPFO: Policies and Procedures
• PPFH: Policies and Procedures FMFO: Financial Management
• FMFH: Financial Management WSFO: Workplace Health and Safety
• WSFH: Workplace Health and Safety 4 Infection Prevention and Control
5. Infection Prevention and Control CIFO: Compliance and Accountability
• CIFH: Compliance and Accountability IPFH: IPAC Program
• IPFH: IPAC Program RPFO: General Reprocessing
• OPFH: Outbreaks and Pandemics OPFO: Outbreaks and Pandemics
• RPFH: General Reprocessing 5 Medication Management
6. Medication Management CMFO: Compliance and Accountability
• CMFH: Compliance and Accountability PSFO: Pharmacy Service
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• PSFH: Pharmacy Service OSFO: Oversight of Pharmacy Service
• OSFH: Oversight of Pharmacy Service RSFO: Receiving and Storing Medication
• RSFH: Receiving and Storing Medication PDFO: Prescribing and Dispensing
• PDFH: Prescribing and Dispensing Medication
Medication AMFO: Administering Medications
• AMFH: Administering Medication
2.4.4 Annual Licensing Renewal Assessment
National Healthcare Facilities Licensing and Accreditation program mandates that all existing licensed
healthcare facilities will be treated as new registrations that will be required to undergo the complete licensing
cycle (both Initial and final licensing assessments) before proceeding to the renewal process.
Healthcare facilities are required to renew their license annually. Therefore, the healthcare facility will
communicate with the licensing specialist three month prior to the license expiratory date to collect the
required Licensing standards as per facility type and services. Attachment 9: Renewal Assessment Application)
During the planned onsite assessment, the Inspectors will evaluate the applicable requirements and
Standards, and provide comments in areas of non‐compliance and a risk rating. It is expected that Inspectors
will also comment on areas of excellence.
The results and recommendations of the Renewal Assessment is submitted by the Inspection team lead to
the assigned Licensing Specialist who will prepare the report for the Decision Committee (DC) to review and
make a decision whether to renew the License to the facility or not.
If the facility does not meet some of requirements that are rated low to medium scores as per the risk matrix
tool, the facility will be asked to submit an action plan followed by a re‐inspection conducted to validate
compliance to the unmet requirements.
Following a successful decision, the facility will be able to maintain their License for one year and continue
operations.
The renewal assessment is comprised of the following standards that are applicable to both Inpatient and
Outpatient facilities.
1. Leadership
CAL: Compliance and Accountability
SFL: Staff
PPL: Policies and Procedures
FML: Financial Management
EPL: Preparedness and Response
WSL: Workplace Health and Safety
2. Physical Environment
CAP: Compliance and Accountability
RCP: Reception
FMP: Facility and Equipment Maintenance
HWP: Housekeeping and Waste management
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FPP: Food Preparation and Cafeteria Service
3. Infection Prevention and Control
CAI: Compliance and Accountability
IPI: IPAC Program
CCI: Client Care
GRI: General Reprocessing
ERI: Endoscope Reprocessing
OPI: Outbreaks and Pandemics
4. Medication Management
CAM: Compliance and Accountability
OPM: Oversight of Pharmacy Service
RSM: Receiving and Storing Medication
PDM: Prescribing and Dispensing Medication
AMM: Administering Medication
5. Diagnostic Services
CAD: Compliance and Accountability
DID: Diagnostic Imaging
BLD: Biomedical Laboratory Services
PCD: Point of Care Testing
ALD: Assisted Reproduction laboratory
2.4.5 Ad‐Hoc Inspections
These inspections initiated following a complaint, a critical incident, and unreported constructions and/ or
renovations. Licensing Specialists will review complaints, critical issues and other items gathered by the
Healthcare Facilities Licensing team. This information can come from a variety of sources, including, but not
limited to Accreditation Surveyors, Labaih (Public Complaint Portal), Minister’s Office and the Fitness of
Practice Office (Qatar Council for Healthcare Practitioners).
These inspections are conducted without prior notice to the healthcare facility and may occur on any day after
a complaint or critical incident has been identified. In the event that during the inspection, if the facility
discovered to be non‐compliant with a law, a High‐Risk Requirement (HRR) or a requirement where it has been
determined there is high level of risk, the particular service or facility may order an immediate temporary
administrative closure. Results of the Ad Hoc Inspection, inclusive of comments, submitted by the Inspection
team to the assigned Licensing Specialist who will forward the report to the DC for review and decision.
Within one working day following the temporary closure of the healthcare facility, if any, the medical director
shall meet with the Healthcare Facilities Licensing and Accreditation Department Director to discuss the
findings and present his/her corrective action plan and timeline for implementation.
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Upon completion, the facility will submit their required corrective action report to the assigned licensing
specialist who will schedule the re‐inspection visit to validate the findings and to allow the facility to
commence operations again.
2.5 Licensing Evaluation Process:
Each requirement within the Standards evaluated by the Inspectors during the licensing assessment and
issued a rating of Met or Unmet.
The Final Assessment is comprised of document review, observations, and interviews with the healthcare
Facilities staff and leadership.
For all unmet standards, the Inspectors will be providing:
Comments to justify the scoring, which can include pictures, documents etc.
Risk Rating by using Risk Matrix tool
Inspectors will also comment on areas of excellence for Met criteria.
The inspection team must focus on the standards that been identified as high‐risk requirement (HRR)
that are considered the core requirements that are instrumental in whether to grant the license or not.
The above information looked collectively, and a report generated by the Team Lead Inspector and submitted
to the assigned Licensing Specialist who in turn submit it to the Decision Committee (DC).
2.6 Decision Process:
2.6.1 Decision Criteria for Initial, Final, Renewal and Ad‐Hoc Assessment
The requirements assessed in the Initial and Final Assessments take into consideration whether a facility is new
or existing. To achieve Preliminary Approval in the Initial Assessment and Final Approval in the Final
Assessment and proceed to the License Renewal process on an annual basis an organization must satisfy the
following requirements:
Type Initial/Final/Renewal
+ OR
Any unmet standards are assessed at (low or Any unmet standards are assessed at (high
medium) level risk based on risk matrix rating. rating / 15‐25) level risk based on risk matrix
rating.
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• Facility action plan report • Facility action plan report
• Follow up on site assessment to confirm • Follow up on site assessment to
the compliance with the unmet non HR confirm the compliance with the
standards. unmet HR and non HR standards
2.6.2 Risk Matrix Tool:
The Risk Assessment Tool is used to determine the overall level of risk for any unmet requirements. Inspectors
are required to use this tool whenever there is an unmet criterion to assess the level of risk.
The level of risk, as denoted by the risk rating of 1‐25, is calculated by determining the likelihood (L Rank) of
the risk occurring and the impact (I Rank) if that risk occurs.
The overall risk rating should be noted in the comments section for any unmet requirements during the Initial
Assessment, Final Assessment, License Renewal or Ad Hoc Inspection. Justification and evidence for the
selection of the likelihood and impact should be explained.
Determining Impact:
Impact refers to the severity of harm to staff or patients within the healthcare facility if exposed to a hazard.
The Impact is assigned a value of 1 – 5.
1 Negligible Minimal injury requiring no or minimal intervention or treatment.
2 Minor Minor injury or illness, requiring minor intervention
3 Moderate Moderate injury requiring professional intervention
4 Major Major injury leading to long term incapacity or disability
5 Catastrophic Incident leading to death; multiple permanent injuries or irreversible
health effects.
It is at the discretion and expertise of the Inspector, based on their observations, to determine the likely
impact of the risk for the unmet requirement.
Determining Likelihood:
Likelihood refers to the probability that exposure to a hazard stemming from a risk for an unmet requirement
will lead to harm. Likelihood is a frequency‐based score to assess how likely the harm will occur. The
likelihood assigned a value of 1 – 5.
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1 Rare It will probably never happen
2 Unlikely Do not expect it to happen, but it is possible that it may happen
3 Possible It might happen occasionally
4 Likely Will probably happen, but is not a persisting issue
5 Almost Certain Will undoubtedly happen, possibly frequently
Similarly, for Impact, it is at the discretion and expertise of the Inspector based on their observations to
determine the likelihood of the risk‐taking place for an unmet requirement.
Calculating the Overall Risk:
Once the Inspector has determined the value of the likelihood and impact of the risk, those two values are
multiplied to calculate the value of the overall risk.
Risk Evaluation = Impact x Likelihood
For example, if the Inspector has determined that the value of the likelihood is 3 and the value of the impact
is 2, both values multiplied to get an overall risk value of 6 (2 x 3). The overall risk rating is located in the
following table:
Likelihood
1 2 3 4 5
Almost
Impact Rare Unlikely Possible Likely
Certain
5 Catastrophic 5 10 15 20 25
4 Major 4 8 12 16 20
3 Moderate 3 6 9 12 15
2 Minor 2 4 6 8 10
1 Negligible 1 2 3 4 5
Mitigation Measures:
Once the overall risk rating is determined, a corresponding mitigating measure is applied. The corresponding
mitigating measure helps to determine the next steps to monitor the overall risk and to eventually lower the
risk.
8
Ranking Mitigation Measure
1 ‐ 3 Low Risk Maintain Existing Controls (Treatments), Ongoing Monitoring
4 ‐ 6 Moderate Risk Review Existing Controls (Treatments), Ongoing Monitoring
8 ‐ 12 High Risk Improve Existing Control through Follow‐up Action to Mitigate
and Monitor Risks
15 ‐ 25 Extreme Risk Improve Existing Controls Straightaway through Immediate
Follow Up Action to Rectify Non‐Compliance
These mitigation measures help the DC (Decision Committee) to determine whether conditions should be
included in the licensing decision, and what those conditions should be. It will indicate whether the level of
overall risk is sufficient to grant a license to the healthcare facility or whether the license should be withheld.
For example, for an overall risk level of 8 corresponds to the following mitigating measure: “Improve Existing
Controls through follow up action to mitigate and monitor risks.” In this case, the inspection team may
recommend a follow‐up action to take place to determine whether or not the risk has been appropriately
resolved at a later time, however it will be at the decision of the DC to decide the follow‐up action.
2.7 Payment:
Following a successful approval of the final assessment by the DC, the licensing specialist notifies the healthcare
facility that they have been successful in the Licensing process. The facility is then required to make a payment
at MOPH. Upon receipt of the payment, a license is issued and the facility is able to operate officially
(Attachment 10: Healthcare Faculties Licensing Fee) .
9
10
3.0 Health Center Licensing Standards:
The safety and quality of health care services begins with a well‐functioning, safe building and equipment that
enables a supportive care environment. The effective and client‐centred planning, design, construction or
renovation of health care facilities is critical to protecting health and safety as well as promoting recovery and
improving experience, and creating an effective working environment. These requirements are designed to be
used by the following types of health center facilities:
PHCC Health Centers without a Wellness Component
Private Polyclinics
Medical Commissions
An assessment of an organization completed by a document review prior to its operation by Licensing
Inspectors to determine compliance with the licensing Assessment Standards. Following a successful initial
assessment, an Initial Approval to proceed to the Final Licensing assessment is granted. In cases where the
facility building is completed the Initial Inspector team may request an on‐site visit to verify their ratings. The
Initial Assessment is further broken down into the following five sections:
1. PPIO: Planning and Pre‐Design of Capital Project
2. DSIO: Design Considerations
3. CSIO: Construction
4. CMIO: Commissioning
5. Initial Assessment Specific Requirements
EEIO: Entrances, Exits and Navigation
PLIO: Parking and Land Requirements
ADIO: Architectural Details
EVIO: Environment
HWIO: House Keeping and Waste Management
WSIO: Workplace Health and Safety
CCIO: Client Care Areas
FPIO: Support Areas‐ Food Preparation
6. Service Specific Content
EDIO: Endoscopy Service
SSIO: Surgical Service
PCIO: Primary Care
UCIO: Urgent Care
ARIO: Assisted Reproduction
DIU: Dialysis Unit
RUI: Rehabilitation Unit
11
Initial Assessment
12
3.1 Initial Assessment: High Risk Licensing Standards
HRR Accr Std.
Section of the Standard Required Documents
Standard
Physical Environment – Building Structure Standards: The safety and quality of health care services begins with a well‐functioning, safe building and
equipment that enables a supportive care environment. The effective and client‐centered planning, design, construction or renovation of health care facilities is
critical to protecting health and safety as well as promoting recovery and improving experience, and creating an effective working environment for staff.
The Initial Assessment is comprised of the following five sections:
• PPIH: Planning and Pre‐Design of Capital Projects
• DSIH: Design (including considerations and specific requirements)
• CSIH: Construction
• CMIH: Commissioning
• Initial Assessment Specific Requirements
PPIO: Planning and Pre‐Design of Capital Projects:
HRR Accr Std. Section of the Standard Required Documents
Standard
14
entrance for those with special requirements or permits, and
washrooms that are built to accommodate those using an assistive
device or mobility aid.
15
This process may be a shared responsibility between the organization For solo clinics, the owner can be
and the building commissioning committee or with a government the sole member.
ministry, where applicable. Provide Information about CCTV
approval, Civil Defense Approval
etc.
A
CMIO.3 All aspects of the design and contract documents are met as part of Commissioning Plan
Commissioning Plan building and operational commissioning. Commissioning Checklist
Guidelines:
Commissioning Committee
Commissioning is a process of verifying, and documenting that all
Terms Of Reference (Refer to
aspects of a capital project meet design specifications, and plans. The
individual responsible for overseeing commissioning ensures all design Templates provided at the end
elements were built according to schematic and design plans and of this document)
meet the terms agreed upon in the contract documents, including
power systems, plumbing, HVAC systems, standardization, lighting,
noise specifications, outdoor spaces and landscaping, waste
management, furnishings and finishes, and others.
Initial Assessment Specific Requirements
EVIO: Environment
HRR Accr Std. Section of the Standard Required Documents
Standard
EVIO.1 Main electrical switchboards are located in an area separate from Show diagrams or photos of main
Electrical Room plumbing and mechanical equipment. functional switchboard with details
Guidelines: to prove that plumbing and
Main switchboards are located in a dry, ventilated space, free from mechanical equipment are
corrosive or explosive fumes, gases, or any flammable material. separated from electrical switch
boards.
EVIO.6 Areas used for client care have provisions for ventilation. Evidence of provision of Mechanical
Ventilation Guidelines: ventilation and Natural Ventilation
Natural ventilation for non‐sensitive areas and patient rooms (via for client care rooms. Provide room
operable windows) is permitted, however mechanical ventilation is layouts and photos.
also provided for all rooms and areas in the facility.
HWIO: Housekeeping and Waste Management
16
DIIO: Diagnostic Imaging
HRR Accr Std. Section of the Standard Required Documents
Standard
DIIO.1 All enclosures including doors, walls and windows used for procedures Plan/ RP Report including Specified
Radiation Protection involving radiation are provided in accordance with relevant codes, Radiation Protection Details.
standards and verified by Qualified Radiation Protection (RP)
Specialist.
LBIO: Laboratory
HRR Accr Std. Section of the Standard Required Documents
Standard
LBIO.1 There is a hand‐washing station located within 7.62 meters of each Site Observation
LAB work area. (FGI‐2.2‐4.1.2.3)
LBIO.4 The blood collection area shall have a work counter, space for patient GA Drawings
LAB seating, and hand washing stations. (FGI A5.11.2.4 (3))
SSIO: Surgical Service
HRR Accr Std. Section of the Standard Required Documents
Standard
A SSIO.1 Operating rooms have at least 20 complete air exchanges per hour. ACPH verification Report
ACPH
18
19
DUIO: Dialysis Unit
HRR Accr Std. Section of the Standard Required Documents
Standard
DUIO. 1 The Dialysis Unit will consist of or have access to the following Floor Plans
functional areas for all service delivery methods:
Dialysis Unit
Main Entry/Reception Area
Waiting Area
Treatment Areas
Staff Areas
Support Areas
Storage Areas
o Clinical
o Non Clinical
o Bulk Items Storage e.g. Fluids, Equipment and Dialysis
Machine
o Service Maintenance
DUIO.3 The internal planning of the Dialysis Unit should be planned by Functional plan
considering the unit functional areas/zones.
Functional Plan
Guidelines:
Some of the critical relationships to be considered include:
Staff workstation requires an unobtrusive view of all patient
treatments areas; the inclusion of decentralized staff work
areas may be considered in larger units that have multiple
rooms or treatment spaces
20
Reception requires a clear view of entry and exit/egress points
of the unit.
Ease access from the waiting area to the Patient Treatment
area for the patients and family.
Functional relationship of training and isolation rooms to the
entry of the unit with access to outdoor space
DUIO.4 The unit shall be designed to provide: Design Document
Ease of public access for patients who may arrive either
Dialysis Design walking, using mobility equipment, families with children, on
Document an ambulance stretcher or patient trolley.
Ease of access to public parking for patients who are often
debilitated and who may need to visit the unit on a regular
basis.
Ease of delivery of large amounts of fluids (dialysate) or
palettes to the Unit on a regular basis.
DUIO.7 The Unit should be designed to Design Document
Ensure confidentiality of personal discussions and medical
Confidentiality and records
Privacy Provide an adequate number of rooms for discreet
discussions and treatments to occur whenever required.
Enable sufficient space within each treatment space to permit
curtains to be easily drawn whenever required.
Appropriately locate windows and doors to enhance visual
and acoustic privacy.
Guidelines:
Confidentiality for persons receiving treatment is a highly important
consideration to be addressed.
DUIO.12 Nurse Call and Emergency Call facilities shall be provided in all patient Nurse Call System
areas (e.g. Bed/chair spaces, Toilets and Bathrooms) and clinical areas
Nurse Call in order for patients and staff to request for urgent assistance. The
individual call buttons shall alert to distributed identified ceiling
mounted annunciators and also to a central module situated at or
21
adjacent to the Staff Station (s) or to a paging system. The alert to
staff members should be done in a discreet manner
DUIO.14 Planning considerations for the design and installation of the water Water Treatment Plan
pre‐treatment shall be done and should include:
Water Treatment water feed quality
pressure of the feed water
maximum water flow – consideration of the growth of service
activity
average water flow per day – consideration of the growth of
the service
spatial requirement to safely install and operate the water
pre‐treatment plant
drainage requirements
weight of the water pre‐treatment plant and the ability of the
floor to safely support that weight
water quality monitoring systems
power supply requirements
facilities and access to safely service and maintain the water
pre‐treatment plant
water distribution loop
DUIO.15 Components of water treatment services should include: Water Treatment Plan
Feed water temperature control
Water Treatment o High feed water temperatures may require a heat
exchanger to cool the feed water; if the feed water is
cold it can be heated by mixing hot and cold water
with a thermostatic mixing valve
Back flow preventer
o All water pre‐treatment systems require a form of
back flow prevention device; this device prevents the
water in the pre‐treatment system from flowing back
into the source water supply system; a reduced
pressure zone device (RPZD) or a break tank with an
air gap may be used
22
Multimedia depth filter
o Particulates of 10 microns or greater are removed by
a multimedia filter (or depth bed filter); these
particulates can clog the carbon and softener tanks,
destroy the Reverse Osmosis (RO) pump, and foul the
RO membrane.
DUIO.16 Booster pumps are required to ensure a certain speed of water (at Water Treatment Plan
least 10 meters/second) and a certain pressure of water (varies
Water Treatment dependent on the concentration of the salt solution on the reject side
of the membrane) to enable these processes and to limit the ability of
tubing contamination by bacteria and moulds. These contamination
processes are also reduced by the application of heat (85 – 90 degrees
Celsius), eliminating any right angle bends, ensuring the internal
surfaces of tubing have a high level of smoothness and by keeping
tubing runs as short as possible.
DUIO.17 The Plant Room for water treatment should be ideally located as part Water Treatment Plan
of the Renal Dialysis Unit to keep tubing runs short and to make it
Water Treatment easy for staff to monitor and service the water treatment systems
23
RUIO: Rehabilitation Unit
HRR Accr Std. Section of the Standard Required Documents
Standard
RUIO. 1 The Rehabilitation – Allied Health Unit will include the following Functional Plan (Appendix 7.5)
Functional Areas:
Functional Areas Entry, Reception and Waiting areas
Patient accommodation areas including Lounge and Dining
areas
Patient Therapy areas which may be shared
Support areas including Utilities, Cleaner’s Room, Disposal,
Pantry and Store Rooms
Staff areas including Offices, Meeting Rooms, Staff Change
and Toilets.
RUIO.3 Where a Physiotherapy service is to be provided the following Floor Plan
facilities shall be allowed for:
Floor Plan Individual treatment area or areas that provide for patient
privacy
Staff hand‐washing facilities close to each treatment space;
this may serve several treatment spaces
An exercise area with facilities appropriate for the level of
intended service
Clean linen storage; in the form of built‐in cupboards, cabinets
or on mobile storage trolleys
Storage for equipment and supplies
Storage for soiled linen and waste
Patient dressing and changing with secure storage of clothing
and valuables, showering and
toilet facilities
Ice‐making facilities to be available in or near the department
Wall oxygen in patient waiting areas depending on service
mode, and access to appropriate outdoor therapy areas.
RUIO.4 The entry shall be covered to provide dry access to the building. Architectural layout
Design considerations include:
24
Floor Plans Ensuring the covered area is large enough to allow vehicles
such as taxis, buses, cars, and emergency vehicles to
maneuver beneath it, and is structured to facilitate free
concurrent traffic flow for multiple vehicles
The use of clear roofing material to maximize natural light
inside the building
The external Entrance Area, best sited at ground floor level, is
the first point of contact for members of the community and
should display clear directions informing people where to
proceed
Guidelines:
Design considerations include:
Vehicle access is required at all times
Entry facilities should be suitable for people with disabilities,
such as limited mobility and poor vision
The entry can incorporate an airlock space and may have
sensor or automatically opening doors to facilitate access.
RUIO.13 Safety aspects of the Patient and clients shall be considered in the Design Document
Design of the Unit.
Patient Safety
Guidelines:
The patient population of this unit in particular requires special
consideration in terms of safety as they will be at once disabled or
incapacitated and yet are being encouraged to be mobile and self‐
sufficient. Every aspect of unit design with regard to finishes, surfaces
and fittings must be assessed to determine the potential for accidents
or hazards to both patients and staff. Sanitary facilities are where
most accidents or mishaps occur, to both patients and staff. In
particular, consider:
Slippery or wet floors
Protrusions or sharp edges
Stability and height of equipment or fittings
Choice of floor covering
25
Handrails and wheelchair access are mandatory.
