€ ‘MoH/DGQACIPRPIOOI/Vers OL Policy & Procedure of Document Development Effective Date: Api 2016 Review Date: Apa 2019 Institution Name: Directorate General of Quality Assurance Centre, MoH Document Title: Policy & Procedure of Document Development Approval Process Name Title Institution Date Signature Written by Document Ministry of Development Health Team Reviewed by DGQAC Team DGQAC_ Ministry of : Health p06 Ry : Validated by Dr. Ahmed Bin DGof Ministry of Salim DGQAC . Health DD Al-Mandhari Approved by H.EDr. Ahmed Minister Ministry of Bin Mohammed of Health Health bo S AL-Saidi av ys Page | of 25\CIPBP/OOL/Vers.01 i aOR EE Policy & Procedure of Document Development Effective Date: April 2016 Review Date: April 2019 Content Table: Acknowledgement Acronyms. 6.1 Step One: Development. 6.2 Step Two: Reviewing 6.3 Step Three: Validat 6.7 Step Seven: Implementation. 6.8 Step Eight: Update.. 7. Responsibil 7.1 Directorate General of Quality Assurance Centre, 7.2 Directors General of Directorates General in HQ 7.3 Directors of Hospitals......cs.. 7.4 Directors/ Heads of Sections/Departments......+ssee 7.5 Department of Control & Development of Quality Document. 7.6 Directors/Head of QM&PS Department/Section in Governorates HQ IGovernorates....esee 7.1 Document Writer... 7.8 Head of Information and Technology Department in Institute/ HQ...sv+++ssseee-14-15 7.9 All Staff... 8. Document History and Version Control 9. Related Documents... 10, References.....sseese 11, Appendix 1: First Page 12, Appendix 2: Main Elements of the Document Developmen 13, Appendix 3: References Table «1...» 14, Appendix 4: Document Development Procedure Flowchart. 15. Appendix 5: Coding System 16, Appendix 6: Document History and Version Control... Page 2 of 25MolDGQACraPiD01/Vers01 Policy & Procedure of Document Development Effetve Date: April 2016 Review Date: April 2019 Acknowledgement Directorate General of Quality Assurance Center would like to thank and appreciate the great efforts of all the staff from different healthcare institutions in the country who participated in writing up this Policy and Procedure and in particular the following staff: Adil A-Shidi Sohar Hospital (Team Leader) ‘Adhra A-Habsi Royal Hospital ‘Asma Al-Hud Khoula Hospital ‘Aza Al-Nabhani Directorate General of Health Services-Al Dakhliya Faiga Al-Sinawi Directorate General of Nursing Affairs Fawziya AFATadi ‘Qurayat Hospital Hind Al-Mandhari Tori Hospital Imad Karama Directorate General of Health Services-Salalah Dr. Khalid Abu Almagd Directorate General of Quality Assurance Center Laila AL-Dhehii Directorate General of Disease Surveillance & Control Maryam Al-Jahwari Sohar Hospital Saleema AL-Farsi ‘Sur Hospital Dr. Samia AL-Rabhi Directorate General of Health Services- Muscat ‘Shamsa Al-Shukaili Directorate General of Health Services- South Batinah Suad Bait-Maghrab Sultan Qaboos Hospital- Salalah Suliman AF-Abri Directorate General of Nursing Affairs Yusra Al-Wahiebt ‘Al Nahdha Hospital ‘Yusif Al-Khamisi Sultan Qaboos University Hospital Page 3 of 26MolYDOQACIPE001/¥er.01 Policy & Procedure of Document Development Eetve Dae: pil 2016 Review Date: Api 2019, ‘Acronyms: DcDa@D Department of Control & Development of Quality Document DGHS Directorate General of Health Services DMS Document Management System DGQAC Director General of Quality Assurance Centre HQ Head Quarter Molt Ministry of Health PRP Policy & Procedure QaPs ‘Quality Management & Patient Safety TA Institutions Acronym DO Document Owner DT Document Type DN Document Number Vers Version Number Page 4 of 25MoH/DGQACIP&PIOOL/Vers 01 Policy & Procedure of Document Development Effective Date: Apil 2016 Review Date: April 2019, Policy& Procedure of Document Development 1. Introduction The Directorate General of Quality Assurance Centre (DGQAC) provides this policy & procedure as a national guidance to standardize the format and the procedure for ‘managing, developing, reviewing, coding and approving documents that initiated by all levels in healthcare institutions (Primary, Secondary, Tertiary and National levels) in Ministry of Health (MoH). 2. Scope This document is applicable to all healthcare institutes in MoH. 3. Purpose 3.1 To provide guidelines for format standardization, template structures, and numbering system for written procedures. 3.2. To ensure that all documents follow a recognized standardized framework and format process (writing, developing, reviewing, coding and approving) before being disseminated and implemented. 4. Defi ions 4.1, Absolute Document: is a document that is no longer in general use and fallen into disuse 42 Co standardized way which composed of (IA/ DO/DT/ DN/Vers. No). 