RUIO.15 Nurse call systems shall be provided in all individual rooms and Nurse Call System
cubicles including those in Gymnasiums.
Nurse Call Staff Assist and Emergency Call at regular intervals. Annunciators
(non‐scrolling) located in Reception, corridors, treatment areas and
Staff Room.
RUIO.19 The floor of the pool should contain no steps Floor Plan
Pool Layout
26
3.2 Initial Assessment: Licensing Standards:
HRR Accr Std. Section of the Standard Required Documents
Standard
PPIO: Planning and Pre‐Design of Capital Projects:
PPIO.1 Information is collected on the types of clients served by the A single document can be submitted
organization, and their needs to inform the design of the facility. which covers all the 7 standards (PPIO
Data Collection and 1 to 7).
A analysis Guidelines:
Information on the types of clients served by the organization can
include age, gender, culture, language, and location. Collecting this Refer to Templates provided at the
information helps team leaders evaluate the demand for services, end of this document ‐ Planning and
identify patterns in service needs, determine the resources needed Predesign Document.
to meet them, and informs the design and functional requirements
No Objection Letter from MOPH
of the facility. The information is collected on an ongoing basis
should be submitted.
about the current needs, predicted future needs of the community,
expected growth and projections of the community. Community
members, clients and families are involved in the process of
identifying needs. The organization may collect existing data or
implement measures to collect new information.
A
PPIO.2 The scope and objectives of the capital project is determined based Same as above.
on the information collected about the needs of the community.
Future Projection
Guidelines:
The organization uses the information collected about the
community to determine the needs that the capital project will
address. The objectives are determined based on the community
assessment and information regarding the status of the current
facility and future projections.
27
The objective setting process is forward thinking, making the
facility resilient to future needs, given that there is a lag time
between the planning and design, and the occupation phase of a
new facility or part of a facility. The objectives are flexible
recognizing the exact purpose and outputs of the project may
evolve with time. The values and strategic direction upon which
decisions are made are maintained.
A
PPIO.3 The facility master plan is reviewed and the capital project is Same as above.
aligned with the master plan of the project.
Project Development
Plan. Guidelines:
(Only applicable to The project Development plan may have been developed within the
Multi phased Projects) organization or another organization, or by the regional or national
government. This plan identifies all of the project planning goals and
objectives, using all of the background information collected in the
early planning stages and is the overarching vision of the project. The
master plan is designed to guide decision making in the short term
to meet long‐term objectives, and is flexible yet implementable. The
master plan assists the project team in planning the implementation
phases of the project.
The organization seeks approval for the capital project as it relates to
the master plan through the appropriate authority, where required.
A
PPIO.4 The site of the capital project is selected in accordance with the Same as above.
master plan.
Site Selection
Guidelines:
28
The site is evaluated and the organization determines whether the
existing site will be expanded or modified or whether a new site is
required. Site selection is a careful process that considers all
qualities of the particular site and needs of the project. The
organization determines the potential impact of development on
the planned site. This process is done in consultation with other
governmental ministries, or municipalities as necessary.
A
PPIO.5 The potential risks and opportunities of the proposed capital Same as above.
project are identified.
SWOT (Strength,
Weakness, Guidelines:
Opportunities and Risks may be internal or external to the organization. Risks and
Treats) Analysis threats may include risks of staying in an existing facility, financial
or strategic risks, zoning issues, municipal capacity, or
environmental issues.
Examples of opportunities include available funding or grants to
take on the project that may be internal or external to the
organization, strategic partnerships, community development or
sustainability.
A
PPIO.6 The resource requirements for the capital project are determined. Same as above.
Resource analysis Guidelines:
The resources include the human resources, expertise, and the
financial requirements of the capital project. Resource needs are
determined for each phase of the project, including the planning,
design, construction, commissioning and post‐occupancy
evaluation.
A
PPIO.7 A functional Brief is developed and implemented for the capital Same as above.
project.
Functional brief
29
Guidelines:
The functional brief is developed with the input of clients,
community members, consultants, and the project team. The
functional program is the specific road map for a project that
focuses on creating a safe and effective care and service delivery
environment, and is the link between the planning and design
phase. The functional program is developed using the master plan
as a guide, and is detailed enough to outline key design and
implementation steps that will ultimately affect the functionality
and operational effectiveness of the facility. The functional
program includes: project assumptions, e.g. regarding costs and
occupancy projections; the master plan; the budget and projected
operational cost considerations; the specifics regarding functions
and operational plans and model for each department or unit,
including who is doing what, when, and how; project
interdependencies, such as the implementation steps that must be
completed prior to construction; departmental relationships;
departmental adjacencies; required equipment; and any design and
sustainability considerations.
A
PPIO.8 A plan is developed for continuing operations during construction. Only applicable for Facilities who are
renovating.
Clinical Operations Guidelines:
during construction (If
The plan outlines whether services will continue to be provided
applicable)
during construction, and if so, which services will be provided and
how. The plan details those responsible for executing the plan,
and includes how the health and safety of all building occupants
(including clients, staff, visitors and contractors) will be protected
during construction.
Temporary electrical installations for the construction areas must
meet the applicable standards to avoid incidents of fires arising
30
from such installations and must be maintained throughout the
duration of construction.
DSIO: Design
A
DSIO.1 Schematic and design development documentation are developed Architectural Plans with
and implemented. dimensions
Architectural Plans
Guidelines: Floor Plans
Schematic and design plans include all design details such as site
plans; floor plans; specifications; and flow of materials, clients,
families, and staff and service providers. Plans take into
consideration how infection prevention and control practices and
the fire safety plan will be adhered to during construction.
A
DSIO.2 Physical and virtual mock‐ups are used to test the proposed design, Existing Facility:
where appropriate. (renovations)
Artist Impression. Take photo of the room.
Guidelines: Draw a layout of the room with
(3rd Perspectives) proposed furnishing. E.g.
Mock‐ups, whether physical or virtual, are simulations or
prototypes of an environment, and are used to test design Consultation room furnished with
decisions, functionality and make improvements prior to doctors table, patient bed,
construction. A range of stakeholders should be involved in equipment etc.
reviewing the mock‐up, including staff and service providers, the
project team, and the organization’s leaders. The rooms or
external environments that require mock‐ups are determined at
the planning stage and will depend on the type and size of the
facility and whether constructing a new facility or renovating an
existing facility. They are primarily used for high‐traffic areas, and
standardized, repeating rooms such as client rooms.
31
A
DSIO.3 Committees responsible for building and operational Commissioning Plan (Refer to
commissioning are identified in the design phase of the project. Templates provided at the end of this
Commissioning Plan. document)
Guidelines:
The organization identifies two separate individuals or committees
to oversee building commissioning and operational commissioning.
The two committees with cross‐representative member(s),
communicate frequently, and are members of the broader project
team. Where internal individuals or committees cannot be
identified with the appropriate skills and abilities, the organization
seeks external consultants with expertise in commissioning. The
appropriate individuals or committees are ideally determined in the
design phase and involved throughout the project planning and
implementation. Sufficient time and resources are set aside to
enable a thorough commissioning process.
Solo Clinic: A person is identified to oversee building commissioning
and operational commissioning. Where internal individuals cannot
be identified with the appropriate skills and abilities, the
organization seeks external consultants with expertise in
commissioning.
and control during times of renovation or construction. given link to see an example and adapt
IPAC plan it.
Guidelines:
The plan for maintaining infection prevention and control http://www.calgaryhealthregion.ca
practices during capital projects is documented. The plan details
/policy/docs/1346/InfectionPreven
how infection prevention and control practices will be
implemented at all stages of the project and will vary based on tionduringConstruction.pdf
the type and size of the facility and the project.
32
A
DSIO.5 Evidence‐based design principles are considered and incorporated. Reference standards/Guidelines used:
A
DSIO.6 Security requirements are incorporated into the design. Official letter from healthcare facility
private or semi‐private rooms and bathrooms; and choosing Show Negative pressure areas or
materials and finishes for floors, walls, and furnishings that can be High Infection areas like Isolation
effectively cleaned and disinfected. room, Operation Theatre etc. (if
applicable)
Provide brochures of Material used for
furnishing walls, floors etc.
A
DSIO.8 Spaces are designed to be standardized where possible. Provide layouts of rooms in a floor
with evidence showing all rooms are
Standardized Design. Guidelines:
standardized. Photos of the room with
Evidence suggests that standardization in design improves patient the appropriate furnishing can also be
safety and increases the long‐term viability of the space. submitted.
Standardization facilitates the staff and service provider
E.g. all rooms shall be furnished in the
interactions with the physical environment and reduces chances of
same way. This is to make sure that
errors and is particularly important in certain areas of a facility, e.g.
health practitioners do not need to re‐
the operating room and emergency department. Standardization
orient themselves to different types of
may apply to unit or department layout, room layout, and the
rooms.
location of devices and equipment.
A
DSIO.9 Spaces are designed that support interactions between clients and Plans showing placement of
staff and service providers.
User‐friendly Design Reception
& Cultural Guidelines: Waiting areas
Sensitivity Facilitating user friendly and visibility between clients and staff and Placement of curtains.
service providers improves client and staff safety as well as the Statement and supporting document
experience of clients. Ease of interactions should not compromise
confidentiality and privacy for clients and must be sensitive to
cultural needs and expectations. Factors that influence interactions
include placement and layout of rooms, centralized vs.
decentralized work stations, proximity, and lighting choices.
34
Wayfinding includes comprehensive signage, landmarks, lighting,
patterns or colours, sounds, windows, views and other elements
that support ease of movement through the facility. Wayfinding is
inclusive of all needs regarding multiple languages, literacy levels,
hearing, and sight considerations.
Where there is re‐routing during times of construction, wayfinding
is considered and temporary signage is used.
A
DSIO.12 Spaces designed support the privacy of the client. Drawings or Photos showing:
Separate waiting areas
35
A
DSIO.13 Spaces are designed to control noise levels in the facility, and to Provide:
maximize client and staff safety and comfort.
Acoustic Design Brochure of Material used.
Guidelines:
Official letter (Refer to Templates
Considering noise in the design of space and selection of materials provided at the end of this document)
and equipment is fundamental to an effective facility. Excessive
noise is a source of distraction that can lead to errors in the care
environment. It is also a source of stress for clients, may interfere
with sleep patterns, and can cause distress among staff and service
providers while performing work. A quiet environment is associated
with reduced stress, improved healing, and improved client
experience and is particularly important for neonates.
A
DSIO.14 Lighting is designed to maximize client and staff safety and comfort. Provide following details
Waste Management room layout.
36
A
DSIO.16 The building system design enables effective monitoring of critical Provide following details:
operations that provides alerts upon failure.
Building Plans to overcome periods of
Management Guidelines: electricity failure, water scarcity
System (BMS) etc.
Critical operations are related to essential utilities and systems
such as electricity; potable water; fuel; medical gases, and vacuum Plans to deal with monitoring of
systems; elevators/escalators; heating, ventilation, and cooling Medical Refrigerator alarms during off
systems; plumbing; security measures; steam for sterilization; hours etc. (If applicable)
communication equipment such as telephones, facsimile machines,
mobile phones, pagers, and intercoms; and information systems.
The level of automation of building systems will vary between
organizations.
Alerts indicate failure or results outside the normal range and
indicate to staff and service providers that there is an issue that
needs to be resolved.
A
DSIO.17 The organization incorporates all applicable legislation, regulations, Provide approvals from Ministries in
and building codes into design. Qatar:
Approvals
Guidelines: MMUP approval
Transport Ministry Approval
The project team is aware of and determines how they will meet all
applicable requirements of the jurisdiction in their design plan. MOI approval
MOEC approval
37
Kahramaa approval.
CSIH: Construction
A
CSIO.1 Contract documents are reviewed and approved with the Provide following details:
construction team.
Contract Documents Official letter from the Healthcare
Guidelines: facility indicating that the construction
agreement has been met.
The contract documents, also called construction documents, are
Describe in the letter how the
the legally binding arrangements between the organization and the
construction is going to be done and in
contractor for the specifics of the project, including timeline and
each phases.
costs.
The project team and participating members of the organization are
responsible for ensuring the accuracy and completeness of the
contracts, and identifying and resolving discrepancies with the
contractors prior to final approval.
CMIO: Commissioning
A
CMIO.1 The commissioning plans for the facility are reviewed and For small Facilities
approved.
Commissioning Plan Develop a checklist by the owner
Guidelines: on what he needs to complete to
Individuals or committees oversee the building and operational make the facility ready in
commissioning, and develop respective commissioning plans with relationship to construction.
input from the organization. The commissioning plans are Specify timelines also. Examples of
developed in accordance with all planning and construction items that can be included in the
agreements, are based on the operational principles and objectives checklist are Government
38
set out by the organization, and address the considerations for approvals, Electricity works,
occupancy of the new facility or area. mechanical works, HVAC works etc.
Refer to Templates provided at the
end of this document.
A
CMIO.4 The organization oversees the operational commissioning process. Provide Commissioning Plan
Commissioning Plan Guidelines:
Operational commissioning is led by the committee responsible in
partnership with the organization and project team and keeps the
interests of staff, service providers, clients and community as the
focus. Management of operational commissioning includes
39
preparing and managing the transition for staff and service
providers to the new location or use of the new facility. Other tasks
include identifying occupational health and safety hazards;
assessing and mitigating risks; establishing orientation and training
programs for staff and service providers; and developing new
operational policies and procedures for the facility.
A
CMIO.5 Issues that need to be resolved as part of commissioning are Provide Commissioning Plan
identified.
Commissioning Plan Should include issues that were
Guidelines: identified with relation to changing
rented facility into health care facility.
A list is created of issues from both the building and operational
commissioning processes, and evaluates whether the issues have
been appropriately resolved in alignment with the requirements of
relevant authorities, where applicable.
A
CMIO.6 An orientation to the new space or facility is provided for clients, Commissioning Plan
families, and staff and service providers as the project is being Operational Commissioning
Commissioning Plan completed. section should contain an
orientation plan for opening the
Guidelines:
facility.
An orientation allows for a smooth transition to caring for clients in Include relevant timelines.
the new space or facility. The orientation includes an overview of
the new layout, design, and features. The orientation is part of the
process to ensure operational readiness in commissioning and is
linked to the organization’s broader change management plan.
Initial Assessments Specific Requirements:
EEIO: Entrances, Exits, and Navigation:
40
Guidelines:
The facility has developed a disabled access plan.
PLIH: Parking and Land Requirements:
ADIO: Architectural Details:
41
Corridors width
• at least 2.70 metres high in all other spaces
The clear width needed to accommodate access by patients and
patient equipment has been taken into consideration in calculating
the door opening dimensions.
Flooring surfaces shall allow for ease of ambulation and self‐
propulsion. Soft flooring (carpet, cushioned flooring) can be used to
reduce the risk of falls and impact of associated injuries.
EVIO: Environment:
42
Every effort should be made to allow individual control over as
many elements of the environment as possible and reasonable,
including but not limited to temperature, lighting, sound, and
privacy.
Supply capacity for hot‐ and cold‐water piping is determined on the This also depends on the number of
basis of fixture units, using recognized engineering standards. floors in the healthcare facility and
also the number of services being
provided.
43
Protection of HVAC systems against chemical, biological, and
radiological attack is considered.
HWIO: Housekeeping and Waste Management:
equipped with an exhaust fan and floor drain.
Waste Disposal Sketch of Waste Management
room. (can include photos)
Official document describing the
furnishing and infrastructure of
the waste management room
HWIO.2 The facility has at least one environmental services room Diagram/layout/photos of
(Housekeeping Closet). housekeeping closet
House Keeping
44
House keeping
WSIO: Workplace Health and Safety:
Invoice.
Eyewash
RPIO: Reprocessing Area
The placement of the clean and dirty area should allow the staff for
efficient functioning and should now allow mixing with clean and
dirty items during the sterilization process.
Reprocessing area 1 Sink for washing dirty equipment
Exhaust fan
CCIO: Client Care Areas
PCIO: Primary Care
DIIO: Diagnostic Imaging
46
LBIO: Laboratory Service
47
Floor Area
SSIO: Surgical Service
Semi Restricted Area Storage areas for clean and sterile supplies
Work areas for storage and processing of instruments
Corridors leading to the restricted areas of the surgical
suite
Scrub sink areas
SSIO.5 The restricted area includes the operating and other procedure Floor Plans
rooms and the clean core.
48
Restricted Area
49
Room Differential
pressure
Smoke plumes may contain toxic gases, vapors, and viruses. For
more information, refer to the International Federation of
Perioperative Nurses Guidelines for Smoke Plume.
Guidelines:
50
Suitable for general anaesthetic with the appropriate medical gases,
power, lighting, air conditioning and ventilation. Staff assistance call
shall be provided.
PCIO: Primary Care
UCIO: Urgent Care
Urgent Care
Urgent Care
ARIO: Assisted Reproduction
51
DUIO: Dialysis Unit
52
Guidelines:
Some of the critical relationships to be considered include:
Staff workstation requires an unobtrusive view of all patient
treatments areas; the inclusion of decentralized staff work
areas may be considered in larger units that have multiple
rooms or treatment spaces
Reception requires a clear view of entry and exit/egress
points of the unit.
Ease access from the waiting area to the Patient Treatment
area for the patients and family.
Functional relationship of training and isolation rooms to
the entry of the unit with access to outdoor space
DUIO.4 The unit shall be designed to provide: Design Document
53
Dialysis Design Ease of public access for patients who may arrive either
Document walking, using mobility equipment, families with children,
on an ambulance stretcher or patient trolley.
Ease of access to public parking for patients who are often
debilitated and who may need to visit the unit on a regular
basis.
Ease of delivery of large amounts of fluids (dialysate) or
palettes to the Unit on a regular basis.
DUIO.5 The Design of the Unit is such as to allow a direct line of vision Design Document
between the patients and the staff.
Patient Staff
Interaction
Guidelines:
Patients should be situated so that healthcare providers have direct
or indirect visualization. This approach permits the monitoring of
patient status under both routine and emergency circumstances.
LUX levels
Guidelines:
Natural light contributes to a sense of wellbeing of patients, staff,
visitors and other users. The use of natural light should be
maximized throughout the unit. This is of particular importance for
patients who spend long periods of time sitting in dialysis chairs.
Every effort should be made to provide a view to all treatment
areas either by locating treatment bays adjacent to a window or
enabling unobstructed sight lines through areas to an outdoor view.
Confidentiality and Provide an adequate number of rooms for discreet
Privacy discussions and treatments to occur whenever required.
Enable sufficient space within each treatment space to
permit curtains to be easily drawn whenever required.
Appropriately locate windows and doors to enhance visual
and acoustic privacy.
Guidelines:
Confidentiality for persons receiving treatment is a highly important
consideration to be addressed.
Guidelines:
Solutions to be considered include
Selection of sound absorbing materials and finishes
Use of sound isolating construction
55
Planning to separate quiet areas from noisy areas
Review of operational management and patient/client
flows. This may include separate areas for patients with
special needs.
Location of the unit.
DUIO.9 Interior design features to be included in the Unit with the following Design Document
considerations:
Interior Design
Use of design features such as colors and artworks to
distract the sight from clinical areas
Inclusion of soft furnishings that act as a design feature
such as screening, lounges, in waiting areas and window
treatments
Elimination of corridors through good design wherever
possible
Inclusion of corridors at the minimum required widths to
meet the service needs e.g. wide corridors are a feature
that potentiates institutional environments
Provision of a beverage bay for people to use while waiting
Background music though a piped system or a centralized
unit
Television systems with head set access to reduce ambient
noise in the unit.
Guidelines:
The décor of the Unit should be of a standard that meets the
expectations of people using the services and make every effort to
reduce an institutional atmosphere. Cleaning, infection control, fire
safety, patient care requirements and the patients’ perception of a
professional inviting environment should always be considered
56
Patient Access
Guidelines:
Consideration should be given to the separation of ambulant and
non‐ambulant patient arrivals to enhance privacy of ambulance and
or stretcher patients frequenting the service
The following factors shall be considered:
aesthetic appearance
acoustic properties
durability
ease of cleaning
infection control
Movement of equipment.
DUIO.12 Equipment, furniture, fittings and the facility itself should be Materials Catalogue and Datasheet
designed and constructed to ensure that users are not exposed to
Finishes avoidable risks or injury. A high standard of safety and security can
be achieved by careful configuration of spaces and zones to include:
control access / egress to and from the Unit
optimize visual observation for staff
Similar functions shall be co‐located for easy staff
management.
Access to public areas shall be considered with care so that the
safety and security of staff areas within the Unit are not
compromised.
57
58
facilities and access to safely service and maintain the water
pre‐treatment plant
water distribution loop
59
ensuring the internal surfaces of tubing have a high level of
smoothness and by keeping tubing runs as short as possible.
DUIO.17 The Plant Room for water treatment should be ideally located as Water Treatment Plan
part of the Renal Dialysis Unit to keep tubing runs short and to
Water Treatment make it easy for staff to monitor and service the water treatment
systems
RUIO: Rehabilitation Unit
60
61
Ice‐making facilities to be available in or near the
department
Wall oxygen in patient waiting areas depending on service
mode, and access to appropriate outdoor therapy areas.
Guidelines:
Design considerations include:
Vehicle access is required at all times
Entry facilities should be suitable for people with
disabilities, such as limited mobility and poor vision
The entry can incorporate an airlock space and may have
sensor or automatically opening doors to facilitate access.
RUIO.5 A Patient Lounge Area is required for therapeutic and social Floor Plan
purposes.
Patient Lounge Area
Guidelines:
62
These include reading, writing and watching television or videos.
The Lounge, Kitchenette and Dining Areas may be combined in a
large Multi‐purpose Day Room or in separate but adjacent areas.
Guidelines:
Design considerations include:
An area large enough to allow vehicles including
ambulances to turn and maneuver
A large space with blank wall space for temporary storage
of items such as linen or food trolleys, furniture or
equipment for repair
Access to soiled linen should only be available through the
service entry or in large institutions separate zones may be
available for the various utilities and deliveries
Adequate infection control
A loading bay that gives access for delivery staff and staff
loading equipment and mobility aids into vehicles, located
away from the client entry point
RUIO.7 An area should be provided near the entrance for parking Floor Plan
wheelchairs and electric scooters.
Wheelchair Bay
Guidelines:
The wheelchair parking area requires power outlets for recharging
of electric wheelchairs and scooters when they are not in use.
Cupboards may be provided over wheelchairs for additional
storage.
63
Patient handling measures may include ceiling hoist systems for
transfers from wheelchair to plinth, or mobile lifters. Mobile patient
lifters will require bays with power for recharging.
Privacy and Guidelines:
Confidentiality The majority of the therapy areas of the Unit are open space.
Further, the activities undertaken therein require hard, impervious
flooring (timber or sheet vinyl) and generate noise. Other areas
within the Unit require acoustic privacy in order to be effective or
prevent embarrassment such as Respiratory Treatment Rooms and
rooms used for women’s health disorders. Account should be taken
of the potential sources of noise within as well as from outside the
Unit. Solutions to the various acoustic characteristics and
requirements include:
Use of curtains and other soft fabrics
Use of solid core doors
Co‐locate potentially noisy areas
Strategic positioning of storage areas to create a sound
buffer
Carpet in patient areas is not recommended.
RUIO.10 Climate control features should be considered in the design of the Design Document
Unit.
Climate Control
Guidelines:
Good temperature control and ventilation in treatment areas as
work can be arduous for both patients and staff. It is important to
64
remember that certain patients such as those with spinal cord
injuries are unable to regulate their body temperature. It is
therefore imperative that the gymnasium is air conditioned.
Regardless of orientation, there must be means of sun control.
The rehabilitation process is often a long one with patients
commencing attendance at the Unit as inpatients and continuing as
outpatients. Consequently, the Unit should seek to provide a
welcoming and supportive environment as it is essential that
patients feel positive about returning to the Unit on a regular basis.
LUX levels Guidelines:
Natural lighting is essential in large treatment areas such as
gymnasiums and in Staff Rooms. Consideration should be given to
lighting levels for patients who are visually impaired.
The patient population of this unit in particular requires special
consideration in terms of safety as they will be at once disabled or
incapacitated and yet are being encouraged to be mobile and self‐
sufficient. Every aspect of unit design with regard to finishes,
surfaces and fittings must be assessed to determine the potential
for accidents or hazards to both patients and staff. Sanitary facilities
65
are where most accidents or mishaps occur, to both patients and
staff. In particular, consider:
Slippery or wet floors
Protrusions or sharp edges
Stability and height of equipment or fittings
Choice of floor covering
Handrails and wheelchair access are mandatory.
RUIO.14 Equipment, furniture, fittings and the facility itself should be Design Document and Material
designed and constructed to ensure that users are not exposed to Catalogs
Patient Safety avoidable risks or injury.
Guidelines:
It is essential that floor finishes are non‐slip and do not create ‘drag’
for patients using walking aids and wheelchairs. Height of light
switches need to abide by accessibility codes. Handrails on both
sides of corridors are recommended.
66
Guidelines:
The ambient temperature should be lower than the water
temperature for comfort of pool side staff and patients. Humidity
control needs to be provided to minimize condensation. A pool
cover may be considered to assist in maintaining water
temperature and to reduce heating costs.
67
Storage Areas Therapy equipment
Consumables, and pool supplies
Pool aids and exercise equipment
Personal property of patient and staff.
RUIO.29 The Water Treatment Plant Room should be located in close Floor Plan
proximity to the Hydrotherapy Pool with easy access for staff to
Accessibility monitor and service the water treatment systems. Design
Requirements for the Water Treatment Plant Room include the
following:
68
Ventilation, exhaust and/or air‐conditioning must be
designed to accommodate the heat loads of the specified
equipment
High level sound isolation is required to ensure noise
generated from this room does not invade the pool area
Structural Engineer's assessment must be sought for floor
load bearing capacity with respect to water treatment plant
equipment
Service access will be required around the perimeter of all
plant equipment
The room shall be provided with required drainage.
Guidelines:
The Water Treatment Plant Room is a lockable room for water
treatment plant equipment used in the hydrotherapy pool and may
include booster pumps and filters. Plant equipment must be
installed according to manufacturer's specifications.
69
Final Assessment
70
3.3 Final Assessment: High Risk Licensing Standards:
Specific Requirements‐ Physical Environment
Entrances, Exits, and Navigation
HRR Accr Std. Section of the Standard Required Documents
Standard
EEFO.2 The route to the main entrance is signed and easily identifiable from Site observation
Signage all major circulation roads.
Guidelines:
External Board of the facility is visible from the major circulation road.
EEFO.8 Egress/Exit maps are posted. Site observation
Signage
A EEFO.9 Exits are clearly marked with illuminated exits signs and directional Site observation
Signage arrows.
Guidelines: Evacuation Maps
The exits and emergency exit routes are marked in a way that will not
be modified or compromised in the case of a power outage. QCDD Approval
ADFO: Architectural Details
HRR Accr Std. Section of the Standard Required Documents
Standard
ADFO.1 Any operable windows in client rooms are restricted to inhibit Site observation
Windows elopement or self‐harm.
ADFO.2 Grab bars are installed in all client washrooms. Site observation
Accessibility Guidelines:
Grab bars, including those that are part of such fixtures as soap dishes,
are sufficiently anchored to sustain a concentrated load of 250 pounds
(113.40 kilograms). Grab bars installed in areas intended for use by
bariatric patients are designed and installed to sustain a concentrated
load of 1,000 pounds (453.59 kilograms).
EWFO: Housekeeping and Waste Management
HRR Accr Std. Section of the Standard Required Documents
Standard
71
A
HWFO.10 Hazardous substances are properly labeled and inaccessible to clients Site Observation
Labelling at all times.
HWFO.16 There are policies and procedures for handling clean, soiled and Policy & Procedure
Waste Management infectious linen.
P&P
HWFO.17 There is education and training for staff on safe handling of waste. Training Records
Waste Management Guidelines:
Training This education and training should be included as part of staff
orientation.
HWFO.19 There is a process to immediately segregate hazardous medical waste Site Observation
Waste Management based on a classification system. Policy & Procedure
Guidelines:
Segregation should always be the responsibility of the waste producer,
should take place as close as possible to where the waste is generated,
and should be maintained in storage areas and during transport.
Waste categories include: general waste, sharps, infectious waste,
highly infectious waste, cytotoxic waste, pharmaceuticals, and
chemicals.
HWFO.25 Medical waste is stored in a designated and appropriate area, Site Observation
Storage protected from the sun and animals, possessing good lighting and, at Policy & Procedure
minimum, passive ventilation.
Guidelines:
A storage location for health‐care waste should be designated inside
the health‐care establishment or research facility. The waste, in bags
or containers, should be stored in a separate area, room, or building of
a size appropriate to the quantities of waste produced and the
frequency of collection.
HWFO.26 Medical waste is stored in secure, labeled containers, appropriate to Site Observation
Storage the type of medical waste. Policy & Procedure
72
Emergency Preparedness
Reception
A
FEFO.3 There is a policy and procedure for removing faulty medical devices or Maintenance and operation
PPM Policies and equipment until repaired or replaced. manual
Procedures Guidelines: Site Observation
Documentation on the maintenance and repair of reprocessing
equipment assists with device tracking and recall.
74
A
DIFO.9 Diagnostic imaging staff members have appropriate training and Training Records
Staff Training competencies, and are licensed. Site Observation
Guidelines:
Staff are recruited and selected based on their qualifications, and
experience. There should be evidence in the form of QCHP practitioner
and radiation license.
A
DIFO.12 There are warning light(s) and posted safety signs at imaging room Site Observation
Signage entrances that restrict access when in use.
Guidelines:
75
Safety warnings may include radiation warning labels and hazards such
as the presence of magnetic fields for magnetic resonance imaging
procedures.
DIFO.17 There is sufficient protective equipment for staff operating diagnostics Site Observation
PPE with potential for radiation exposure.
Point‐of‐Care Testing
76
Examples of infection prevention and control policies and procedures
include a hand hygiene program and additional practices to limit
infections including respiratory etiquette promotion; antibiotic
resistant organism screening and management programs; policies
about preventing and controlling infections when services are
delivered in a home or community setting; procedures for handling
specimens, contaminated equipment, linen, or devices; policies
guiding certain practices, e.g., use of antibiotic prophylaxis in surgical
clients, use of aseptic practices such as sterile barriers when placing
central venous catheters, and invasive device insertion and
maintenance protocols; and procedures on how to identify and report
outbreaks to the appropriate public health authorities.
A
IPFO.4 There is a hand hygiene program in place, with access to hand wash Site Observation
Hand Hygiene sinks and alcohol‐based hand‐rub at the point of care.
Guidelines:
‘Point of care’ means that the product must be capable of being used
at the required moment, without leaving the zone of activity. It should
be located as close as possible (as resources permit) to where patient
contact is taking place.
The World Health Organization guidelines on hand hygiene require
that hand rubs be within three feet of where care is delivered in
hospitals, and there is growing support for placing hand rubs at the
bedside to provide reminders to staff. However, fire regulations or
other considerations may limit the placement of alcohol‐based rubs.
In community‐based organizations and other organizations without
beds, hand rubs are placed as close to the point‐of‐care as possible,
e.g. in the clinic room, at the entrance to the client's room, or directly
in the client's home. Staff may also carry hand rubs with them.
IPFO.7 There is a process of triage, screening, and assessment for clients who Site Observation
Triage for screening present with symptoms of acute infection.
Infection
General Reprocessing
A
RPFO.7 Staff members assigned to reprocess medical devices have completed Training Records/Certificate
Staff Training a recognized course in reprocessing.
Guidelines:
A recognized course includes minimum theoretical and practicum
components, with a curriculum approved by a relevant authority.
A
RPFO.9 There is a policy and procedure in place to prevent the reprocessing of Policy & Procedure
Singe use policy Single‐use medical devices. Site Observation
RPFO.10 Devices are reprocessed in a designated area that is physically Site Observation
Re processing area separate from direct care areas and from where clean, disinfected, or
Labelling sterile items are handled or stored.
RPFO.13 Sterilizers are rigorously tested on installation and following any Sterilization records
Sterilization Test disruption of their regular use, with documentation maintained. Site Observation
Medication Management
Receiving and Storing Medication
A
RSFO.3 Medications are located in a secure, medication room, or cart to which Site Observation
Secured Access only authorized staff have access.
A
RSFO.9 Look‐alike, sound‐alike, and different concentrations of the same Site Observation
Medication Storage medication are separated.
Guidelines:
79
Separating or isolating these types of medications in the medication
storage area prevents confusion and promotes safety.
Prescribing and Dispensing Medication
Administering Medications
80
3.4 Final Assessment: Licensing Standards
Specific Requirements‐ Physical Environment
Compliance and Accountability
81
A
EEFO.9 Exits are clearly marked with illuminated exits signs and directional Site observation
Signage arrows. Evacuation Maps
Guidelines: QCDD Approval
The exits and emergency exit routes are marked in a way that will
not be modified or compromised in the case of a power outage.
Architectural Details
82
Environment:
A
HWFO.3 The following spaces are clean and in good repair: Site observation
Cleaning activities Entrance, reception area, and male and female waiting area(s) Cleaning procedure/schedule and
Furnishings in waiting areas checklist
Restrooms
Windows and window treatments
Doors, sills, tracks, and door closure mechanisms
Examination rooms
Guidelines:
Cleaning activities include cleaning all surfaces including walls,
windows, and ceilings; removing waste; promptly cleaning and
managing spills; and maintaining general tidiness. The organization's
procedures outline the cleaning schedule and expectations for
documenting the frequency of cleaning; the choice of cleaners or
disinfectants, e.g. hospital grade disinfectant with valid drug
identification number, the proper dilution, and effective contact
time; and cleaning protocols for equipment such as brooms and
mops.
83
A
HWFO.10 Hazardous substances are properly labeled and inaccessible to Site Observation
Labelling clients at all times.
HWFO.11 Nothing is stored under sinks in any location, except for the Site Observation
Storage requisite cleaning supplies.
HWFO.12 When spills or leaks occur, they are wiped up promptly and spill kits Site Observation
Spill kits are available.
HWFO.13 There are no uncontrolled, unpleasant odours. Site Observation
Odours
HWFO.14 There is a waste management plan and contract based on facility Waster Management plan/Policy
Waste Management type and size. Site Observation
plan/Policy Guideline:
Plan should include procedures to be followed in safe handling of
waste.
84
85
The most appropriate way of identifying the categories of health‐
care waste is by sorting the waste into colour‐coded plastic bags or
containers.
Instructions on waste separation and identification should be
posted at each waste collection point to remind staff of the
procedures.
A
HWFO.22 Puncture‐resistant sharps containers are available at the point‐of‐ Site Observation
Waste containers care.
Guidelines:
Sharps include needles and blades. (any items causing puncture or
wound)
HWFO.23 There is a policy and procedure for appropriate storage and disposal Waste Management policies
Waste Management of sharps. Site Observation
HWFO.24 All waste containers are clean inside and outside and have self‐ Site Observation
Waste containers closing lids.
HWFO.25 Medical waste is stored in a designated and appropriate area, Site Observation
Waste Management protected from the sun and animals, possessing good lighting and,
at minimum, passive ventilation.
Guidelines:
A storage location for health‐care waste should be designated
inside the health‐care establishment or research facility. The waste,
in bags or containers, should be stored in a separate area, room, or
building of a size appropriate to the quantities of waste produced
and the frequency of collection.
HWFO.26 Medical waste is stored in secure, labeled containers, appropriate Site Observation
Waste Management‐ to the type of medical waste.
Labelling
HWFO.27 Access to the storage sites is limited to authorized personnel only. Site Observation
Waste Management‐
Access
HWFO.28 There is a process to transport waste to storage sites within the Policy & Procedure
Waste Management facility and external to the facility for processing. Site Observation
Process
86
A
EPFO.5 There is a written emergency preparedness and response plan. Emergency Preparedness plan
Emergency Guidelines:
Preparedness plan The plan identifies immediate actions to respond to disasters and
emergencies including internal and external functional roles and
responsibilities (e.g., those of community partners) and establishes
lines of authority. The disaster and emergency plans are integrated
with partner organizations and governments to facilitate
coordinated, large‐scale responses as required.
EPFO.6 The written emergency plan identifies: Emergency Preparedness plan
Emergency (i) roles and responsibilities in an emergency;
Preparedness plan (ii) information about the fire safety system and equipment;
87
(iii) emergency preparedness and response procedures for an
all‐hazard plan
EPFO.7 Fire safety plans are developed and available concerning the QCDD Approval
Fire safety Plan protection of all persons in cases where occupants cannot Stamped Fire Drawings
independently evacuate. Fire safety plans provide the following:
i) Use of alarms;
ii) Transmission of alarms to fire department;
iii) Emergency phone call to fire department;
iv) Response to alarms;
v) Isolation of fire;
vi) Evacuation of immediate area;
vii) Evacuation of smoke compartment;
viii) Preparation of floors and building for evacuation;
ix) Extinguishment of fire
EPFO.8 The fire safety plan is prepared and administered by the health care Emergency Preparedness plan
Designation facility’s designated fire safety officer.
EPFO.9 Exit means are maintained free and unobstructed at all times. Site Observation
Egress
EPFO.10 A copy of the fire safety plan is posted at or near the reception area Site Observation
Fire Safety Plan in the facility.
EPFO.11 The building is equipped with emergency response (life safety) Site Observation
Emergency Response equipment, including a defibrillator and a crash cart (emergency
Equipment medications).
EPFO.12 The building is equipped with fire extinguishers that are checked Site Observation. Check list
Fire Extinguishers and tagged monthly.
EPFO.13 The building is equipped with a sufficient number of fire blankets as Site Observation, QCDD Approval
Fire Safety Blankets deemed necessary by the fire safety officer.
EPFO.14 Staff members are trained in the use of fire extinguishers. Training Records
Training
EPFO.15 There is a policy and procedure to regularly inspect all components PPM (Plan Preventive Maintenance)
Fire Safety of the fire safety system, boilers, pressure vessels, and pressure
Maintenance Policy piping systems and documentation of inspection is maintained.
Reception
88
A
RCFO.6 There is a policy on retention, storage and removal of Client Retention Policy
Retention Policy Records.
Guidelines:
Client records are retained for a minimum of five years after the
date of registration, or as outlined in applicable legislation.
RCFO.7 Reception staff maintain: Site Observation
Staff/Service List • A medical staff list
• A service/test list
Guidelines:
Each department should include the type of medical services or
tests they provide.
RCFO.8 Ministry approved price list for services is displayed at a visible Price List
Price List place within the healthcare facility. Site Observation
RCFO.9 Fax machines are located and positioned in a way to ensure the Site Observation
Fax machines confidentiality of client information.
89
A
FEFO.2 There is a documented preventive maintenance program in place Planned Preventive Maintenance
Planned Preventive for the health care facility’s building systems, equipment, and (PPM)/Checklist
Maintenance medical devices.
(PPM) Guidelines:
An effective preventive maintenance program helps the
organization ensure medical devices, building systems, and
equipment are safe and functional. It also helps identify and address
potential problems with medical devices, medical equipment, or
medical technology that may result in injury to staff or clients.
A
FEFO.3 There is a policy and procedure for removing faulty medical devices Operational & Maintenance Plan
PPM or equipment until repaired or replaced.
Guidelines:
Documentation on the maintenance and repair of reprocessing
equipment assists with device tracking and recall.
A
FEFO.4 Ventilation systems are installed in the facility, especially where HVAC drawings for storage area, site
Ventilation System chemicals are used. observation
Guidelines:
Considerations include maintaining heating, ventilation, and air‐
conditioning systems that control temperature, humidity, odours,
90
and availability of fresh air; preventing exposure to second‐hand
smoke.
A
FEFO.6 There is a process to regularly monitor water quality and respond Water Disinfection Report from
Water Quality when results are out of the acceptable range. Authorized Labs
Guidelines:
The organization maintains records of its testing and water quality
in accordance with applicable legislation.
FEFO.7 Biohazard areas are kept locked. Site Observation
Secured Access
FEFO.8 Biohazard signs are available and used in all areas in which Site Observation
Signage biohazards are used and/or stored.
FEFO.9 All windows have insect‐netting installed. Site Observation
Windows
FEFO.10 There is air conditioning in all rooms. Site Observation
HVAC
FEFO.11 Parking lots, walkways, ramps, and corridors are free of clutter. Site Observation
FEFO.12 Water and gas shut‐off are clearly marked. Site Observation
Water and Gas Shut
Off Signs.
FEFO.13 The emergency generators are checked and load‐tested with Load Test Documentation, Testing
Load Test Documents documentation. Reports.Site Observation
Client Care Areas
91
Provision are made to preserve patient privacy from observation
from outside the examination/treatment room through an open
door.
CCFO.3 Client care areas are equipped with private, separate, and secure Site Observation
Client Cubicle spaces for both male and female clients to change.
CCFO.4 Single‐use bibs or drapes are used to protect clients’ clothing, and Site Observation
Dental Section reduce their exposure to spatter and debris created during dental
PPE for Clients procedures.
CCFO.5 Where general, personal or community dental services are to be GA Drawings
Dental Section provided from new or significantly refurbished facilities, the
following facilities will be required (dental treatment room;
decontamination suite; clean utility room; sub‐wait/sitting recovery
area). (HBN 11‐01, Dental Cluster 7.59)
CCFO.6 The dental treatment room shall contain specialist built‐in Room Data Sheet (RDS)
Dental Section cabinetry, a reclining chair, ceiling mounted lamp, wall‐mounted
inter‐oral periapical X‐ray machine and a console adjacent to the
chair supplying dental gases. ( HBN 11‐01 , Dental Cluster 7.73)
CCFO.7 Dental gases may be piped from a central manifold or provided Medical Gas drawings
Dental Section from bottles. If a bottle store is provided, it should be located on an Site verification
outside wall with good ventilation. When nitrous oxide is used, a
gas scavenging system must be fitted.
CCFO.8 Clinical contact surfaces are protected from contamination by the Site Observation
Dental Section use of barriers (e.g., clear plastic wrap, paper sheets).
Contact Surface
Support Areas – Food Preparation
92
93
A
DIFO.9 Diagnostic imaging staff members have appropriate training and QCHP license
QCHP license competencies, and are licensed.
Guidelines:
Staff are recruited and selected based on their qualifications, and
experience. There should be evidence in the form of QCHP
practitioner and radiation license.
A
DIFO.10 There is a diagnostic imaging department organization chart that Organization Chart
Organization Chart clearly defines reporting relationships and lines of accountability.
A
DIFO.11 The medical director and all physicians providing diagnostic imaging QCHP License
QCHP License are imaging specialists credentialed by the appropriate professional
college and licensed to practice.
A
DIFO.12 There are warning light(s) and posted safety signs at imaging room Site Observation
Warning lights entrances that restrict access when in use.
Guidelines:
Safety warnings may include radiation warning labels and hazards
such as the presence of magnetic fields for magnetic resonance
imaging procedures.
A
DIFO.13 All chemicals and solutions are appropriately labeled and stored in Site Observation
Material Safety Data compliance with applicable regulations.
Sheet (MSDS) Guidelines:
94
Material Safety Data Sheet (MSDS) and Manufacturer
recommendation should be incorporated for labelling and storing.
A
DIFO.14 Staff follows regulations to register, install, and calibrate diagnostic MOPH equipment approvals,
Approvals and reports imaging equipment. Installation and calibration reports
A
DIFO.15 Diagnostic imaging providers are trained on the diagnostic imaging Training certificates
Training certificates equipment prior to use.
Guidelines:
Training is provided by appropriate personnel (e.g. equipment
manufacturer) on new equipment and following upgrades and/or
updates to existing equipment. Evidence of approval of equipment
from Ministry of Public Health.
DIFO.16 There is a program for radiation exposure monitoring and records Radiation Protection policy
Radiation Protection are maintained as appropriate.
policy
DIFO.17 There is sufficient protective equipment for staff operating Site Observation
PPE diagnostics with potential for radiation exposure.
A
DIFO.18 There is an equipment log in which staff record equipment Equipment Log and checklist
Equipment checklist problems, downtime and maintenance.
A
DIFO.19 There is a policy and procedure for client verification. Client verification policy
Client verification Guidelines:
policy The team uses at least two methods (e.g. name and date of birth) to
identify a client before providing any service or procedure.
The team confirms the client's identity, nature, and site of the
procedure.
A
DIFO.20 There is a policy, procedure on informed consent. Informed consent Medication Administration Policy
Medication forms are readily available.
Administration Guidelines:
Information about the diagnostic imaging examination is reviewed
with clients and their families, including the reason the examination
was chosen, the benefits, risks and alternatives (if applicable), and
the diagnostic information expected. This information can be
provided to clients by the referring medical professional. However,
the team reviews this information with the client as part of the
process for obtaining informed consent.