43 Document: is an official paper/electronic file that gives information about any g System: is a systematic method for organizing documents in a matter or that is used as a proof of something, 44 Document owner: is the document writer (Directorate General /Departments /Section). Page $ of 25Policy é& Procedure of Document Development Effective Date: Apil 2016 MoH/DGQACIP&>PICON/Vers 01 Review Date: April 2019, 45 4.6 47 48 49 4.10 41 4.12 4.13 414 4.15 4.16 4.17 Document Review: is a set of steps which ensure the document is edited and written as per agreed structure, Document Management System: is a computer based system in the case of the management of digital documents used to track, manage and store documents and reduce paper usage. Document Writer: is the person/group that initiates and develops the standard document. Document Validation: is a process done by the Quality Management & Patient Safety (QM&PS) department/section or DGQAC in which the document is checked to ensure that it was developed based on this document. Document Control: is the process whereby all MoH institute policies, processes and guidelines are systematically written, reviewed, updated and stored to maintain document integrity Forms: is a structured document with fixed arrangement of captioned spaces, designed for entering, extracting, or communicating the required information. Instituti is an organization, establishment, foundation, society devoted to the promotion of a particular cause or program e.g universities, hospitals, directorates (Douglas, 2010). Institutional Document: is any document related/ applied to the institutional level, National Documents: is any document applied to the national level. Policy: is the basic principle, by which a government is guided, it declares objectives of the institute. Procedure: is the established steps to be followed routinely in order to ensure that the outcome and values expressed in the policy are achieved (Athabasca University, 2009). Process: It is a set of mandatory step by step, detailed action required to successfully accomplish a task. Protocol: Protocol has several different meanings, all connected to the idea of guidelines or procedures to follow, including: Page 6 of 25Policy & Procedure of Document Development Effective Date: April 2016 Mol/DGQACIPRP/DOI/Vers.01 Review Date: April 2019 5. 4.17.1 An accepted or established code of procedure or behavior in any group, organization or situation. 4.17.2. A set of rules explains the ideal procedures. 4.18 Record: Document that memorializes and provides objective evidence of activities performed, events occurred, results achieved, or statements made. 4.19 Review: is a process of going over a subject or document again and again to correct it and make it valid. 4.20 Revision: is a process of re-reading or reviewing a document periodically for updating purpose. 4.21 Storage/Archiving: Options to maintain system files via data storage hardware, utilizing one or several distributed location. 4.22 Version: Refers to the status the document currently at with regard to the number of times the document has been revised. Policy The DGQAC ensures that all MoH departments and institutions’ documents are written in accordance with the Directorate’s approved style and format, further to this, the following will be applied: Sl 5.2 53 54 5.5 Document development template shall be obtained from the MoH website / QM&PS Department/ Section in their institute, Document Style: The document writing style is Times New Roman, size 12, and 1.5 line spacing, Abbreviations: Any abbreviation used shall be stated in full form when it is first mentioned in the document with the abbreviation in brackets, Policies and procedures from outside origin will be reviewed by DGQAC/ QM&PS Directorate/ Department) Section at the institutions and then to follow the same procedure illustrated in this document. Document Control: All national documents have to be maintained in a Master Document List (Referred to: MoH/DGQAC/F/004/Vers.01) by the DCDQD. Documentation developed or modified locally by Primary Healthcare/ Secondary Page 7 of 25a“ MoHDGQACIPAPIODLVers OL Policy & Procedure of Document Development Effective Date: April 2016 Review Dae: April 2019 Healthcare and Tertiary Healthcare institutions shall be recorded on a local document control register and regularly maintained by QM&PS Directorate/ Department. 5.6 Document Monitoring: All the documents have to be monitored in order to evaluate the efficiency of them. Document monitoring will be through regular auditing conducted by DCDQD/ QM&PS Directorate/ Department (referred to Central Internal Audit Policy). 5.7 Structure of the approved document: 5.7.1 First Page (see appendix 1: First Page) which contains of: ‘A. Institution Name. B. Document Title C. Approval Process which contains Name, Designation, Institution, Date and the signatures of the Document Writer, Validator, Reviewers, and Approvers. 5.7.2. All pages contains of A. Header which contains institution’s logo, document title, and the coding details (Document Number, Review Date and Effective Date). B. Footer which contains page number formatted as (page x of y). C. Main Headings of the document (see appendix 2: Main Elements of the Document Development) are as following: i, Introduction ii, Scope. iii, Purpose. iv. Definition. v. Procedure. Responsibility. Document history and version control table. Vili, Related document. ix. Attachment. Page 8 of 25Mol/DGQACIPRPIOOI/Vers.01 Policy & Procedure of Document Development Effective Date: April 2016 Review Date: April 2019) x. Reference (see appendix 3: Reference Table ). 