95
A
DIFO.21 There is a protocol for managing clients who are or may be Consent policy
Consent policy pregnant Staff Interviews
Guidelines:
For procedures involving radiation to the abdomen or pelvis on
women, the team asks female clients of childbearing age if they are
or may be pregnant and documents the response..
A
DIFO.22 There is a safety manual adapted for diagnostic imaging services. Safety manual.
Safety manual. Guidelines:
The safety manual includes requirements specific to diagnostic
imaging services such as client and staff safety; equipment safety;
radiation safety; magnetic safety; fire safety; electrical safety;
compressed gases; chemicals, solutions, and radioactive material;
waste management and disposal; and infection control.
Point‐of‐Care Testing
A
PTFO.3 There are standard operating procedures for the tests performed. SOPs
SOP (Standard Guidelines:
Operational There is an SOP for each test, and the SOP contains the purpose and
Procedures) limitations of the test; step‐by‐step instructions on how to properly
complete the test and use the corresponding instruments;
reference ranges for the results, including critical values; criteria for
accepting and rejecting samples; quality control procedures; and
literature references.
Primary Care
96
97
CLFO.1 The organization verifies that it meets all terms, specifications, and
Scope of Service health and medical conditions as prescribed by applicable
legislation.
Staffing
HRR Accr Std. Section of the Standard Required Documents
Standard
SFFO.1 Health care facilities that provide assessments, treatments, or admit QCHP License
Staff License clients for convalescing are managed by a physician licensed to
practice in the state of Qatar.
SFFO.2 There is a policy and procedure for identification for all staff, service Site Observation
Staff IDs providers, temporary workers and visitors to the facility.
A
SFFO.3 There is an Organization chart that clearly defines Organization Chart
Organization Chart supervision/reporting relationships for staff.
Guidelines:
Reporting relationships are reflected in the chart and understood by
everyone in the health care facility. They are aligned with the
facility’s structure; the scope and type of services offered; efficient
and effective leadership and teamwork throughout the
organization.
SFFO.4 The staffing plan at minimum adheres to applicable legislation. Staffing Plan
Staffing Plan Guidelines:
Each healthcare facility should comply with the applicable
legislation as to the required staffing regulations. These regulations
are available in the MOPH website.
SFFO.5 There is a policy and procedure to protect client privacy and Policy & Procedure
Confidentiality confidentiality.
Policies and Procedures
98
Hazards
WSFO.4 There is a program to effectively manage the Globally Harmonized MSDS
MSDS System of Classification and Labeling of Chemicals (GHS) and Safety Site Observation
Data Sheets (SDS).
WSFO.5 There is a program to address the prevention and management of Workplace Safety Program
Workplace Safety occupational illness and injury.
Program
WSFO.6 There are written measures to protect staff who might be exposed Workplace Safety Program
Workplace Safety to hazardous biological, chemical, or physical agents.
Program Guidelines:
Written measures should include processes for managing exposure
to these hazards, for example: reporting instructions, immediate
first aid etc.
WSFO.7 Personal protective equipment (PPE) is provided for all staff, PPE
PPE applicable to their roles. Site Observation
WSFO.8 Safety‐engineered needles or needleless systems are used in place Site Observation
Safety Engineered of conventional hollow‐bore needles.
Needles
WSFO.9 There is an adequate number of first aid kits located strategically Site Observation
First aid throughout the health care facility.
Infection Prevention and Control
Compliance and Accountability
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When developing its policies and procedures, the health care facility
considers trends in diseases and infections in the community; their
strategic direction and objectives; the availability of resources; the
services offered by the facility, including service setting and multiple
sites; and scientific research, best practice, and standards of
practice related to infection prevention and control.
Examples of infection prevention and control policies and
procedures include a hand hygiene program and additional
practices to limit infections including respiratory etiquette
promotion; antibiotic resistant organism screening and
management programs; policies about preventing and controlling
infections when services are delivered in a home or community
setting; procedures for handling specimens, contaminated
equipment, linen, or devices; policies guiding certain practices, e.g.,
use of antibiotic prophylaxis in surgical clients, use of aseptic
practices such as sterile barriers when placing central venous
catheters, and invasive device insertion and maintenance protocols;
and procedures on how to identify and report outbreaks to the
appropriate public health authorities.
IPFO.2 A designated and qualified staff member is responsible for IPAC Organization chart and
IPAC leader overseeing the IPAC program. Credentials
A
IPFO.3 There are clear reporting relationships and reporting procedures for Organization chart and JD, procedure
IPAC Reporting all IPAC‐related issues.
Guidelines:
All staff play a role in preventing and controlling infections. Staff
roles include how to conduct risk assessments, select appropriate
precautions, follow routine practices, and properly place or isolate
clients with or at risk for infection. It is important for everyone to
understand their role and the roles of others in the facility.
A
IPFO.4 There is a hand hygiene program in place, with access to hand wash Policies & Procedures
Hand Hygiene Policy sinks and alcohol‐based hand‐rub at the point of care. Site Observation
Guidelines:
‘Point of care’ means that the product must be capable of being
used at the required moment, without leaving the zone of activity.
101
It should be located as close as possible (as resources permit) to
where patient contact is taking place.
The World Health Organization guidelines on hand hygiene require
that hand rubs be within three feet of where care is delivered in
hospitals, and there is growing support for placing hand rubs at the
bedside to provide reminders to staff. However, fire regulations or
other considerations may limit the placement of alcohol‐based rubs.
In community‐based organizations and other organizations without
beds, hand rubs are placed as close to the point‐of‐care as possible,
e.g. in the clinic room, at the entrance to the client's room, or
directly in the client's home. Staff may also carry hand rubs with
them.
IPFO.5 Alcohol‐based hand‐rub, masks, and tissues are available in the Site Observation
IPC Personal reception area.
Protection
IPFO.6 Signs are posted in reception area(s) to advice clients and visitors Site Observation
IPC Signage where to report signs of acute infection (e.g., cough, fever,
vomiting, and diarrhea).
IPFO.7 There is a process of triage, screening, and assessment for clients Site Observation
IPC Triage who present with symptoms of acute infection.
General Reprocessing
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A
RPFO.6 There are written policies and procedures for reprocessing that are Policies and procedure
Policies and procedure based on current recognized standards.
Guidelines:
The policies include staff and management responsibilities; staff
qualifications, including training, education, and competency
assessment; infection prevention and control; the establishment
and maintenance of policies and procedures; staff health and
safety; and the requirements of subcontractors. They also address
ongoing quality assurance, including controls to ensure medical
devices and equipment are functional and sterile before being
released from the sterilization area; recall procedures; the
evaluation and purchase of reprocessing equipment; and back‐up
and contingency planning regarding inventory and temporary
shortages.
A
RPFO.7 Staff members assigned to reprocess medical devices have Training Certificate
Staff Training completed a recognized course in reprocessing.
Guidelines:
A recognized course includes minimum theoretical and practicum
components, with a curriculum approved by a relevant authority.
A
RPFO.8 A recognized classification system is used to determine the level of Operational Procedures
Operational reprocessing required.
Procedures‐ Guidelines:
Reprocessing A classification system, e.g., the Spaulding Classification System,
categorizes medical devices based upon their use and the risk of
infection associated with their use in order to determine the
cleaning and reprocessing required to prevent infection.
The facility uses the classification system to identify critical, semi‐
critical, and non‐critical items, and each classification has
requirements for decontamination, cleaning, and disinfection or
103
sterilization that reduce the risk of infection. An item that only
comes into contact with clients' intact skin, i.e., blood pressure
cuffs, stethoscopes, may be classified as non‐critical and require
low‐level disinfection. Items that contact mucous membranes are
considered semi‐critical and require high‐level disinfection. Those
that enter sterile spaces or contact non‐intact skin are critical
devices and must be sterile. The classification system clearly states
that critical items may be used for non‐critical activities or
procedures, but non‐critical items may not be used for critical
activities or procedures.
A
RPFO.9 There is a policy and procedure in place to prevent the reprocessing Policy & Procedure
Single use Policy of Single‐use medical devices. Site Observation
RPFO.10 Devices are reprocessed in a designated area that is physically Site Observation
Reprocessing area separate from direct care areas and from where clean, disinfected,
or sterile items are handled or stored.
A
RPFO.11 Staff members contain and transport contaminated items to the Site Observation
Containment and reprocessing area. Staff training, Procedure
transport Guidelines:
The health care facility follows formal criteria for containing used
items and transporting them to and from the area where they are
sterilized. Reprocessing may be done in a specific area of the
organization or at another site, or be outsourced to a private
company.
RPFO.12 The sterilization section of the reprocessing area includes the Site Observation
Reprocessing area sterilizer and related supplies, with adequate space for loading,
unloading and cool down.
RPFO.13 Sterilizers are rigorously tested on installation and following any Sterilization test records
Sterilization test disruption of their regular use, with documentation maintained.
records
Outbreaks and Pandemics
104
A
OPFO.2 There is an outbreak management system in place for detecting, Disaster Plan
Disaster Plan managing and controlling disease outbreaks that:
(a) Defines staff responsibilities
(b) Defines protocols for communication and reporting
Medication Management
Compliance and Accountability
A
RSFO.3 Medications are located in a secure, medication room, or cart to Site Observation
Secured Access which only authorized staff have access.
A
RSFO.4 Medication storage areas are visibly clean, effectively ventilated and Site Observation
Medication Storage adequately lit, with a method of ensuring temperature control, in
105
accordance with manufacturers’ specifications for the medications
stored.
Guidelines:
The team maintains a clutter‐free environment where medications
are stored. Annex 9 of the World Health Organization WHO Expert
Committee on Specifications for Pharmaceutical Preparations: 37th
Report (http://who.int/) provides a guide to good storage practices
for pharmaceuticals.
Appropriate storage conditions pertain to temperature
(refrigerator), lighting, packaging, and delivery containers.
RSFO.5 Medication storage areas are used exclusively for medications and Site Observation
Medication Storage medication‐related supplies.
RSFO.6 Medications that require cold chain storage are kept within the Site Observation
Medication Storage manufacturer’s designated limits as all times during storage or
transportation.
RSFO.7 Medication refrigerators are clean and organized and no non‐ Site Observation
Medication Storage medication items are stored in them.
A
RSFO.8 The temperature of all medication refrigerators is checked regularly Check list
Medication Storage and documentation maintained. Site Observation
Guidelines:
The team is aware of and follows the manufacturer’s recommended
storage temperature for each type of medication stored. Ensuring a
consistent temperature in the refrigerator is essential to preserving
the efficacy and safety of medications, including the vaccine cold
chain.
A
RSFO.9 Look‐alike, sound‐alike, and different concentrations of the same Site Observation
medication are separated.
Medication Storage Guidelines:
Separating or isolating these types of medications in the medication
storage area prevents confusion and promotes safety.
RSFO.10 Medications are separated and categorized by route of Site Observation
Medication Storage administration.
A
RSFO.11 Medication labels are clear and distinctive, with an alert system Site Observation
Labelling used as necessary for high‐alert/high‐risk medications.
106
Guidelines:
Accurate identification of medications is required. Abbreviations
that can be misinterpreted or involved in harmful medication errors
are not be used.
A
RSFO.12 Emergency medication is maintained, readily accessible in client
Emergency Medication service areas and audited regularly.
Prescribing and Dispensing Medication
A
AMFO.2 Medications remain in the original labelled container or as packaged Site Observation
Labeling by the pharmacy until administered.
Guidelines:
Administration may be at the client's bedside or in an ambulatory,
community, or home setting.
107
A
AMFO.3 Medication reference materials are available to staff members Medication Reference Material
Medication Reference administering medications. Site Observation
Material Guidelines:
Medication‐related information is available in written and/or
electronic formats, and is available through consultation with the
pharmacy, medication reference texts, and infusion charts.
A
AMFO.4 There is a written policy requiring the 5 R’s to be used when Policy & Procedure
Medication administering medications: Site Observation
Administration Policy • Right patient
• Right medication
• Right dose
• Right time
• Right route
108
109
Renewal and Ad‐Hoc Assessment:
Renewal Assessment: Healthcare facilities are required to renew their license annually. Therefore, the Licensing specialist will communicate
with the focal point of the facility three month prior to the license expiratory date and provide them with the required Licensing standards as per
facility type and services. The health care facility is evaluated against the appropriate Licensing Renewal Protocols according to their facility type
and services. During the license renewal, the inspector will evaluate compliance with each requirement through:
Visual examination of the facility, grounds, and equipment
Review of documents, including policies, procedures, and plans
Interviews with the leadership, staff, and clients and families
Following a successful annual renewal inspection, the annual license to operate is issued.
Ad‐Hoc Assessment: These inspections are initiated following a complaint, a critical incident, and unreported constructions and/ or
renovations. Complaints, critical issues and other items are gathered by the Healthcare Facilities Licensing team and reviewed by Licensing
Specialists. This information can come from a variety of sources, including, but not limited to Accreditation Surveyors, Labaih (Public Complaint
Portal), the Minister’s Office and the Fitness of Practice Office (Qatar Council for Healthcare Practitioners). These inspections are conducted
without prior notice to the healthcare facility and may occur on any day after a complaint or critical incident has been identified.
3.5 Renewal and Ad‐Hoc Assessment: High Risk Licensing Standards
SFL: Staff
HRR Accr Std. Section of the Standard Required Documents
Standard
SFL.1 Health care facilities that provide assessments, treatments, or QCHP License
QCHP License admit clients for convalescing are managed by a physician licensed
to practice in the state of Qatar.
SFL.3 The current health care facility license, service agreements, and Facility License
License/Price List payment receipts are kept at the head office of the
establishment/healthcare facility to be submitted to the relevant
authority upon request.
110
Guidelines:
For example, physicians should be licensed by the applicable
regulatory authorities and certified by the appropriate college.
Requirements for other health professionals, including nurses and
other allied health providers, will differ by profession and
jurisdiction. The qualifications of team members who are not
regulated by professional bodies, i.e., unregulated health providers
such as personal support workers are also verified.
PPL: Policies and Procedures
HRR Accr Std. Section of the Standard Required Documents
Standard
PPL.9 There are procedures in place to immediately report to security Policy & Procedure
Reporting Policy authorities about any accidents, deaths, or suspicious diseases that
occur in the facility.
Guidelines:
Policy should include steps and processes to be followed in the
advent of a reportable incident.
FML: Financial Management
HRR Accr Std. Section of the Standard Required Documents
Standard
FML.2 There are written policies and procedures to guide the operating Policy & Procedure
Policies and capital budget planning and reporting. Reporting structure
Guidelines:
The policies include who is responsible for overseeing financial and
administrative functions. The policies and procedures are approved
by the relevant authority and a copy of the approval is retained.
Changes to the policy must also be approved.
EPL: Emergency Preparedness and Response
HRR Accr Std. Section of the Standard Required Documents
Standard
A EPL.4 The components of the emergency plan are tested through regular Records/check list
Emergency Plan drills and exercises. Site Observation
Guidelines:
111
Depending on the level of risk, regular testing of at least one type of
emergency or one element of the plan is done at least quarterly
and annual evacuation drills are held for each shift. The timing and
frequency of drills and exercises may depend on the time sensitivity
or complexity of the emergency plans. A facility that experiences a
high degree of staff turnover may need more frequent exercises.
Often training and exercise schedules can be linked to seasonal
hazards or to trigger events. As many staff as possible should be
encouraged to participate in testing disaster and emergency plans,
and participation should be monitored and documented.
EPL.7 Fire safety plans are developed and available concerning the Fire Safety Plan
Fire Safety Plan protection of all persons in cases where occupants cannot Site Observation
independently evacuate. Fire safety plans provide the following:
i) Use of alarms;
ii) Transmission of alarms to fire department;
iii) Emergency phone call to fire department;
iv) Response to alarms;
v) Isolation of fire;
vi) Evacuation of immediate area;
vii) Evacuation of smoke compartment;
viii) Preparation of floors and building for evacuation;
ix) Extinguishment of fire
EPL.12 The building is equipped with emergency response (life safety) Site Observation
Emergency Response equipment, including a defibrillator and a crash cart (emergency
Equipment Medications).
EPL.13 The building is equipped with fire extinguishers that are checked Site Observation
Fire Extinguisher and tagged monthly. Check list
EPL.16 Established procedure is followed to regularly inspect all Site Observation
Fire Safety System components of the fire safety system, boilers, pressure vessels, and Policy & Procedure
pressure piping systems and documentation of inspection is
maintained.
112
WSL: Workplace Health and Safety
HRR Accr Std. Section of the Standard Required Documents
Standard
WSL.4 There are no observable hazards in the building Site Observation
Hazards
WSL.10 The eye wash bottles are available and checked regularly Site Observation
Eye Wash
WSL.11 There are written measures to protect staff who might be exposed Protocols/Policy & Procedure
Staff safety to hazardous biological, chemical, or physical agents.
Guidelines:
Written measures should include processes for managing exposure
to these hazards, for example: reporting instructions, immediate
first aid etc.
WSL.12 Personal protective equipment (PPE) is provided for all staff, PPE
PPE applicable to their roles. Site Observation
Physical Environment – Process Requirements
RCP: Reception
HRR Accr Std. Section of the Standard Required Documents
Standard
RCP.5 Reception staff maintain the registration book, which is stamped by Site Observation
Registration Book MOPH and includes the following information for each client: Registration Book
Name and Surname
Qatar ID
Age
Address
Date of Admission and Discharge
RCP.6 There is a Patient file maintained by medical staff where the Site Observation
Patient File diagnosis and condition of each patient are recorded.
RCP.9 Ministry approved price list for services is displayed at a visible Price List
Price List place within the healthcare facility. Site Observation
113
FMP: Facility and Equipment Maintenance
HRR Accr Std. Section of the Standard Required Documents
Standard
A FMP.2 There is a documented preventive maintenance program in place PPM
PPM for the health care facility’s building systems, equipment, and Site Observation
medical devices.
Guidelines:
An effective preventive maintenance program helps the
organization ensure medical devices, building systems, and
equipment are safe and functional. It also helps identify and
address potential problems with medical devices, medical
equipment, or medical technology that may result in injury to staff
or clients.
114
115
Infection Prevention and Control
IPI: IPAC Program
HRR Accr Std. Section of the Standard Required Documents
Standard
A IPI.1 There are clear written policies and procedures for the infection Policy & Procedure
IPAC Program prevention and control (IPAC) program.
Guidelines:
When developing its policies and procedures, the health care
facility considers trends in diseases and infections in the
community; their strategic direction and objectives; the availability
of resources; the services offered by the facility, including service
setting and multiple sites; and scientific research, best practice, and
standards of practice related to infection prevention and control.
Examples of infection prevention and control policies and
procedures include a hand hygiene program and additional
practices to limit infections including respiratory etiquette
promotion; antibiotic resistant organism screening and
management programs; policies about preventing and controlling
infections when services are delivered in a home or community
setting; procedures for handling specimens, contaminated
equipment, linen, or devices; policies guiding certain practices, e.g.,
use of antibiotic prophylaxis in surgical clients, use of aseptic
practices such as sterile barriers when placing central venous
catheters, and invasive device insertion and maintenance protocols;
and procedures on how to identify and report outbreaks to the
appropriate public health authorities.
116
and targets those settings with high‐risk populations, e.g., the
elderly, immune‐suppressed or surgical clients, and those in high‐
risk environments, e.g. in the home, long term care, the operating
room, or the intensive care unit.
Staff participate in the infection prevention and control education
program on hiring, i.e. at orientation, and on a regular basis
thereafter, i.e. annually or biannually.
117
118
119
120
3.6 Renewal and Ad‐Hoc Assessment Licensing Standards:
Leadership:
Leadership is fundamental for every successful organization. In health care, leaders need to ensure regulatory compliance as well as quality and
safety for clients. They need to manage and sustain change and effectively collaborate with colleagues, staff members and clients. The licensing
requirements clarify the leadership and management systems needed to operate a healthcare organization effectively.
The Leadership Protocol contains content in the following areas:
• Compliance and Accountability
• Staff
• Policies and Procedures
• Financial Management
• Emergency Preparedness and Response
• Workplace Health and Safety
Leadership
CAL: Compliance and Accountability:
HRR Accr Std. Section of the Standard Required Documents
Standard
CAL.1 Leaders have implemented programs and processes to operate all
aspects of the organization in compliance with requirements.
CAL.2 When areas of non‐compliance are identified, leaders take immediate Quality Improvement plan
Quality Improvement action to correct any deficiencies and use “lessons learned” to guide
sustainable improvement.
CAL.3 The organization verifies that it meets all terms, specifications, and Scope of service
Scope of Service health and medical conditions as prescribed by applicable legislation.
SFL: Staff
HRR Accr Std. Section of the Standard Required Documents
Standard
SFL.1 Health care facilities that provide assessments, treatments, or admit QCHP License
License clients for convalescing are managed by a physician licensed to
practice in the state of Qatar.
121
A
SFL.6 There is an Organization chart that clearly defines Organization chart
Organization chart supervision/reporting relationships for staff.
Guidelines:
Reporting relationships are reflected in the chart and understood by
everyone in the health care facility. They are aligned with the facility’s
structure; the scope and type of services offered; efficient and
effective leadership and teamwork throughout the organization.
SFL.7 There is a written staffing plan that meets the safety needs of clients. Staffing Plan
Staffing Plan
SFL.8 There is a policy and procedure to protect client privacy and Policy & Procedure
Client privacy and confidentiality. Site Observation
confidentiality.
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A
PPL.2 There is an operational plan to guide work in the coming year. Operational Plan
Operational Plan Guidelines:
An operational plan is a detailed, short‐term term plan used to
implement the strategic plan.
A typical operational plan outlines: clear objectives; services to be
delivered; quality standards; desired outcomes; staffing and resource
requirements; implementation timetables; and a process for
monitoring progress.
PPL.3 There are sufficient equipment, tools, and instruments to provide List of Equipment & Supplies
Equipment & Supplies necessary care and treatment, and meets any applicable legislation. Site Observation
PPL.4 There are procedures in place to ensure that there are no outdated or Procedure
Outdated supplies expired supplies in use. Site Observation
PPL.5 There is a written smoking policy that prohibits smoking except in Policy & Procedure
Smoking Policy designated areas. Site observation
Guidelines:
123
Policy should consider that smoking is not permitted in any hazardous
locations, such as areas containing flammable liquids, combustible
gases, or where oxygen is used or stored.
PPL.6 Smoking is not permitted in any hazardous location, such as areas Policy & Procedure
Smoking Policy containing flammable liquids, combustible gases, or where oxygen is Site observation
used or stored.
PPL.7 There is a policy and procedure to respond to and resolve complaints Policy & Procedure
Compliant Policy and disputes between the organization and its clients. Site observation
A
PPL.8 There is a procedure in place to identify and manage adverse events Policy & Procedure
Adverse event Policy and sentinel events. Site observation
Guidelines: Staff interviews
An adverse event is an unexpected and undesirable incident directly
associated with the care or services provided to the client. The incident
occurs during the process of receiving health services. The adverse
event is an adverse outcome, injury or complication for the client. A
sentinel event is an adverse event that leads to death or major and
enduring loss of function for a recipient of healthcare services. Major
and enduring loss of function refers to sensory, motor, physiological,
or psychological impairment not present at the time services were
sought or began, i.e., a client dies or is seriously harmed by a
medication error.
The frequency and severity of sentinel events and adverse events, and
near misses are analyzed in order to learn from the events, prevent
recurrences and strengthen safety practices.
PPL.9 There are procedures in place to immediately report to security Policy & Procedure
Incident Reporting authorities about any accidents, deaths, or suspicious diseases that Site observation
Policy occur in the facility. Staff interviews
Guidelines:
Policy should include steps and processes to be followed in the advent
of a reportable incident.
PPL.10 There is a process to monitor compliance with all policies and Procedure
Compliance to procedures. Site Observation
Policies & Procedures
124
A
PPL.11 There is a procedure in place to review and update policies and Policy on Policies & Procedures
Policy on Policies & procedures on a regular basis. Site Observation
Procedures
FML: Financial Management
HRR Accr Std. Section of the Standard Required Documents
Standard
A
FML.1 There is a procedure in place to verify that the legal requirements for Financial Audit
Financial Audit managing and reporting financial information are met.
Guidelines:
Legal requirements for financial management and reporting will vary
by the size of the facility and whether it is public or private.
FML.2 There are written policies and procedures to guide the operating and Budgeting Process/Procedures
Budgeting Process capital budget planning and reporting.
Guidelines:
The policies include who is responsible for overseeing financial and
administrative functions. The policies and procedures are approved by
the relevant authority and a copy of the approval is retained. Changes
to the policy must also be approved.
FML.3 There are policies and procedures in place to ensure clients are aware Approved Price list
Approved Price list of and charged according to the approved price list. Site Observation
EPL: Emergency Preparedness and Response:
HRR Accr Std. Section of the Standard Required Documents
Standard
A
EPL.1 There is a written emergency preparedness and response plan. Emergency Preparedness Plan
Emergency Guidelines:
Preparedness Plan The plan identifies immediate actions to respond to disasters and
emergencies including internal and external functional roles and
responsibilities (e.g., those of community partners) and establishes
lines of authority.
The disaster and emergency plans are integrated with partner
organizations and governments to facilitate coordinated, large‐scale
responses as required.
125
EPL.2 The written emergency plan identifies:
Emergency (i) roles and responsibilities in an emergency;
Preparedness Plan (ii) information about the fire safety system and equipment;
(iii) emergency preparedness and response procedures for an all‐
hazard plan
A
EPL.3 All staff receive orientation and training about the health care facility’s Staff Training Records
Staff Training emergency preparedness and response plan. Site Observation
Guidelines:
The objective of the training is to create awareness and enhance the
skills required to develop, implement, maintain, and execute the
emergency preparedness and response plan. The training may include
advanced first aid (how to sustain life and prevent further injuries);
field triage (sorting clients into those who need critical attention and
immediate medical attention and those with less serious injuries); or
the use of altered care standards (e.g., when demand for care provided
in accordance with current standards exceeds resources) including
conditions under which altered care standards are activated, how
emergency responders will be notified of the activation, and how to
apply altered care standards in the field.
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EPL.6 Written records are kept of each drill. Records of Drills
Records of Drills Site Observation
EPL.7 Fire safety plans are developed and available concerning the Fire safety plans
protection of all persons in cases where occupants cannot Site Observation
Fire safety plans independently evacuate. Fire safety plans provide the following:
i) Use of alarms;
ii) Transmission of alarms to fire department;
iii) Emergency phone call to fire department;
iv) Response to alarms;
v) Isolation of fire;
vi) Evacuation of immediate area;
vii) Evacuation of smoke compartment;
viii) Preparation of floors and building for evacuation;
ix) Extinguishment of fire
EPL.8 The fire safety plan is prepared and administered by the health care Job Description
Designated Staff facility’s designated fire safety officer.
EPL.9 All staff are aware of the use and response to fire alarms, including the Staff Training /Awareness
Staff Training use of code phrases that ensure transmission. Site Observation
/Awareness Staff Interviews
EPL.10 Exit means are maintained free and unobstructed at all times. Site Observation
Exit
EPL.11 A copy of the fire safety plan is posted at or near the reception area in Site Observation
Fire Safety Plan the facility.
EPL.12 The building is equipped with emergency response (life safety) Site Observation
Emergency system equipment, including a defibrillator and a crash cart (emergency
Equipment Medications).
EPL.13 The building is equipped with fire extinguishers that are checked and Monitoring Log
Fire extinguishers tagged monthly. Site Observation
EPL.14 The building is equipped with a sufficient number of fire blankets as Site Observation
Fire Blankets deemed necessary by the fire safety officer.
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128
129
The safety and quality of health care services begins with a well‐functioning, safe building and equipment that enables a supportive care environment. The
effective and client‐centered operations and maintenance of the facility is essential to protecting health and safety as well as promoting recovery and improving
experience, and creating an effective working environment for staff.
The Physical Environment ‐ Process Protocol contains content in the following areas:
• Compliance and Accountability
• Reception
• Facility and Equipment Maintenance
• Housekeeping and Waste Management
• Food Preparation and Cafeteria Service
CAP: Compliance and Accountability
HRR Accr Std. Section of the Standard Required Documents
Standard
CAP.1 Leaders have implemented programs and processes to operate all Process for Physical Environment
Physical environment in aspects of the physical environment in compliance with requirements. compliance
compliance Site Observation
CAP.2 When areas of non‐compliance are identified, immediate action is Process to manage non
Non Compliance taken to correct any deficiencies and to guide sustainable compliance
improvement. Site Observation
CAP.3 Past inspection reports are acted upon to plan and achieve any Improvement Plan
Improvement Plan improvements needed. Site Observation
RCP: Reception
HRR Accr Std. Section of the Standard Required Documents
Standard
RCP.1 There is adequate reception room and appropriate place for storing Site Observation
Storage Space files and medical records.
RCP.2 The hours of operation and instructions for after‐hours care and Site Observation
The hours of operation service are posted at the entrance.
and instructions for
after‐hours care
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RCP.3 There are way‐finding signs inside the main entrance. Site Observation
Signage
RCP.4 Visible signage guides visitors to reception, waiting areas and Site Observation
Signage restrooms (toilets).
RCP.5 Reception staff maintain the registration book, which is stamped by Site Observation
Client Register MOPH and includes the following information for each client:
Name and Surname
Qatar ID
Age
Address
Date of Admission and Discharge
RCP.6 There is a Patient file maintained by medical staff where the diagnosis Site Observation
Client File and condition of each patient are recorded.
RCP.7 There is a policy on retention, storage and removal of Client Records. Policy & Procedure
Client Record Guidelines: Site Observation
retention Client records are retained for a minimum of five years after the date
of registration, or as outlined in applicable legislation.
RCP.8 Reception staff maintain: Site Observation
Staff/Service List • A medical crew list
• A tests list
Guidelines:
Each department should include the type of medical services or tests
they provide.
RCP.9 Ministry approved price list for services is displayed at a visible place Site Observation
Price list within the healthcare facility.
RCP.10 Fax machines are located and positioned in a way to ensure the Site Observation
Fax Machine confidentiality of client information.
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A
FMP.4 Ventilation systems are adequate and well maintained in the facility, Site observation
Ventilation especially where chemicals are used.
Guidelines:
Considerations include maintaining heating, ventilation, and air‐
conditioning systems that control temperature, humidity, odours, and
availability of fresh air; preventing exposure to second‐hand smoke.
132
133
Doors, sills, tracks, and door closure mechanisms
Examination rooms
Guidelines:
Cleaning activities include cleaning all surfaces including walls,
windows, and ceilings; removing waste; promptly cleaning and
managing spills; and maintaining general tidiness. The organization's
procedures outline the cleaning schedule and expectations for
documenting the frequency of cleaning; the choice of cleaners or
disinfectants, e.g. hospital grade disinfectant with valid drug
identification number, the proper dilution, and effective contact time;
and cleaning protocols for equipment such as brooms and mops.
HWP.2 Clinic areas, examination rooms, including floors, and all high‐touch Site observation
Clinic areas surfaces are cleaned and disinfected daily.
HWP.3 Restrooms are equipped with sufficient toilet paper, liquid hand soap, Site observation
Rest rooms and hand‐drying capability (dryers or filled paper towel dispensers).
HWP.4 There is no observable accumulation of dust or debris on the following: Site observation
Dust/Debris Walls
Floors
Equipment
Vents, hoods, heat registers, air conditioners
Light fixtures
HWP.5 All materials are stored: Site observation
Storage In designated storage areas only
On pallets or 6 inches off the ground
HWP.6 Housekeeping closet(s) is clean, well‐organized and secured. Site observation
Housekeeping Closet
HWP.7 Up‐to‐date Safety Data Sheets (SDS) are present in the housekeeping MSDS
MSDS closet(s). Site observation
HWP.8 All chemicals are clearly labelled with the manufacturer’s original label. Site observation
Labelling
134
135
Black bags for domestic waste
Yellow bags for clinical waste
Puncture‐proof plastic containers for sharps
HWP.20 Signs are posted near waste collection sites to remind staff of Site Observation
Waste management segregation procedures.
Guidelines:
The most appropriate way of identifying the categories of health‐care
waste is by sorting the waste into colour‐coded plastic bags or
containers.
Instructions on waste separation and identification should be posted at
each waste collection point to remind staff of the procedures.
A
HWP.21 Puncture‐resistant sharps containers are available at the point‐of‐care. Site Observation
Sharp containers Guidelines:
Sharps include needles and blades.(any items causing puncture or
wound)
HWP.22 There is a policy and procedure for appropriate storage and disposal of Policy &Procedure
Sharp Disposal sharps. Site Observation
HWP.23 All waste containers are clean inside and outside and have self‐closing Site Observation
Waste containers lids.
HWP.24 Waste collection bags, containers, and vessels are removed and stored Site Observation
Waste collection when ¾ full.
Guidelines:
Appropriate containers or bag holders should be placed in all locations
where particular categories of waste may be generated.
Staff should never attempt to correct errors of segregation by
removing items from a bag or container after disposal or by placing
one bag inside another bag of a different colour. If general and
hazardous wastes are accidentally mixed, the mixture should be
treated as hazardous healthcare waste.
HWP.25 Soiled linen or trash receptacles do not exceed 121 L in capacity, Site Observation
Trash receptacles unless located in a room protected as a hazardous area.
HWP.26 Procedures are followed for collecting and storing soiled items in order Site Observation
Soiled Items to prevent contamination of clean items.
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137
138
139
A
IPI.3 There are clear reporting relationships and reporting procedures for all Reporting procedures
Reporting channel IPAC‐related issues. Site Observation
Guidelines: Staff interviews
All staff play a role in preventing and controlling infections. Staff roles
include how to conduct risk assessments, select appropriate
precautions, follow routine practices, and properly place or isolate
clients with or at risk for infection. It is important for everyone to
understand their role and the roles of others in the facility.
140
bedside to provide reminders to staff. However, fire regulations or
other considerations may limit the placement of alcohol‐based rubs.
In community‐based organizations and other organizations without
beds, hand rubs are placed as close to the point‐of‐care as possible,
e.g. in the clinic room, at the entrance to the client's room, or directly
in the client's home. Staff may also carry hand rubs with them.
IPI.6 Alcohol‐based hand‐rub, masks, and tissues are available in the Site Observation
Hand hygiene reception area.
IPI.7 Signs are posted in reception area(s) to advice clients and visitors Site Observation
Signage where to report signs of acute infection (e.g., cough, fever, vomiting,
and diarrhea).
IPI.8 There is a process of triage, screening, and assessment for clients who Site Observation
Triage for Screening present with symptoms of acute infection.
Infection
IPI.9 Where a doctor suspects or confirms a client is infected with a Policy & Procedure
Reporting Policy reportable communicable disease, they report the case to the Site Observation
appropriate authority within 24 hours.
IPI.10 Staff members notify clients with suspected communicable diseases Protocols/Procedure
Client Information when they may require quarantine. Site Observation
CCI: Client Care
HRR Accr Std. Section of the Standard Required Documents
Standard
CCI.1 During periods of infectiousness (skin, viral, or other communicable Site Observation
diseases), staff members are not permitted to care for clients.
CCI.2 Medical equipment and devices used for multiple clients are cleaned Site Observation
between client uses.
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CCI.7 Dental gases may be piped from a central manifold or provided Medical Gas drawings
from bottles. If a bottle store is provided, it should be located on
Dental Section an outside wall with good ventilation. When nitrous oxide is Site verification
used, a gas scavenging system must be fitted.
CCI.8 Clinical contact surfaces are protected from contamination by the use Site Observation
Dental Section of barriers (e.g., clear plastic wrap, paper sheets).
Contact Surface
GRI: General Reprocessing
HRR Accr Std. Section of the Standard Required Documents
Standard
A
GRI.1 There are written policies and procedures for reprocessing that are Policies & Procedures
Re processing Polices based on current recognized standards. Site Observation
& Procedures Guidelines: Staff Interviews
The policies include staff and management responsibilities; staff
qualifications, including training, education, and competency
assessment; infection prevention and control; the establishment and
maintenance of policies and procedures; staff health and safety; and
the requirements of subcontractors. They also address ongoing quality
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assurance, including controls to ensure medical devices and equipment
are functional and sterile before being released from the sterilization
area; recall procedures; the evaluation and purchase of reprocessing
equipment; and back‐up and contingency planning regarding inventory
and temporary shortages.
A
GRI.3 A recognized classification system is used to determine the level of Operational Procedures‐
Operational reprocessing required. Site Observation
Procedures‐ Guidelines:
Reprocessing A classification system, e.g., the Spaulding Classification System,
categorizes medical devices based upon their use and the risk of
infection associated with their use in order to determine the cleaning
and reprocessing required to prevent infection.
The facility uses the classification system to identify critical, semi‐
critical, and non‐critical items, and each classification has requirements
for decontamination, cleaning, and disinfection or sterilization that
reduce the risk of infection. An item that only comes into contact with
clients' intact skin, i.e., blood pressure cuffs, stethoscopes, may be
classified as non‐critical and require low‐level disinfection. Items that
contact mucous membranes are considered semi‐critical and require
high‐level disinfection. Those that enter sterile spaces or contact non‐
intact skin are critical devices and must be sterile. The classification
system clearly states that critical items may be used for non‐critical
activities or procedures, but non‐critical items may not be used for
critical activities or procedures.
143
Re processing
Solution
GRI.6 Devices are reprocessed in a designated area that is physically Site Observation
Re processing area separate from direct care areas and from where clean, disinfected, or
sterile items are handled or stored.
A
GRI.7 Staff members contain and transport contaminated items to the Site Observation
Transport reprocessing area. Staff interviews
contaminated items Guidelines:
The health care facility follows formal criteria for containing used items
and transporting them to and from the area where they are sterilized.
Reprocessing may be done in a specific area of the organization or at
another site, or be outsourced to a private company.
GRI.8 The method of reprocessing is consistent with the manufacturer’s manufacturer’s instructions
Standardized method instructions. record
Site Observation
A
GRI.9 Disinfectants used are based on compatibility with the equipment or Disinfectants details
Disinfectants device to be disinfected. Site Observation
A
GRI.10 For each disinfectant used, staff follow the manufacturer’s instructions manufacturer’s instructions
Disinfectants for use, contact time, shelf life, storage, appropriate dilution and record
personal protective equipment required. Site Observation
A
GRI.11 The concentration of disinfectants used is monitored daily with test Disinfectants monitoring Log
Disinfectants strips and a log is kept of the results. Site Observation
Guidelines:
Test strips are dated when opened and are not used past the expiry
date.
GRI.12 Staff members do not use disinfectants past the expiry date. Expiry check
Disinfectants Site Observation
GRI.13 The sterilization section of the reprocessing area includes the sterilizer Site Observation
Sterilizer and related supplies, with adequate space for loading, unloading and
cool down.
GRI.14 Sterilizers are rigorously tested on installation and following any Sterilizer tests documents
Sterilizer tests disruption of their regular use, with documentation maintained. Site Observation
144
A
GRI.17 A log is kept of devices that are reprocessed, including date and time, Sterilization results
Sterilization results length of contact time with disinfectant, and person who performed Site Observation
the procedure.
GRI.18 Packaged, sterilized instruments are stored securely in a manner that Site Observation
Sterilization Storage keeps them clean, dry and prevents contamination.
GRI.19 Sterile items are stored in their sterile packaging until time of use. sterile packaging
Sterilization Site Observation
GRI.20 Sterilizers are maintained in accordance with the manufacturer’s manufacturer’s
Sterilizes recommendations. recommendations documents
Site Observation
GRI.21 Any malfunction of the sterilizer is noted and corrected before re‐use.
Sterilizes
A GRI.22 Improperly sterilized medical equipment/ devices are recalled. Sterilization log
Sterilized equipment Guidelines: Site Observation
Instruments, devices, and supplies could be recalled for a variety of
reasons, such as when reprocessing fails or when an unusual pattern of
postoperative infection is discovered.
OPI: Outbreaks and Pandemics
145
A
OPI.2 There is an outbreak management system in place for detecting, outbreak management system
Outbreak management managing and controlling disease outbreaks that: Site Observation
system (a) Defines staff responsibilities Staff Interviews
(b) Defines protocols for communication and reporting
Medication Management: Medication management is not only the responsibility of the pharmacy service but also of managers and clinical care providers. Medical,
pharmacy, and administrative staff members all participate in a collaborative process to develop, monitor and improve the policies and safe operating proced
medication management. Each health care facility has the responsibility to identify individuals with the requisite knowledge and experience, who are permitted by re
to prescribe, dispense and/or administer medications.
The Medication Management Protocol contains content in the following areas:
• Compliance and Accountability
• Oversight
• Receiving and Storing Medication
• Prescribing and Dispensing Medication
• Administering Medications
CAM: Compliance and Accountability
HRR Accr Std. Section of the Standard Required Documents
Standard
A
CAM.1 The health care facility ensures that all aspects of pharmacy services Regulatory requirements
Regulation and medication management comply with regulatory requirements. Site Observation
Guidelines:
Written evidence from the MOPH pharmacy of compliance to
regulatory requirement.
CAM.2 When areas of non‐compliance are identified, immediate action is Actions against Non Compliance
Non Compliance taken to correct any deficiencies and to guide sustainable
improvement.
CAM.3 Past inspection reports are acted upon to plan and achieve any Quality Improvement Plan
improvements needed. Site Observation
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Quality Improvement
Plan
OPM: Oversight
HRR Accr Std. Section of the Standard Required Documents
Standard
A
OPM.1 Procedures are followed for the Policies & Procedures
Medication • Selection; Site Observation
Management • Procurement;
• Storage;
• Maintenance;
• Dispensing;
• Ordering;
• Administration;
• Recall;
• Disposal of medications.
Guidelines:
Policies and procedures help to improve clarity and collaboration
among team members, and can eliminate duplication.
Policies and procedures related to medication management ensure
that medications are handled in a safe and consistent manner
A
OPM.2 Procedures are followed for reporting and managing medication Policies & Procedures
Medication Incidents incidents (near misses and adverse events). Site Observation
Reporting Guidelines: Staff Interviews
The policy and process defines to whom the adverse drug events and
near misses should be reported, such as appropriate internal staff and
external organizations, where required.
The review of adverse drug events may consist of a root cause analysis
or another similar process. It may include analyzing and using
published adverse drug event experiences from other organizations to
proactively target improvements in the organization's medication use
process.
A
OPM.3 All staff keep clear, accurate, legible and up‐to‐date records about all Medication Records
Medication Records medications received, stored, and dispensed. Site Observation
Guidelines:
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Maintaining records and auditing inventory has several functions,
including: organizing medications; evaluating appropriate storage of
look‐alike, sound‐alike medications; monitoring expiry dates; and for
loss prevention purposes. Documenting this information helps monitor
compliance with appropriate dispensing methods and sign‐offs.
A
RSM.4 Medication storage areas are visibly clean, effectively ventilated and Site Observation
Medication storage adequately lit, with a method of ensuring temperature control, in
148
accordance with manufacturers’ specifications for the medications
stored.
Guidelines:
The team maintains a clutter‐free environment where medications are
stored. Annex 9 of the World Health Organization WHO Expert
Committee on Specifications for Pharmaceutical Preparations: 37th
Report (http://who.int/) provides a guide to good storage practices for
pharmaceuticals.
Appropriate storage conditions pertain to temperature (refrigerator),
lighting, packaging, and delivery containers.
RSM.5 Medication storage areas are used exclusively for medications and Site Observation
Medication Storage medication‐related supplies.
RSM.6 Medications that require cold chain storage are kept within the Site Observation
Cold Chain manufacturer’s designated limits as all times during storage or
transportation.
RSM.7 Medication refrigerators are clean and organized and no non‐ Site Observation
Medication medication items are stored in them.
Refrigerators
A
RSM.8 The temperature of all medication refrigerators is checked regularly Site Observation
Medication and documentation maintained.
Refrigerators Guidelines:
The team is aware of and follows the manufacturer’s recommended
storage temperature for each type of medication stored. Ensuring a
consistent temperature in the refrigerator is essential to preserving
the efficacy and safety of medications, including the vaccine cold
chain.
A
RSM.11 Emergency medication is maintained, readily accessible in client Site Observation
Medication Storage service areas and audited regularly.
RSM.12 Medications that will expire within 2 months (or within manufacturer’s Site Observation
Medication Storage recommended timeframe) are stored separately from other
medications.
RSM.13 Expired medications are removed from the active medication stock Site Observation
Medication Storage area.