6. Procedure Prior to develop any document (see Appendix 4: Document Development Procedure Flowchart) 6.1 Step One: Development: 6.1.1 The document's writer shall fill the Document Request Form (Referred to: MoH/DGQAC/F/001/Vers.01) and submit it to the DGQAC (DCDQDYQM&PS Directorate/Department at the institutions. The form will be available in the MoH website/ Local site. 6.1.2 The document initially reviewed and approved by the Head of the document's writer. 6.1.3 The document’s owner ensures that the document hardcopy is watermarked by “DRAFT” before it has been sent for review to the concem directorates/departments. 6.2. Step Two: Reviewing 6.2.1 Inall levels, Document’s Owner ensures that the document is reviewed by all involved affected institutions, before sending the document for validating. 6.2.2 The reviewing directorates at HQ/ Departments) Sections must send their comments even for nil comments to the document owner within a maximum period of three weeks. 6.2.3 Upon receiving feedback from the reviewing directorates at HQ/ Departments/ Sections, the document's owner will modify the document according to the feedback, as per the necessity. 6.2.4 If the document contains any legal issues, it should be reviewed by the Legal Affairs Department. Page 9 of 25Policy & Procedure of Document Development Effective Date: April 2016 MoW/DGQACIPRPIOOI/Vers.01 Review Date: Aptl 2019 63 64 65 62.5 If the document involves more than one institute and in case of disagreement then it be rise to the next level of authority. Step Three : Validation 6.3.1 QM&PS Directorate/Department/Section at the institutions will validate the reviewed document as per Document Validation Checklist (Referred to: MoH/DGQAC/F/002/Vers.01). 6.3.2 The National documents shall be validated by DGQAC (DCDQD) after it has been reviewed by the concerned directorates HQ. Step Four: Coding 6.4.1 The National documents shall be coded by document owner. 6.4.2 In Institutional level, QM&PS Directorate/ Department’ Section at the institutions will code the document according to the coding System (see appendix 5: Coding System) as following: ‘A. IA=Refers to Institutions Acronym (e, g MoH= Ministry of Health). B. DO=Refers to the Document Owner (e.g directorate/department/section). C. DT =Refers to Document Type (see Appendix 5: Coding System ) DN= Refers to the Document Number. E, _Vers.No= Refers to the Version Number. It will start by 01 and continued according to the status of the document. Step Five: Approval 6.5.1. The National documents shall be approved by the concerned directorate governorate at HQ and to be sent to the DGQAC for Approval Stamp. 6.5.2 The Institutional documents shall be approved by the DG of the concerned Directorate Governorate/ Directors of the hospital and to be sent to the QM&PS Directorate/ Department at the institutions for Approval Stamp. Page 10 of 25Policy & Procedure of Document Development Effective Date: April 2016 Mol/DGQACTPaPICOL/Vers 01 Review Date: April 2019 6.5.3 The documents which involve more than one Directorate Department Section shall be approved by all DG of the concemed Directorate Governorate at HQ Directors of the hospital. 6.6 Step Six: Distribution 67 6.8. 6.6.1 6.6.2 6.6.3 6.6.4 6.6.5 The institutional approved document shall be converted to PDF format and distributed by QM&PS Directorate/ Department. The National approved documents shall be converted to PDF format by DGQAC and distributed officially to the concerned directorates The approved Institution document shall be uploaded to the local site by concerned directorate governorate at HQ/ QM&PS Directorate Department/ Section with the coordination of IT Department. The approved documents shall be send officially to the departments who are applied to and use Document Distribution Form (Referred to MoH/DGQAC/F/003/Vers.01), The Directors/ Heads of Departments! Sections at the institute shall announce the release of the approved document to their staff. Step Seven: Implementation 67.1 6.7.2 The DG/ Directors’ Heads of Departments/ Sections shall ensure and follow the full implementation of the approved document DGQAC (DCDQD) QM&PS Department! Section shall conduct a regular audit/ survey to monitor the document's implementation, Step Eight: Update 68.1 68.2 6.8.3 All documents need to be revised every three years unless a change in practice or legislation requires an urgent revision. All documents have to have a Document History and Version Control as explained in appendix 6. Once the document is updated: Page 11 of 25i MoHIDGQACTPAPIOOLVers OL Policy & Procedure of Document Development Effective Date: April 2016 Review Due: April 2019 A. The original document shall be watermarked with “Cancelled Document’ in red colour by DGQAC (DCDQD) QM&PS Department Section. B. The Obsolete document shall be removed by DGQAC (DCDQD)/ QM&PS Department/ Section (with coordination of IT Department) from MoH website/ Local system and withdraw the original copy from the document owner. CC. Shall be archived in the ‘*Cancelled Document” file at DGQAC (DCDQD)/ QM&PS Department/ Section. 