RSM.14 All medication storage areas are audited regularly. Site Observation
Medication Storage
PDM: Prescribing Medication
HRR Accr Std. Section of the Standard Required Documents
Standard
A
PDM.1 Medical prescriptions are completed on a special form with: Site Observation
Medical prescriptions • The doctor’s name, academic qualifications, specialization, if
any, and license number;
• The clinic’s address and telephone number;
• The name and age of the client;
• The date of the prescription;
• The name and dose of the medication;
• The medication’s indication;
• Signature and seal of the doctor.
A
PDM.2 Prescriptions are written in clear script without any abbreviations or DO NOT USE List
Medical prescriptions codes from the Do Not Use List. Site Observation
Guidelines:
Criteria for medication orders include that the order is complete, clear,
and readable; specifies the therapeutic objective; does not use
unacceptable abbreviations; and indicates special precautions or
requirements for “when needed” medications are ordered.
A process for when the order is not legible or complete is established.
PDM.3 Prescription pads are not left in any place where unauthorized persons Site Observation
Medical prescriptions could have access to them.
authorized Access
150
AMM: Administering Medications
HRR Accr Std. Section of the Standard Required Documents
Standard
A
AMM.1 Staff members that are authorized to administer medications are QCHP License
License defined in writing. Job Description
Guidelines:
Minimum qualifications may differ by drug class and by administration
route
A
AMM.2 Medications remain in the original labelled container or as packaged Site Observation
Labeling by the pharmacy until administered.
Guidelines:
Administration may be at the client's bedside or in an ambulatory,
community, or home setting.
A
AMM.3 Medication reference materials are available to staff members Medication reference materials
Medication reference administering medications. Site Observation
materials Guidelines:
Medication‐related information is available in written and/or
electronic formats, and is available through consultation with the
pharmacy, medication reference texts, and infusion charts.
151
A
AMM.8 Staff document in the client record as soon as possible after Patient Medication Record
Medication Record administering the medications. Site Observation
Guidelines:
The staff who administer or assist with administering the medication
document the details in the client record. Information about a delayed
or missed dose is also recorded.
Exceptions may be made when a client is in isolation or for other
infection control‐related reasons.
Diagnostic Services: Safe, accurate diagnostic services are essential to the provision of high quality health care. Substantial risks are inherent in the organization and p
of diagnostic services, resulting in the need for effective controls. Client safety must be a top priority.
The Diagnostic Services Protocol contains content in the following areas:
• Compliance and Accountability
• Diagnostic Imaging
• Point‐of‐Care Testing
CAD: Compliance and Accountability
HRR Accr Std. Section of the Standard Required Documents
Standard
A
CAD.1 The health care facility ensures that all aspects of diagnostic services MOE radiation License
MOE radiation comply with regulatory requirements. Site Observation
requirements Guidelines:
Applicable laws, regulations, and standards of practice may differ by
jurisdiction, depending on the specific services provided by the
laboratory.
A
CAD.2 When areas of non‐compliance are identified, immediate action is Action against non‐Compliance
Non Compliance taken to correct any deficiencies and to guide sustainable Site Observation
improvement.
CAD.3 Past inspection reports are acted upon to plan and achieve any Quality Improvement Plan
Quality Improvement improvements needed. Site Observation
Plan
DID: Diagnostic Imaging
HRR Accr Std. Section of the Standard Required Documents
Standard
152
A
DID.1 The license to deliver diagnostic imaging services is posted on the front Facility License
Facility License of the facility. Site Observation
A
DID.2 The license clearly states which diagnostic imaging services it provides. Site Observation
License Guidelines:
The list of services can be viewed by all clients, families, visitors, and
staff and service providers.
A
DID.5 The medical director and all physicians providing diagnostic imaging QCHP License
Credentials & are imaging specialists credentialed by the appropriate professional
Privileges college and licensed to practice.
A DID.6 There are warning light(s) and posted safety signs at imaging room
Signage entrances that restrict access when in use.
Guidelines:
Safety warnings may include radiation warning labels and hazards such
as the presence of magnetic fields for magnetic resonance imaging
procedures.
A
DID.7 All chemicals and solutions are appropriately labeled and stored in
Labeling compliance with applicable regulations.
Guidelines:
Material Safety Data Sheet (MSDS) and Manufacturer
recommendation should be incorporated for labelling and storing.
153
A
DID.8 Staff follow regulations to register, install, and calibrate diagnostic PPM Log
PPM imaging equipment. Site Observation
A
DID.9 Diagnostic imaging providers are trained on the diagnostic imaging Training Records
Training to use the equipment prior to use. Site Observation
Equipment Guidelines:
Training is provided by appropriate personnel (e.g. equipment
manufacturer) on new equipment and following upgrades and/or
updates to existing equipment.
DID.10 There is a program for radiation exposure monitoring and records are Radiation Exposure monitoring
Radiation Exposure maintained as appropriate. log/records
DID.11 There is sufficient protective equipment for staff operating diagnostics Personal Protective Equipment
Personal Protective with potential for radiation exposure. (PPE)
Equipment (PPE) Site Observation
A
DID.12 An equipment log is maintained in which staff record equipment PPM Log
PPM problems, downtime and maintenance and the steps taken to correct Site Observation
the identified problems.
A
DID.13 A client verification protocol is implemented for all services and Client verification
Client verification procedures. Protocol/Procedure
Guidelines: Site Observation
The team uses at least two methods (e.g. name and date of birth) to
identify a client before providing any service or procedure.
The team confirms the client's identity, nature, and site of the
procedure.
A
DID.14 There is a policy, procedure on informed consent. Informed consent Policy & Procedure
Informed consent forms are readily available. Site Observation
Guidelines:
Information about the diagnostic imaging examination is reviewed
with clients and their families, including the reason the examination
was chosen, the benefits, risks and alternatives (if applicable), and the
diagnostic information expected. This information can be provided to
clients by the referring medical professional. However, the team
reviews this information with the client as part of the process for
obtaining informed consent.
154
A
DID.15 There is a protocol for managing clients who are or may be pregnant Protocol/Procedure
Pregnant client Guidelines: Signage
For procedures involving radiation to the abdomen or pelvis on Site Observation
women, the team asks female clients of childbearing age if they are or
may be pregnant and documents the response.
A
DID.17 Accurate and specific medical records and diagnostic images are Client Medical Record
Client Medical Record maintained, specifying the serial number, patient’s full name, address, Site Observation
nationality and ID card, type of test, request date, referring physician
name, test results, results date and recipient date.
Guidelines:
Information about the procedure includes the date of request; date
received; date of examination; number of images taken; and
medications administered including type of contrast used, amount of
contrast and/or materials used, fluoro time, and radiopharmaceuticals.
Films are also documented with this information.
A
DID.18 There is a secure, proper storage area for keeping numerically‐sorted Site Observation
Storage films and files.
Guidelines:
Diagnostic images and reports are labelling in such a way that they can
be retrieved using client identification information.
A
DID.19 There is a safety manual adapted for diagnostic imaging services. Safety Manual
Safety Manual Guidelines: Site Observation
The safety manual includes requirements specific to diagnostic imaging
services such as client and staff safety; equipment safety; radiation
safety; magnetic safety; fire safety; electrical safety; compressed
gases; chemicals, solutions, and radioactive material; waste
management and disposal; and infection control.
PCD: Point‐of‐Care Testing (POCT)
HRR Accr Std. Section of the Standard Required Documents
Standard
155
A
PCD.1 There is designated oversight of point‐of‐care testing (POCT) by a QCHP License
License trained specialist. Qualification/Certificate
PCD.2 POCT is limited to the tests approved by MOPH: Approved List
MOPH approved list Guidelines: Site Observation
Approved list of tests for POCT are listed in Appendix A of this
document
A
PCD.4 Records of tests performed and results are documented, and include: Test Records
Test Records • The client name Site Observation
• Qatar ID number of the client
• Name of person who performed the test
• Test date and results
A
PCD.5 There are quality control processes in place to ensure the reliability Quality Control
Test Results and validity of results. Documents/SOPs/Manufacturer’s
Guidelines: recommendations
Quality controls are based on the SOPs, manufacturer's Site Observation
recommendations or instrument‐generated quality controls.
PCD.6 All POCT equipment used is licensed in the state of Qatar. Approved Medical Equipment
Equipment License Site Observation
156
Glossary
157
4.0 Glossary
Accreditation: Accreditation is an ongoing process of assessing health care facilities against standards of
excellence to identify what is being done well and what needs to be improved.
Building commissioning: The systematic process of identifying, verifying, and documenting that all
aspects of a capital project meet design specifications, applicable regulations and codes, function as
intended, and support the comfort and safety of occupants. This process differs from commissioning for
operational readiness. See ‘Operational commissioning’.
Capital project: A facility project outside the scope of day‐to‐day operations, usually involving building
construction, expansion or renovation that requires separate planning, management, and financing, and
often has significant resource implications.
Client: Any person receiving health care services provided by the organization. May also be called the
patient; resident; inmate; or individual.
Commissioning plan: The framework documenting the processes and activities for commissioning. The
commissioning plan contains information about identification, sequence, and duration of all activities
required to bring a facility into operation; timeline and contingencies; responsibilities for planning and
commissioning activities; human resourcing strategies; new policies and procedures; communication
plan; budget; and risk mitigation plans.
Emergency: A situation or an impending situation that constitutes a danger of major proportions that
could result in serious harm to persons or substantial damage to property and that is caused by the forces
of nature, a disease or other health risk, an accident or an act whether intentional or otherwise.
Evidence‐based design: A design process that uses research and evidence about the built environment
to inform decision making, with the intent of improving outcomes through purposeful design decisions.
Family: Person or persons who are related in any way (biologically, legally, or emotionally), including
immediate relatives and other individuals in the client’s support network. Family includes a client’s
extended family, partners, friends, advocates, guardians, and other individuals. The client defines the
makeup of their family, and has the right to include or not include family members in their care, and
redefine the makeup of their family over time. The definition of family will depend on the purpose, i.e.
there may be a different definition of family for legal matters, than for care decisions, or for providing
feedback on experience.
Functional program: The planning document that links the master plan to the design phase, that includes
the scope of services, objectives and basic operational description of each component to be addressed
in a capital project, current and expected workload and staffing of the components, together with an
estimate and description of the facility resources (space) required to support them. See ‘Master plan’
definition.
Health hazard: A condition of a premises; a substance, thing, plant or animal other than man; a solid,
liquid, gas; or combination of these that is likely to have an adverse effect on the health of any person.
Licensing Process: It is a multi‐step process for healthcare facilities to obtain and maintain a license to
158
operate, which signifies that the foundational safety requirements are met.
Master plan: A broad plan that guides decision making throughout a capital project. The master plan is a
living document that details the community need, project objectives, required resources and proposed
implementation plan required to achieve the project objectives while ensuring the project aligns with the
long‐term strategic objectives of the organization. See ‘Functional program’ definition.
Medical waste: Hazardous waste generated by a health care facility that requires special handling and
disposal as it presents a risk to health.
Mortuary: A facility of one or more rooms or a building, which is used for the storage of bodies, including
a refrigerated body storage facility. This may include a body viewing area, space for the family, body
preparation room, and an autopsy suite.
Operational commissioning: Commissioning that focuses on operational readiness to occupy and use the
new space or facility, including equipping and familiarizing staff with new facility operation, policies,
procedures, and equipment. This process differs from commissioning for functional readiness. See
‘Building commissioning’.
Organization’s leaders: Leaders at all levels, including directors, managers, supervisors, clinical leaders,
and others who have leadership responsibilities within the organization.
Personal protective equipment (PPE): Items that when worn correctly form a barrier or shield against
hazardous materials. Personal protective equipment (PPE) includes footwear, hardhats, gowns, gloves,
masks, facial protection (i.e., masks and eye protection, face shields or masks with visor attachment),
respirators, and others.
Pre‐design: A phase of the planning and conceptualization of a specific capital project that occurs before
the design phase. Activities occurring as part of the pre‐design phase include: identifying relevant
legislation, ensuring community engagement and collaboration, launching the planning process,
determining the budget and financial requirements, site selection and considerations, and assessing risks
and opportunities for the project.
Risk: The probability of a hazard causing harm and the degree of severity of the harm, e.g. risks to health
and safety or project completion.
Service providers: Health care professionals that are granted privileges to deliver services in the
organization by the governing body or external regulatory body. These professionals may or may not be
employees of the organization. Service providers may include Medical Staff, Midwifery Staff, Pathologists,
Pharmacists, Dental Staff and Extended Class Nursing Staff. Also referred to as ‘Professional Staff’ or
‘Licensed Independent Practitioners.’
Solo Clinic: A solo clinic is a facility that provides services in one healthcare specialty regardless of the
number of healthcare professionals licensed by the Ministry of Public Health’s Medical Licensing
Committee operating from it. The main function of a clinic is to provide ambulatory primary and/or
secondary care services in its designated healthcare specialty, such as consultations, simple treatments,
159
minor procedures and point of care testing, ensuring adequate access to medical and preventive services
for local communities. A clinic is not intended to provide emergency services. Clinics may provide basic
diagnostic imaging and physiologic testing that do not require a radiology assistant such as a dental
panoramic x‐ray or an ultrasound.
Sustainability: Creating and maintaining conditions that are productive for humans, society, and the
natural environment; fulfilling social and economic needs in a way that is supportive of present and future
generations. Sustainability also refers to the sustainability of an organization from a financial and
operational perspective. It applies to planning and design of capital projects from a financial, human, and
physical resource perspective.
Team: The team is composed of clinical, technical, or administrative personnel and leadership personnel
that participate in the assessment, planning, and/or implementation of services with close interaction and
integration among its members to achieve common goals. Each organization assigns roles and
responsibilities to their team members. Team leaders may be formally or informally appointed members
of the team.
Timely/Regularly: Carried out in consistent time intervals. The organization defines the appropriate time
intervals for various activities based on best available knowledge and adheres to those schedules.
Way finding: The use of infrastructure and design elements to help clients, families, visitors, staff and
service providers orient themselves within a health care facility and arrive at their destinations.
160
5.0 References:
Alberta Health and Wellness. (2008). Alberta Infection Prevention and Control Strategy. Edmonton: AB.
Available online: http://www.health.alberta.ca
Alberta Health and Wellness. (2007). Provincial Review of Infection Prevention and Control. Edmonton:
AB. Available online: http://www.health.alberta.ca
ASC Quality Collaboration. Endoscope Reprocessing Toolkit. Available online: http://www.ascquality.org
British Columbia Patient Safety Branch, Ministry of Health (2007). Best Practice Guidelines for the
Cleaning, Disinfection and Sterilization of Medical Devices in Health Authorities. Available online:
http://www.health.gov.bc.ca
Canadian Commission on Building and Fire Codes (2010). National Fire Code of Canada. National
Research Council Canada. Ottawa: ON. Available online: http://www.nrc‐cnrc.gc.ca/eng
College of Nurses of Ontario. (2014). Practice Standard: Medication. Toronto: ON. Available online:
http://www.cno.org
College of Physicians and Surgeons of Alberta (2013). Diagnostic Imaging ‐ Standards and Guidelines.
http://www.cpsa.ab.ca
College of Physicians and Surgeons of British Columbia (2010). Walk‐In Clinics ‐ Standard of Care.
https://www.cpsbc.ca
College of Physicians and Surgeons of British Columbia (2010). Primary Care Multi‐Physician Clinics
https://www.cpsbc.ca
College of Physicians and Surgeons of British Columbia (2010). Accreditation Standards: Medication
Management. https://www.cpsbc.ca
Dubai Health Authority (2012). Diagnostic Imaging Services Regulation. Health Regulation Department:
Government of Dubai.
Environmental Health Standards in Accrediting Hospitals and Healthcare Facilities. World Health
Organization and the Health Ministries Council of the GCC States.
Government of Australia (2006). Guiding Principles for Medication Management in the Community.
Australian Pharmaceutical Advisory Committee: Commonwealth of Australia. www.health.gov.au
Government of Ontario. (1990). Health protection and promotion act. Available online: http://www.e‐
laws.gov.on.ca
Government of Ontario. (1990). Occupational Health and Safety Act. Available online: http://www.e‐
laws.gov.on.ca
The Australasian Health Infrastructure Alliance (2010). Australasian Health Facility Guidelines (Vol. 4).
Available online: http://www.healthfacilityguidelines.com.au/guidelines.aspx
161
The Facility Guidelines Institute (2010). Guidelines for Design and Construction of Healthcare Facilities.
2010 Edition. American Society for Healthcare Engineering of the American Hospital Association (ASHE):
Chicago, IL.
Ministry of Public Health. Amiri Decree No 5 of 2001: Licensing Fees Levied by the Ministry of Public
Health. http://www.sch.gov.qa
Ministry of Public Health Amiri Decree No 8 of 1991: Practicing Paramedical Professions.
http://www.sch.gov.qa
Ministry of Public Health. Amiri Decree No 9 of 2001: Decree Regarding the Law Exempting the Private
Health Facilities from Customs Duties. http://www.sch.gov.qa
Ministry of Public Health. Amiri Decree No 11 of 1982: Law of Regularizing the Health Care Facilities.
http://www.sch.gov.qa
Ministry of Public Health. Amiri Decree No 11 of 1983: Practicing the Professions of Human Medicine
and Dentistry. http://www.sch.gov.qa
Ministry of Public Health Healthcare Facilities Licensing: Conditions and Requirements for Licensing Day
Surgery Centres. Doha: Qatar. http://www.sch.gov.qa
Ministry of Public Health Healthcare Facilities Licensing: Conditions and Requirements for Licensing
General and Specialized Medical Centres. Doha: Qatar. http://www.sch.gov.qa
Ministry of Public Health. Healthcare Facilities Licensing: Conditions and Requirements for Licensing
Hospitals. Doha: Qatar. http://www.sch.gov.qa
Ministry of Public Health Healthcare Facilities Licensing: Conditions and Requirements for Licensing IVF
Units. Doha: Qatar. http://www.sch.gov.qa
Ministry of Public Health Healthcare Facilities Licensing: Conditions and Requirements for Licensing
Medical Laboratories. Doha: Qatar. http://www.sch.gov.qa
Ministry of Public Health. Healthcare Facilities Licensing: Conditions and Requirements for Licensing X‐
Ray Laboratories. Doha: Qatar. http://www.sch.gov.qa
Ministry of Public Health Ministerial Resolution No 2 of 1989: Conditions and Requirements for Licensing
Medical Laboratories. http://www.sch.gov.qa
Ministry of Public Health. Ministerial Resolution No 2 of 2005: The Requirements for the Trainee
Dentists, and the Supporting Medical Professions. http://www.sch.gov.qa
Ministry of Public Health. Ministerial Resolution No 3 of 1990: Conditions and Requirements for
Licensing X‐Ray Units. http://www.sch.gov.qa
Ministry of Public Health. Ministerial Resolution No 9 of 1987: Conditions and Specifications and
Hygienic Equipment that Should be Available In Private Clinics. http://www.sch.gov.qa
Ministry of Public Health Ministerial Resolution No 10 of 2003: Adding More Paramedical Professions.
http://www.sch.gov.qa
162
Health Canada (2002). Prevention and Control of Occupational Infections in Health Care. An Infection
Control Guideline. Canadian Communicable Disease Report (vol. 2851). Available online: http://hc‐
sc.gc.ca
Institute for Healthcare Improvement (IHI) (2012). How‐to Guide: Prevent Harm from High‐Alert
Medications. http://www.ihi.org
Institute for Safe Medication Practices (ISMP) (2001). Medication Safety Self Assessment for
Community/Ambulatory Pharmacy. Retrieved from http://www.ismp.org
International Pharmaceutical Federation and World Health Organization (2011). FIP/WHO Joint
Guidelines on Good Pharmacy Practice ‐ Standards for Quality Services. http://www.fip.org/statements
Joint Commission International (2012). Accreditation Standards for Hospitals Including Standards for
Academic Medical Center Hospitals, 4th ed. expanded. Illinois. Available online: http://www.jcrinc.com
Minister of Justice (2014). Canada Occupational Health and Safety Regulations. Available online:
http://laws.justice.gc.ca
Ministry of Health and Long‐Term Care. (2007). Annual Report of the Office of the Auditor General of
Ontario. Available online: http://www.auditor.on.ca/en
Ministry of Health and Long‐Term Care (2009). Infection Prevention and Control Best Practices for
Personal Services Settings. Infection Prevention and Control Unit: Public Health Division. Ontario,
Canada. Available online: http://www.health.gov.on.ca
National Association of Pharmacy Regulatory Authorities (2009). Model Standards of Practice for
Canadian Pharmacists. Retrieved from http://www.napra.ca
National Association of Pharmacy Regulatory Authorities (2014). Professional Competencies for
Canadian Pharmacists at Entry to Practice. Retrieved from http://www.napra.ca
National Fire Protection Association (2005 Edition). NFPA 99: Standard for Health Care Facilities.
http://www.nfpa.org
National Fire Protection Association (2006 Edition). NFPA 101: Life Safety Code. http://www.nfpa.org
New Zealand Council on Healthcare Standards (2001). The Safe Environment and Practice (SEP)
standards. Community Services (vol. 2).
Peel Public Health (2013). Infection Prevention and Control Resource Guide: Requirements of the
Infection
Prevention and Control Program. Toronto: ON. Available online: http://www.peelregion.ca
Public Health Agency of Canada (2013). Canadian Biosafety Standards and Guidelines; for Facilities
Handling Human and Terrestrial Animal Pathogens, Prions, and Biological Toxins. 1st ed. Available
online: http://canadianbiosafetystandards.collaboration.gc.ca
163
Public Health Agency of Canada (2010). Essential Resources for Effective Infection Prevention and
Control Programs: A Matter of Patient Safety: A Discussion Paper. Available online: http://www.phac‐
aspc.gc.ca
Public Health Ontario (2012). Best Practices for Infection Prevention and Control Programs in Ontario in
All Health Care Settings, 3rd ed. Provincial Infectious Disease Advisory Committee. Available online:
http://www.publichealthontario.ca
Public Health Ontario (2013). Best Practices for Cleaning, Disinfection and Sterilization of Medical
Equipment/Devices In All Health Care Settings, 3rd ed. Provincial Infectious Disease Advisory
Committee. Available online: http://www.publichealthontario.ca
Public Health Ontario, Provincial Infectious Disease Advisory Committee. Best Practices for Infection
Prevention and Control Programs in Ontario in All Health Care Settings (2012).
http://www.publichealthontario.ca
Royal College of Dental Surgeons of Ontario (2010). Guidelines: Infection Prevention and Control in the
Dental Office. Toronto: ON. Available online: http://www.rcdso.org
World Health Organization (1999). Safe Management of Wastes from Health‐care Activities. Pruss, A.
Giroult, E., Rushbrook, P., eds. Available online: http://www.who.int
World Health Organization (2008). Core Components for Infection Prevention and Control Programmes.
Report of the Second Meeting Informal Network on Infection Prevention and Control in Health Care.
Geneva, Switzerland. Available online: http://www.who.int
World Health Organization (2011). Ensuring Balance in National Policies on Controlled Substances:
Guidance for Availability and Accessibility of Controlled Medicines.” http://www.who.int
World Health Organization and International Pharmaceutical Association (2006). Developing Pharmacy
Practice ‐ A focus on patient care. Retrieved from: http://www.fip.org
Australasian Health Facility Guidelines (AusHFG Version 4.0), Part B Health Facility Briefing and Planning,
Rev 4, 201; refer to website www.healthfacility design.com.au
Guidelines for Design and Construction of Health Care Facilities; The Facility Guidelines Institute, 2010
Edition; refer to website www.guidelines.org
NSW Health – NSW Hemodialysis ‘Models of Care’ Program, NSW Renal Services Network; 2008
Department of Health (DH) (UK). ‘Health Briefing Note 8 Facilities for Rehabilitation Services’ 2004.
164
Attachments
165
6.0 Attachments:
6.1: Facility Guidelines
166
167
168
Types of Healthcare Facilities defined by Qatar Healthcare Master Planning (QHFMP)
169
such as clinical laboratory (simple and complex), diagnostic
imaging (basic and advanced) and pharmacy services. A general
hospital also provides critical services such as an accident and
emergency department, adult intensive care and a fully
equipped ambulance service.
Specialized A specialised hospital is a facility comprised of all services of a
Hospital general hospital but which provides these services in only one or
two clinical specialties (e.g. cancer, women’s and children’s
services).
Long Term A long term care facility provides services on an inpatient basis, Rehabilitation Facilities
Care Facility but may also provide rehabilitative and chronic care on an Skilled Nursing Facilities
outpatient basis. Mental Health Facilities
A long term care facility provides post‐acute skilled nursing care Substance Misuse
and/or skilled rehabilitation services and other related health Facilities
services that cannot be provided on an outpatient basis. Geriatric Facilities
A long‐term care facility provides medical, nursing or custodial
care for patients requiring rehabilitation following acute medical
or surgical treatment, as well as those who are increasingly
unable to function independently due to chronic disease and/or
physical frailty.
Diagnostic A diagnostic centre is a facility that provides a range of Stand‐alone
Centre diagnostic procedures and/or diagnostic imaging services. These Laboratories
services will be supervised by an appropriate pathologist or Stand‐alone Imaging
radiologist and may not always require the presence of a facilities
healthcare professional licensed by the Supreme Council of
Health’s Medical Licensing Committee
170
6.2: Healthcare Facilities Licensing Process Flow chart
Healthcare Facilities Licensing Process
National Licensing and Accreditation for Healthcare Facilities Program
Facility / Client MOPH / Licensing Specialist MOPH / QCON INSPECTORS
Start Submit Rejection
Rejection report
report to facility
End
Submit Official
letter addressed to Verify the letter
MOPH
Assign licensing
specialist
Complete the
Sent Registration Generate rejection
Registration form
form to the facility letter
with attachments
Submit Registration Is it QCON
Yes QCON reviewer
form to MOPH reviewable? No
No
Check site of the
facility against
Generate LOA – Qatar Healthcare
preliminary master plan
Yes Approved?
approval & CID
letter
Check Facility
Services of the
facility against
Qatar Healthcare
Generate Licensing master plan
Seek Excusive
requirements (Initial
Yes committee approval
& Final)
Generate
Recommendation
No report
Submitto the client:
Apply for :
1. LOA
1. Police clearance
2. Licensing requirements Submit
2. Commercial License
3. Initial assessemnt recommendation
3. Municipality License QCON approval
application report to Licensing
manager
Complete Initial
Assessment
Requirements
Complete Initial
assessment
registration form
Submit Initial
Review The
Assessment
application form
documents
Submit missing Request for missing
No Is it complete?
documents documents?
Yes
A
Phase
171
Healthcare Facilities Licensing Process
National Licensing and Accreditation for Healthcare Facilities Program
Facility / Client MOPH / Licensing Specialist MOPH / QCON INSPECTORS
Select dates for
initial assessment
Select initial
Assessment
Inspector
Check Inspectors Confirm your
Avilability avilability
No
Prepare initial
assessment Agenda
Prepare initial
assessment
information
package Documents
Sent the following to the inspector:
1. Agenda for desk review and site visit
Review the package
2. Assigned licensing standards
and the licensing
3. Disclosure of conflict of interest form
requirements
4. Agreement form
5. Peer review evaluation form
Communicate with the
Agree on Sign the disclosure
facility the following:
inspector & form and sent it
1. Inspector list
Dates? back to MOPH
2. onsite date
Yes
Conduct Pre initial Conduct initial
Confirm initial
assessment meeting Assessment desk
assessment site visit
with inspectors review
Conduct Initial
Assessment onsite
visit
Complete Peer
review evaluation
form
Submit peer review
Keep date in peer
evaluation form to
review records
MOPH
Review and edit
Submit initial
initial assessment
Assessment report
report
B
Phase
172
Healthcare Facilities Licensing Process
National Licensing and Accreditation for Healthcare Facilities Program
Facility / Client MOPH / Licensing Specialist MOPH / QCON INSPECTORS
Select dates for
initial assessment
Select initial
Assessment
Inspector
Check Inspectors Confirm your
Avilability avilability
No
Prepare initial
assessment Agenda
Prepare initial
assessment
information
package Documents
Sent the following to the inspector:
1. Agenda for desk review and site visit
Review the package
2. Assigned licensing standards
and the licensing
3. Disclosure of conflict of interest form
requirements
4. Agreement form
5. Peer review evaluation form
Communicate with the
Agree on Sign the disclosure
facility the following:
inspector & form and sent it
1. Inspector list
Dates? back to MOPH
2. onsite date
Yes
Conduct Pre initial Conduct initial
Confirm initial
assessment meeting Assessment desk
assessment site visit
with inspectors review
Conduct Initial
Assessment onsite
visit
Complete Peer
review evaluation
form
Submit peer review
Keep date in peer
evaluation form to
review records
MOPH
Review and edit
Submit initial
initial assessment
Assessment report
report
B
Phase
173
174
Healthcare Facilities Licensing Process
National Licensing and Accreditation for Healthcare Facilities Program
Facility / Client MOPH / Licensing Specialist MOPH / QCON INSPECTORS
Generate Re‐
Conduct Re‐
Inspection
Inspection visit
documents
Confirm re‐
Agree on re‐
inspection dates
inspector list and
and inspectors list
dates
with facility
Prepare re‐
inspection agenda
Check inspector Confirm Your
Avilability Avilability
Select re‐inspection
inspectors
Generate Final Submit re‐
inspection inspection
Preliminary report preliminary report
Submit Compliance schedule for Re‐
report to MOPH Inspection visit Submit final
inspection
Preliminary report
for decision
Issue Non Licensing
No
Compliance report Decision?
Yes
Complete non Submit Non
Issue Final
compliance Compliance report
Inspection report
standrds to the client
Generate Payment
Request
Send Final
Pay the licensing inspection report
fees and payment
request to client
Generate Service
price list
Submit the payment
slip and price list to Approve Price list
Licensing Specialist
Generate Facility
License
Submit price list and
Licensing certificate licensing certificate
to the client
E
Phase
175
Healthcare Facilities Licensing Process
National Licensing and Accreditation for Healthcare Facilities Program
Facility / Client MOPH / Licensing Specialist MOPH / QCON INSPECTORS
Operate as per
services license
No
One Month
before License
Expire?
Yes
Fill in License
Renewal Application
Prepare all attached
documents J
Submit Application
Review The
and attachments to
application form
MOPH
Complete missing Request for missing
No Is it complete?
documents documents?
Yes
Select dates for
H
Renewal Inspection
Select Renewal
Inspection Inspector
Check Inspectors Confirm your
Avilability avilability
Prepare Renewal
Inspection Agenda
Prepare Renewal
inspection
information
package Documents
Sent the following to the inspector:
1. Agenda for Renewal inspection
Review the package
2. Assigned licensing standards
and the licensing
3. Disclosure of conflict of interest form
requirements
4. Agreement form
5. Peer review evaluation form
F
Phase
176
Healthcare Facilities Licensing Process
National Licensing and Accreditation for Healthcare Facilities Program
Facility / Client MOPH / Licensing Specialist MOPH / QCON INSPECTORS
H
F
No
Communicate with the
Agree on Sign the disclosure
facility the following:
inspector & form and sent it
1. Inspector list
dates back to MOPH
2. onsite Inspection agenda
Yes
Conduct Pre
Confirm final Conduct renewal
inspection meeting
inspection date Inspection
with inspectors
Complete Peer
review evaluation
form
Submit peer review
Keep date in peer
evaluation form to
review records
MOPH
Verify & Finalize
Submit Renewal
Renewal inspection
inspection report
report
Send Feedback
Fill‐in feedback
questionner to the
questionner
client
Send Questionner Add data to KPI
back to MOPH manual report
Generate Renewal
inspection
Preliminary report
J Submit Renewal
inspection
Preliminary report
for decision
Submit Compliance
report to MOPH
Issue Non Licensing
No
Compliance report Decision?
Yes
Complete non Submit Non
compliance Compliance report
standrds to the client
Issue Final
Inspection report
Generate Payment
Request
Send Final
inspection report
I
and payment
request to client
Phase
177
178
6.3: Registration Application:
Registration Application
Facility Details
Facility Name:
Facility Type (QCON classification): Capital of Investment:
PIN No. Square Meters (land)
Square Meters (Built Up Area) Premise:
Estimated Start Date Estimated Completion Date:
Facility Address: Street Name:
Street Number: Building Number:
City: Municipality:
Zone Number: Google Map:
Scope/Services Provided
Sl.No Service Name Number of Beds (If Applicable) Age Group
1
2
3
4
5
*If more number of services are provided please prepare a table in the above format and attach it as an
appendix document along with completed registration form.
Contact Name (General)
First Name: Last Name:
E‐mail: Phone:
Owner Details
First Name: Last Name:
Qatar ID Number: Email:
Company Details (If owned by company)
Company Name: ID number:
Trade Name: Commercial Activity Type:
Business Address: Physical Address:
Email: Attach Commercial License:
Authorized Person (Legal Signatory)
First Name: Last Name:
Email Address: Attach Signatory License
179
Focal Point (Employer Representative)
First Name: Last Name:
Email Address: Mobile Number:
Telephone Landline: Qatar ID number:
Type of Applications (Please tick)
1. Clinics 2. Health Centre
□ Governmental/ Private Clinic □ PHCC Health Centers
□ Governmental/Private ‐ First Aid Unit □ Private polyclinics
□ Solo Clinic/Clinic Specialist □ Medical Commissions
□ Company Clinics
□ General Clinics
□ Blood Samples Collection Unit
□ Vaccination Unit
□ Dialysis Centers
□ AHP Clinics
3. Health & Wellness Centre 4. Diagnostic & Treatment Centre
□ PHCC Health Centers with wellness
component
□ Private polyclinics with Wellness
component
5. General Hospital 6. Specialized Hospital
□ Governmental/ Semi Government
□ Private
7. Long Term Care Facility 8.Diagnostic Centre
□ Skilled Nursing Facilities □ Stand‐alone Medical Laboratory and/or X‐
□ Mental Health Facilities Ray and/or Imaging facilities
□ Geriatric Facilities □ Medical Polyclinic Lab
□ Rehabilitation Centers □ Radiology Center
□ Substance Misuse Facilities □ X‐Ray Dept. / Medical Hospital Lab/
Radiation Protection Unit
□ Dental Laboratory
□ Research Center
□ Medical Optic shop / Medical Equipment
Shops/Medical shop
□ Herbal Medicine
9. Pharmacy
□ Commercial pharmacy
□ Governmental Pharmacy
□ Private Pharmacy (polyclinic pharmacy)
□ Medicine store
□ Medicine factory
Status of Land Acquisition
□ Purchased (attach deed) □ Leased (attach lease)
□ Under option (attach option agreement) □ Under Contract (attach contract or bill of
180
□ Other; Please specify: sale)
Land Use/MME Approval
Is the land appropriately zoned to permit its use for the purpose stated within □ YES
the application and according to MME land use? □ NO
If YES please attaché MME land use approval:
If NO Describe what steps have been taken to obtain the correct land use :
Project Category
Construction Service Change
(Any service charge related to inpatient service ,
day surgery, home health services , and major
medical equipment)
□ New Facility □ New Service
□ Expansion of Existing Facility □ Expansion of Service
□ Renovation of Existing Facility □ Expansion or Acquisition of Service Area
□ Replacement of Existing Facility □ Consolidation of Service
□ Relocation of Facility
Procurement of Medical Equipment (if Applicable) Type of Major Medical Equipment (If Applicable)
□ Purchase □ Cobalt unit
□ Lease □ CT Scanner
□ Donation □ Cyber Knife
□ Cyclotron
□ Fluoroscopy (Cath Lab)
□ Gamma Knife;
□ Linear Accelerator (conventional or
dedicated SRS unit)
□ Lithotripter
□ MRI Scanner
□ Nuclear Medicine Spectrometer (Gamma
camera); PET Scanner
□ Proton Beam
Please tick box if you require an Orientation session on the licensing process
Required Attachments (Please Check box)
Qatar ID (Owner): Commercial License (Company):
Scope/Services Provided:
181
References
QCON Classification: Licensing Guidelines:
Declaration
I affirm that the information given by me in this form and the enclosures is true and I am solely
responsible for its accuracy.
Name (Authorized Person): Date:
Signature with Stamp:
182
6.4: Role of Licensing Specialist
Healthcare Facility Licensing Specialists play an essential role in the management and the implementation
of the National Healthcare Facilities Licensing and Accreditation program. The Licensing Specialist under
the guidance of the Head, Healthcare Facilities Licensing, provides a wide variety of management,
coordination and support required for the healthcare licensing section.
The Licensing Specialists are required to have initiative, independent judgement and extensive knowledge
of national healthcare regulation, requirements, laws and Licensing Protocols. They are responsible for
the licensing process including issuing and renewing all healthcare facility licensing, and will be responsible
for coordinating Inspectors for all types of assessments conducted as a part of the licensing process.
At all times, Licensing Specialists are expected to exercise their duties with due regard to the health,
safety, and rights of patients/clients and operators/owners of healthcare facilities; and to support and
protect the professional credibility of the Ministry of Public Health (MOPH).
The responsibilities of Licensing Specialists are as follows:
Providing a comprehensive range of professional and timely administration services for
licensing, renewal and customer service management
Creating Inspection schedules for healthcare facilities based on size and services. Licensing
Specialists are responsible for coordinating with healthcare facilities to determine dates of any
pre‐scheduled on‐site inspections so to choose a time that is convenient for the facility.
Liaising with stakeholders, service providers and healthcare facilities.
Liaising with other relevant government bodies if necessary.
Monitoring the status of healthcare facilities’ License and scheduling Initial Assessments, Final
Assessment, Annual Renewals or Ad Hoc Inspections.
Answering questions from healthcare facilities about the National Healthcare Facilities Licensing
and Accreditation Program.
Convening and supporting Licensing team at the Ministry of Public Health. Providing routine
information and support to staff; scheduling activities, answering questions, and resolving or
referring day‐to‐day operational problems and concerns.
Editing the Licensing Requirements as per Facility Type.
Determining during the application process whether a healthcare facility is QCON Reviewable.
Supporting on‐going data collection and analysis.
Supporting the Decision Committee (DC) as required.
Producing a variety of correspondence, reports and presentations using the appropriate
software for word processing, graphics and spreadsheets.
Reviewing complaints made against healthcare facilities and coordinate with top management
and the inspection team on investigation of the complaint.
Licensing Specialists may also act as Inspectors depending on their expertise and background, as well as if
they have undergone the necessary Inspector training. Licensing Specialists, however, should not act as
Inspectors for any healthcare facilities where they have provided customer service, advised or provided
additional support for that healthcare facility.
183
6.5: Initial Assessment Application
Facility Details
Facility Name:
Facility Type (QCON classification):
Street Name: Street Number:
Building Number: City:
Municipality: Zone Number:
Google Map:
Focal Point (Employer Representative)
First Name: Last Name:
Email Address: Mobile Number:
Telephone Landline: Qatar ID number:
Required Ministry Certifications (Please Check box)
Police Clearance Certificate (owner) Ministry of Muncipality and Urban Planning
Ministry of Labor and Social Affairs Commercial License
Civil Defense Approval No‐Objection letter from MOPH
Hard copies of evidence to comply Soft copies of evidence to comply
with the licensing standards. with the licensing standards.
Declaration
I affirm that the information given by me in this form and the enclosures is true and I am solely
responsible for its accuracy.
Name (Authorized Person): Date:
Signature with Stamp:
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6.6: Role of Inspector
The Ministry of Public Health (MOPH) will hire inspectors either as a full‐time employee or as a part‐time
peer reviewer. Inspectors are individuals that have experience and expertise in the healthcare field that
will enable them to interpret and evaluate the protocols effectively. They will receive training on the
National Healthcare Facility Licensing and Accreditation Program for the State of Qatar. Currently we have
fulltime MOPH Inspectors and Peer Review Inspectors who have been selected and given adequate
training.
Inspectors play an essential role in the implementation of the National Healthcare Facilities Licensing and
Accreditation program. The Inspector is responsible for inspecting, investigating and evaluating matters
related to legislation and regulations.
Inspectors should be:
• Familiar with Licensing Standards of Healthcare Facilities
• Cultural requirements of Qatar
• The rights of patients/clients,
• Current International best practices,
• Policies and Procedures of Healthcare Facilities Licensing & Accreditation Department,
• Code of Ethics,
• Established practices for the operation of healthcare facilities,
• Regulations and legislations of Qatar Law.
At all times, Inspectors are expected to exercise their duties with due regard to the health, safety, and
rights of patients/clients and operators of healthcare facilities; and to support and protect the
professional credibility of the Ministry of Public Health.
The responsibilities of the inspector are as follows:
Conducting inspections of healthcare facilities for the purpose of Licensing, reviewing complaints,
annual and ad‐hoc on‐site inspections, and ensuring general compliance with the provisions of
legislation and regulations as set out by the Licensing Protocols.
Liaising with stakeholders and service providers.
Identifying, collecting and documenting evidence gathered in the course of inspections to
determine level of compliance.
Ensuring that information is collected consistently through the National Healthcare Facilities
Licensing and Accreditation Program.
Interviewing healthcare facility staff and other related parties, including taking statements and
obtaining and discussing information related generally to the operation of the facility, the care
and safety standards and any other information that may assist in determining compliance.
Be prepared to conduct professional lines of questioning with healthcare facility staff.
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Collecting, evaluating and assessing any immediate risk of harm to patients/client/staff/public’s
health, safety and welfare and taking appropriate action and/or making referrals as required, so
that appropriate action can be taken.
Verifying and assessing data and information/evidence gathered in inspections to identify non‐
compliance; providing recommendations on areas of non‐compliance.
Maintaining the highest level of care, sensitivity and integrity regarding information and data
observed and recorded during on‐site inspections of healthcare facilities. All comments, remarks
and assessments written by inspectors will be based directly on evidence they have seen through
either document reviews, interviews or observations.
Role of the Team Lead
A Team Lead shall be designated for each group of inspectors conducting an on‐site inspection. The Team
Lead will be responsible for the management of the on‐site component of the inspection, ensuring that
the Inspectors complete the assessment of all the appropriate requirements of the Licensing Protocols
needed for the facility to achieve the appropriate license in the designated timeframe. The Team Lead
will manage any issues that arise during the inspection with the assistance of other Inspectors as
appropriate.
The Team Lead will be responsible for completion and submission of the inspection report for the Decision
Committee (DC) at the end of the on‐site inspection. The Team Lead will also be responsible for collating
all the comments and making an overall recommendation based on observations and overall risk ratings.
The Team Lead will carry their Judicial Control Card for all inspections at all times and will present it to
staff at the healthcare facility if asked.
The key responsibilities of the team leader are as follows.
Planning
Approve the selected applicable standards set by licensing specialist before conducting the
mission
Approve the list of selected inspector and the agenda towards the mission.
Conduct the on‐site pre‐inspection meeting with the inspection team
Collect feedback from the team about the inspection schedule, and provide it to the Licensing
Specialist.
Managing
Discuss, negotiate, and finalize team members’ roles and responsibilities
Define inspection tasks and milestones to achieve objectives
Track work according to the inspection schedule
Identify and follow up on areas of concern
Identify and resolve conflicts within the team or with the organization
Organize and facilitate information exchanges with fellow inspectors to ensure they are
gathering data and information required to assess compliance
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Keep notes from the on‐site inspection in case these are needed later, and remind the rest of
the team to do the same
Mentoring, Coaching and Evaluating
Mentor, coach and provide performance feedback to new inspectors (for example, interns).
Share concerns about inspectors’ performance with Inspector Resources.
Compiling the Results
Write the summary of team observations with input from other inspectors
Review the results for consistency and completeness: spell check, grammar, accuracy, and flow
Leading the Debriefing Sessions
Plan the debriefing sessions and assign responsibilities
Lead the debriefing sessions with participation from the rest of the team
6.7: Decision Committee (DC) Terms of Reference (TOR)
Qatar Healthcare Facilities Licensing and Accreditation Department
Licensing and Accreditation Decision Committee (LADC)
TERMS OF REFERENCE
Purpose
To confer licensing and accreditation decisions, decide on appropriate follow‐up conditions, and review
data, evidence submitted by facilities. Licensing and Accreditation Decision committee assist the
Healthcare Facilities Licensing and Accreditation department in providing high quality services to our
clients.
This committee mitigate risk by formalizing decision process to ensure the appropriate transparent
licensing or accreditation decision is taken as per predefined decision matrix and guidance.
In addition, the process ensures the appropriate use of materials and evidence and allows LADC members
and teams to forecast the work that needs to be done in the days and weeks ahead in order to align with
other work commitments.
LADC will identify high risks/alerts of incidents, findings, and processes during the Licensing and
Accreditation Inspection/Survey and report findings to higher authorities for needed action.
Scope of Authority
The Licensing and Accreditation decision committee (LADC) is authorised by the Minister decree. The
LADC is established by Licensing and Accreditation of Healthcare Facility Department under the Ministry
of Public Health (MOPH) in accordance with Emiri Degree (10) 2016.
Main Activities
The main activities of the LADC shall be as follows:
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To review all inspection and survey reports/data submitted by inspectors and surveyors
following their on‐site visits, as per procedure.
To render decisions (to include detail reports on how the facility has met/not met required
conditions) regarding Licensing and Accreditation to higher Authorities within two weeks; after
the last day of the on‐site visit.
To ensure consistency and transparency in the use of the decision making process.
To respond to any queries from higher authorities regarding decisions submitted in their
reports.
The Terms of Reference of the LADC will be reviewed periodically with its members.
Membership and Leadership
The composition of the LADC is as follows:
1. Chair – Director of Licensing and accreditation department,
2. Inspector or Surveyors (did not participate with the Facility).
3. Manager Licensing
4. Manager Accreditation
5. Official minute ‐secretary
Duration of Appointment
The Chairman, Staff Members and the Secretariat of the LADC are assigned for the term of their
leadership of the department.
Selection of committee members will be determined by Ministry of Public Health Leadership based on
identified knowledge, skills and experience required.
Responsibilities
Chairperson’s Responsibility
The Chairman of the LADC shall be overall responsible about the outcomes of the Committee. In
addition the Chairman shall have the following basic responsibilities:
Reporting the status of the Committee to the higher authorities.
Facilitating and moderating the discussions during the meetings by giving equal chances to all
members to express their views and to avoid bias.
Placing relevant items on the Agenda.
Signing and endorsing the Minutes.
Secretary’s Responsibility
The Secretary is responsible to:
Prepare the agenda and calling for the meetings.
Record and distribute the minutes after the approval of the Chairman.
Follow up on all the decisions taken by the committee and reporting to the Chairman any
delinquencies.
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Member’s Responsibility
The members shall have the following basic responsibilities:
Attending the LADC Meetings on time.
Reading the minutes and any other material distributed and come prepared to the Committee to
discuss the topics addressed in the Agenda.
Participating in the discussions during the meetings.
Performing the tasks and/or activities assigned to them.
All members shall ensure the confidentiality of the deliberations that took place during the
meeting.
Meetings Policy
Frequency of Meetings
The LADC is conducted weekly or as required to process all scheduled business.
Quorum
The LADC Meeting requires the minimum presence of 2 of the members to constitute a formal
forum for the Committee.
The LADC Meeting requires a quorum within 15 minutes from the specified time, failure to
achieve that, and then the meeting is automatically cancelled.
Recording/Reporting
Agenda
The agenda will be prepared by the Chairman and the Secretary and distributed at least one day
prior to the next scheduled meeting.
Members are expected to send the topics that they need to discuss during the meetings to the
Secretary at least one day prior to the scheduled date of the meeting.
Urgent topics can be added to the agenda after obtaining the approval of the Chairman.
Minutes
The minutes shall be prepared and signed by the Secretary; approved and endorsed by the
Chairman.
The minutes shall be distributed to the members within one week from the conducted meeting
by mail or e‐mail.
The minutes of the previous meeting shall be approved and changes discussed at the beginning
of each meeting shall be reflected in the next minutes.
The minutes shall indicate the members who were Present, Apologized or Absent.
The LADC Meeting’s minutes shall be distributed to the Chairman, Members, Secretary, and a
copy to the Director General.
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6.8: Final Assessment Application
Final Assessment Application
Facility Details
Facility Name:
Facility Type (QCON classification): Electricity Number:
Focal Point (Employer Representative)
First Name: Last Name:
Qatar ID Number: Mobile Number:
Scope/Services Provided
Sl.No Service Name Number of Beds (If Applicable) Age Group
1
2
3
*If more number of services are provided please prepare a table in the above format and attach it as an
appendix document when you submit the registration form.
Required Attachments (Please Check box)
QCHP practitioners License Civil Defence Approval
Security Camera Approval (CCTV) Waste Management Contract
Ministry of Environment (Radiation License) Initial Assessment Approval
For X‐ray Devices
Approval of Medical Equipments External Board Photo
Equipment List Blacklist Practitioners Undertaking
Declaration
I affirm that the information given by me in this form and the enclosures is true and I am solely
responsible for its accuracy.
Name (Authorized Person): Date:
Signature with Stamp:
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6.9: Renewal Assessment Application
Application for Renewal of License
Facility Details
Facility Name:
Facility Type (QCON classification): Facility License No:
Focal Point (Employer Representative)
First Name: Last Name:
Qatar ID Number: Mobile Number:
Scope/Services Provided
Sl.No Service Name Number of Beds (If Applicable) Age Group
1
2
3
*If more number of services are provided please prepare a table in the above format and attach it as an
appendix document when you submit the registration form.
Required Attachments (Please Check box)
Facility License Copy Civil Defence Approval
Security Camera Approval (CCTV) Waste Management Contract
Price List Patient Bill of Rights and Responsibilities
Ministry of Environment Radiation Certificate Commericial Registration and Commercial
License
Blacklist Practitioners Undertaking List of Practitioners with License Number
And Expiry Date.
Declaration
I affirm that the information given by me in this form and the enclosures is true and I am solely
responsible for its accuracy.
Name (Authorized Person): Date:
Signature with Stamp:
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6.10: Fees for approved health services
Fees for Approved Health Services
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7.0 Appendices:
7.1: Point of Care Testing Services
Point of Care Testing Services
Glucose
Blood Gases
Urine dipstick
Creatinine
Hemoglobin
Coagulation - PT/INR, ACT LR, ACT +
Thromboelastography (TEG)
Fetal Fibronectin
Fetal Membrane Rupture Test (AmniSure ROM)
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7.2: Crash Cart Check List
Crash Cart Top
Side
Defibrillator with leads 02 tank
Disposable gloves Backboard
Sharps container
(1) package of defibrillator pads
(2) Amiodorone
(2) Atropine 1 mg
(2) Vasopressin
(2) Calcium gluconate
(1) Dextrose 50% 5ml
(4) Epinephrine 1 mg
(3) Lidocaine 100mg
(2) Sodium Bacarbonate 50 meq
(2) Dopamine
(2) Lasix
(2) Dobutamine
(2) Tridil (nitroglycerin)
(2) Pronestyl
(2) Nipride
(2) Verapamil
(1) Magnesium sulfate
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(1) 20 ml syringe
(4) 3 ml syringes
(1) TB syringe
IV start equipment: (4) 18 gauge angiocaths
(4) 20 gauge angiocaths
(1) 22 gauge angiocath
Tourniquet
Assorted butterflies
3 way stopcock
Assorted needles
Band- aids & Tape
Betadine swabs
Alcohol swabs
Saline locks
(1) Lidocaine topical solution
(1) Radial artery catheterization set
Drawer 4
Electrodes
B/P cuff with stethoscope
Assorted sterile gloves
(2) Packages of defibrillator pads
NG tube
(1) 60 ml syringe
Locks
Drawer 5
IV solutions: 1000 ml each of D5W, RL, NS
500 ml each D5W, NS
(2) 100 ml NS
(2) 500 ml Lidocaine 2 grams
(1) Dobutamine
(1) Dopamine
(1) Amiodarone IVPB
Tubing (2) microdrips (60 drops/ml)
(2) macrodrips (15 drops/ml)
(2) extension sets
Medication additive labels
Drawer 6 (Bottom)
Tracheostomy tray
Transvenous Packing Electrode kit
Ambu bags, Adult & Pedi
Suction set up (portable cart)
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7.3: Initial Assessment Guidelines
5 A PPIO.5 The potential risks and opportunities of the proposed capital
project are identified.
6 A PPIO.6 The resource requirements for the capital project are determined.
7 A PPIO.7 A functional program is developed and implemented for the capital
project.
Floor Plans
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Draw a layout of the room with
proposed furnishing. E.g.
Consultation room furnished with
doctors table, patient bed,
equipment etc.
http://www.calgaryhealthregion.ca/policy/
docs/1346/InfectionPreventionduringConst
ruction.pdf
Refer to Templates provided at the end of
this document
Refer to Templates provided at the end of
this document
Mark hand washing sinks
Mark where alcohol scrubs will be
placed
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Draw flow of clean and dirty items.
Show Negative pressure areas or
High Infection areas like Isolation
room, Operation Theatre etc. (if
applicable)
Provide brochures of Material used for
furnishing walls, floors etc.
E.g. all rooms shall be furnished in the
same way. This is to make sure that health
practitioners do not need to re‐orient
themselves to different types of rooms.
Waiting areas
Placement of curtains.
Toilets with grab bar
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Hand bar/rails for elderly/disabled
Also facility can provide details of any
special language (braille, sign language)
that will be used within the facility.
Fire exit sigs etc.
Separate waiting areas
Single consultation rooms.
Official document describing the privacy of
patients during consultation. (e.g. One
patient at a time.)
Official letter (Refer to Templates provided
at the end of this document)
Use of natural lighting like window
Individual control over lights
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Type of bulbs and lighting to be
used.
Waste Management room layout.
All details with regards to provision
of ventilation, drainage etc. should
be provided in layout.
Plans to deal with monitoring of
Medical Refrigerator alarms during
off hours etc. (If applicable)
Transport Ministry Approval
MOI approval
MOEC approval
Kahramaa approval
200
Official letter from the Healthcare
facility indicating that the
construction agreement has been
met.
Describe in this letter how the
construction is going to be done
and in each phases.
Refer to Templates provided at the
end of this document
For solo clinics the owner can be
the sole member.
Provide Information about CCTV
approval, Civil Defense Approval
etc.
201
Commissioning Checklist
Commissioning Committee Terms
Of Reference (Refer to Templates
provided at the end of this
document)
Include relevant timelines.
202
• at least 2.70 metres high in all other spaces
• at least 2.7 metres high in residential facility rooms
203
equipment are separated from electrical
switch boards.
This also depends on the number of floors
in the healthcare facility and also the
number of services being provided.
204
Official document describing the
furnishing and infrastructure of the
waste management room.
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TEMPLATES
1.0 PPIO.1 – PPIO.7 Planning and Predesign Document
Preplanning and Predesigned Document
Introduction (Briefly provide an introduction incorporating the following points)
Type of Healthcare Facility
Location of Healthcare Facility
Type of Service Being Provided
Types of Clients served by the organization.
Potential Risks and Opportunities (Describe the risks and opportunities related to your project)
Identify potential risks
o Risks can be internal and external. (E.g. expected delays due to government approvals etc.)
o Financial Risks
o Environmental Risks (e.g. waste management issues, radiation etc.)
Identify Potential Opportunities.
o Available Funds
o Source of Funds
o Partnerships
o Marketability of the Facility
Community Needs Analysis (Describe the needs of the community)
How many facilities providing the same type of service in the area.
Population of people in that area.
Age demographics (Include details of age group of people requiring that service)
Disease Prevalence Reports (Include details and statistics about the healthcare needs for that service)
o E.g. if opening a diabetic facility details with regards to the prevalence and number of diabetic
patients in that area.
Data related to needs assessment is readily available in MOPH annual health report.
Resource Requirements (Give details with regards to the resource requirements identified)
Financial Resources
Human Resources – staffing plan
Equipment Resources.
Scope and Objectives (Include details with regards to the scopes and objective of this project)
Services that are being provided based on the needs assessment.
What you expect to achieve by opening this healthcare facility
Include any future plan on expansion or etc.
Master Plan
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Definition: A master plan is a plan that shows an overall development concept that includes urban design,
landscaping, infrastructure, service provision, circulation, present and future land use and built form. It consists
of three dimensional images, texts, diagrams, statistics, reports, maps and aerial photos that describe how a
specific location will be developed. It provides a structured approach and creates a clear framework for
developing an area.
Include the following details in this section:
Include a Master Layout of the Organization
o Photo of the healthcare facility.
o Aerial Photo
E.g. from Google earth.
Services provided on each floor of the organization.
Parking Lots provision including disabled access
Road Network showing major circulation
Functional Plan
Definition: It can be defined as a plan that gives overall guidance and detailed description on the capital project
proposal and implementation.
Functional Relationships (Describe in detail)
Specify and describe the placement of each room.
Site Selection
How and why did you choose the current site for your healthcare facility?
Transportation (Describe in detail if applicable)
Describe the access for emergency vehicles.
Emergency and Disaster Planning
Provide a copy of your fire safety and evacuation plan. Describe your fire safety and evacuation training
program.
Identify the types and locations of emergency supplies.
Describe how you will maintain operational continuity during the events listed above, including
o Heat/Cooling
o Water
o Medications, if necessary.
Types of Rooms
List room types included in this facility such as client care rooms, waiting areas, waste management etc.
Laundry Service
Where is facility laundry done?
How are clean and soiled areas separated?
Is the laundry co‐mingled?
207
What type of laundry equipment is being used?
Who is doing the facility laundry?
Medication Storage and Use
Where does the facility store medications? Describe the lighting and work surfaces in this area?
Describe how the temperature and humidity are monitored in the Medication Storage room.
Who assists and supervises medications? What kind of assistance do they provide? How are the
medications distributed? Is there a handwashing sink nearby?
Where are the medications administered?
Communication Systems
How will staff notify other staff in an emergency?
How will staff notify outside services of an emergency?
Security Systems
How are the building(s) and surrounding areas secured?
What alarm systems, if any, are used?
Describe in details the methods, hardware or locking mechanisms, and operational plans to be
used when securing residents.
Other Components
Please list and describe any other components pertaining to the facility such as initial and ongoing
physical assessments, verification of staff, hospital transfer agreements, infection control, safety,
charting and documentation, limited nursing services, etc. (where applicable)
Introduction:
Type of Services that are going to be added.
Continuing Operations Plan
Include Infection Prevention and Control Requirements
Flow of Clients
Flow of Construction Worker
Flow of Staff
Flow of Clean and Dirt Utility
Who oversees the implementation of this plan?
This plan can include a checklist also on the continuing operations.
208
Commissioning Plan (Definition)
The purpose of the commissioning plan is to provide direction for the commissioning process during
construction/renovations, providing resolution for issues such as scheduling, roles and responsibilities, lines of
communication and reporting, approvals, and coordination.
In simpler terms it can be described as a plan that describes the healthcare facility at the initial stage of the
project and type of work required to make the healthcare facility ready to operate. This can also be a checklist.
Commissioning Plan
Commissioning Committee
Include the Terms of Reference (TOR) of the Commissioning Committee
o Members of the Committee (Can be the sole owner)
o Purpose or Function of the committee
Purpose can be to identify any required changes for conversion of existing building to a
solo clinic.
Commissioning Plan
Include Checklist for Building Commissioning.
o These checklists should list all requirements needed to be checked prior to approval and sign
off with the owner of the facility. E.g. required changes in infrastructure, HVAC systems, Water
systems, Leaks etc.
Include Checklist for Operational Commissioning.
o Plans for occupying the building.
Moving equipment in, Procurement of supplies, Medication Kits, QCHP license process,
Staff education etc.
Official Approval of this plan can be taken as an evidence for CMIO.1
Official Letter from healthcare facility owner (Describe with below details)
Identify the type of Facility
Refer to the guidelines/best practices used to design the facility
o Eg. MOPH requirements incorporated, Infection Prevention Control Incorporated, Privacy
Issues (Separate male and female waiting areas) etc.
This letter should be officially stamped and signed by the owner of the healthcare facility.
209
Official Document/Letter (Describe in detail the security measures incorporated)
Security Measures
o SSD Approval Status
Placement of Cameras
o Secured Access Systems
Placement of Secured Access
o Fire Safety Approval
Fire Safety
Provision of Fire Extinguisher
Fire Alarms, Sprinkler Etc.
o Windows
Provision of bars on windows
Provision of non‐opening windows if any
Child Elopement Measures.
o Disability Provisions
Provision of Ramps with hand rails
Provision of Wheelchairs access
Official Document/letter from the owner of the facility (Describe in detail how the construction agreement was
met)
Describe in the letter how they are planning to do the construction.
Provide copy of tenancy contract if applicable
Example of a commissioning terms of reference:
Background/Context
Based on a review of the demographics and disease prevalence in Qatar a decision was made to
The following capital project objectives were developed:
1. Open a ____________ that reflects the needs of the community served.
2. Stay within the budget and meet our financial obligations.
210
3. Stay within our time lines for project completions.
4. Obtain all of the necessary approvals for regulations and codes.
The following risks to the capital construction project were identified:
1. Cost over runs
2. Unable to get all approvals necessary
3. Lack of compliance to all requirements
4. Unable to meet time lines for completion
In order to resolve these risks, it was decided to appoint ______________________ to oversee the planning,
construction and commissioning of the ______________ in Doha.
Function
The commissioning process main goal is to improve a project from the rental phase through to
occupancy.
Role
The Role is to:
take on responsibility for the project's feasibility, business plan and achievement of outcomes
ensure the project's scope aligns with the requirements of the stakeholder groups
provide those directly involved in the project with guidance on project business issues
ensure effort and expenditure are appropriate to stakeholder expectations
address any issue that has major implications for the project
keep the project scope under control as emergent issues force changes to be considered
reconcile differences in opinion and approach, and resolve disputes arising from them
report on project progress to those responsible at a high level
take on responsibility for any government issues associated with the project.
Role of individual member(s)
The role of the individual member includes:
understand the strategic implications and outcomes of initiatives being pursued through
project outputs
appreciate the significance of the project for some or all major stakeholders and represent
their interests
be genuinely interested in the initiative and the outcomes being pursued in the project
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be an advocate for the project's outcomes
have a broad understanding of project management issues and the approach being adopted
be committed to, and actively involved in pursuing the project's outcomes
In practice, this means they:
ensure the requirements of stakeholders are met by the project's outputs
help balance conflicting priorities and resources
provide guidance to the Project Team and users of the project's outputs
consider ideas and issues raised
review the progress of the project
check adherence of project activities to standards of best practice, both within the organization
and in a wider context
General
a. Membership
The Commissioning function shall be comprised of:
b. Frequency of Meetings
Meetings will be convened on an as needed base. If an issue arises related to commissioning the responsible
person will notify the owner who will arrange a meeting to discuss and resolve the issue.
c. Minutes
The minutes of each meeting will be prepared by one of the participants be determined at the beginning of
each meeting. In situations where the owner is the sole person responsible for the commissioning, he/she will
keep notes on issues and resolutions.
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7.4: Dialysis Unit Design Guidelines
Room Quantity and Sizes: Outpatient Unit with 12, 18, 24 & 30 spaces
Reception/Waiting Areas
12 Treatment 18 Treatment 24 Treatment 30 Treatment
Space Space Space Space
Type of Room Number m2 Number m2 Number m2 Number m2
of of of of
Rooms Rooms Rooms Rooms
Covered Entrance 1 10 1 10 1 10 1 10 Covered entrance
should be provided
Reception 1 9 1 9 1 12 1 15
Waiting Area General 1 10 1 15 1 15 1 20
Waiting Area Female 1 10 1 10 1 15 1 15
Consultation 1 14 2 14 2 14 3 14
Training/Treatment room See Note 2
Meeting Room 1 20 1 20 1 40 1 40 See Note 1
Nurse Manage Office 1 9 1 9 1 9 1 9
File Store 1 6 1 6 1 6 1 8
Toilet Disabled 1 6 1 6 1 6 1 6
Toilet Public 1 3 2 3 2 3 2 3
Treatment Areas
Type of Room 12 Treatment 18 Treatment 24 Treatment 30 Treatment
Space Space Space Space
Treatment bay – Renal 11 9 15 9 20 9 25 9 See Note 3
Dialysis
Isolation Room 1 14 3 14 4 14 5 14
Ensuite – Standard 1 5 3 5 4 5 5 5 For Isolation room
Shower – Accessible 1 4 2 4 2 4 2 4
Toilets 1 6 1 6 2 6 2 6
Linen Bay 1 2 1 2 2 2 2 2
Resuscitation Trolley Bay 1 1.5 1 1.5 1 1.5 1 1.5 Adjacent to Staff
Station
Clean Utility 1 12 1 12 1 14 1 14 Including
medications and
dressing setups
Dialysate Preparation Area 1 2 2 2 2 2 2 2 Adjacent to
Dialysate Fluid Bay
Dirty Utility 1 10 1 10 1 10 1 10
Staff Station 1 12 2 10 2 10 2 12
Storage Areas (Treatment Zone)
12 Treatment 18 Treatment 24 Treatment 30 Treatment
Space Space Space Space
Wheelchair Bay 1 4 1 4 1 8 1 8
Dialysate Fluid Bay 1 1 2 1 2 2 2 2 See Note 4
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Note 1: Meeting Room; to support patient education, community training and other functions; should have
teleconferencing capability; add 4m2 to room if including a beverage bay
Note 2: Training/Treatment room; where there is a developed program of training for home based dialysis as
approved in the Service Plan a dedicated space should be provided; this space could also be used for related
procedures such as the insertion of catheters etc.
Note 3: Treatment Bays; Bay size needs to be 9 square meters with a clear width of 3 meters along the back of
the bay to ensure appropriate service placement, machine accommodation and curtain track placement;
spaces of 12m2 will need to be considered where more than 50% of patients are receiving dialysis inpatient
beds rather than chairs); bays will accommodate beds or chairs
Note 4: Dialysate Fluid Bay; to hold dialysis fluid in a convenient location close to treatment bays; temperature
is important for some dialysate fluids and this area may require air‐conditioning
Note 5: Main Store Room; for general stores, fluids and equipment, to be located on the perimeter of the Unit
and accessible by a palette lifter. Shelving must have 100 kg weight capacity and shelves need to be at least 400
mm apart and adjustable.
Please also note the following:
Areas noted in Schedules of Accommodation take precedence over all other areas noted in the FPU.
Rooms indicated in the schedule reflect the typical arrangement according to the Role Delineation.
Exact requirements for room quantities and sizes will reflect Key Planning Units identified in the service
plan and the policies of the Unit.
Room sizes indicated should be viewed as a minimum requirement; variations are acceptable to reflect
the needs of individual Unit.
Office areas are to be provided according to the Unit role delineation, organizational office policy and the
number of endorsed full time positions within the Unit
214
Staff and support rooms may be shared between Functional Planning Units dependent on location and
accessibility to each unit and may provide scope to reduce duplication of facilities.
215
7.5: Rehabilitation Unit – Functional Relationship Diagram
216