7. Responsibilities 7.1 Directorate General of Quality Assurance Centre Shall: 7.1.1 Provide the consultations whenever it is required for the DCDQD / QM&PS Department! Section in all institutions. 7.1.2. Send the documents for review and approval to the concerned directorates inHQ 7.1.3 Disseminate of all national documents to all levels. 7.1.4 Monitor the compliance of the implementation of this document. 7.1.5 Provide training needs for master trainers in the QM& PS Department! Section regarding Document Development. 7.1.6 Provide all the support to the QM&PS Department/ Section in all institutes by facilitating their director general/director of their areas. 7.1.7 Maintain a computerized database of all filed documents that ensures fast retrieval of documents. 7.2. Directors General of Directorates General in HQ Shall: 7.2.1 Review and approve all national documents relevant to their specialty. 7.2.2. Ensure that all the national documents are send to DGQAC for Validating. Page 12 of 25Policy & Procedure of Document Development Effective Date: April 2016 MoH/DGQACTPAPIOOL/Vers OL Review Date: April 2019, 723 Send the reviewed document to the next level of authority for approval in case of disagreement between two directorates. 7.3. Directors of Hospitals Shall: 731 732 733 Support and encourage the departments to develop and review documents that would facilitate their work. Approve all documents at their institutes’ level Ensure that all documents are approved based on the procedure outlined in this document. 7.4 Directors/ Heads of Sections/ Departments Shall: 741 74.2 7.43 144 145 Review the developed documents before being sent to the QM&PS Department/ Section for validating, Ensure that all the documents within the department are developed, reviewed and approved based on this document. Ensure that all the approved documents are up-dated according to this document. Ensure that all staff is aware of the approved documents by taking their signature, Ensure that all staff adheres to approved documents. 7.5 Department of Control & Development of Quality Document Shall 751 7382 1583 134 15.5 156 Guide the QM&PS Department/ Section in all institutions in regards to Ds. Ensure the implementation of this document at HQ. Stamp the documents accordingly; Approved Document. Maintain the master list of approved documents at HQ. Distribute the original copy of the approved documents to the document ‘owners at HQ. Ensure that the approved document is uploaded in MoH web site. Page 13 of 25Policy & Procedure of Document Development Effective Date: April 2016 MoH/DGQACIP&>PICON/Vers 01 Review Date: April 2019 7.6 Directors/ Head of QM&PS Department/ Section Governorates HQ/ Governorate Shall: 7.6.1 1.62 163 7.64 1.65 7.6.6 1.6.7 7.68 Make sure that all documents are written according to this document. Communicate the approved document with the concerned institute's DG/ Director for approval. Train all departmental/ sections heads/In charges at their institute regarding P&P of Document Development. Monitor the implementation of this document. Guide the heads of departments and the staff on how to develop a particular document based on this document. Validate and code the documents according to this document. Send a message to all Al Shifa system users about the availability of approved document. Ensure that the approved document is uploaded in the local web site. 7.7 Document Writer Shall: TIA 142 7.8 Head of Information and Technology Departmen 78.1 Ensure that the document is evidence based and produced in accordance with this document. Ensure that the document is up-dated according to this document (if the writer has moved position, then this responsibility is assumed by whoever is in post). Ensure to fill the Document Request Form (Referred to: MOH/DGQAC/F/001/Vers.01) for developing/ reviewing documents. Institute/ HQ Shall: Ensure that the final approved document (PDF format) is uploaded into MoH Website/ Local system whenever requested by the DGQAC/ QM&PS Department/ Section. Page 14 of 25z MotiDaQacrPe0ot/ver.01 Policy & Procedure of Document Development Etectve Dit. Api 2016 Review Date Apt 2019, 7.8.2 Ensure that the cancelled document is removed from the MOH website/ Local system when requested by the DGQAC/ QM& PS Department/ Section. 7.9 All Staff Shal 7.9.1 Be familiar and adhere with this document. 7.9.2 Be aware of all approved documents. Page 15 of 25Mol/DGQACIPAPIOOLVers OL Policy & Procedure of Document Development Efletive Dat Apr 2016 Review Date: Api! 2019, 8. Document History and Version Control Document History and Version Control Version Description of Amendment Author Review Date o1 Initial Release Document — April /2019 Developme nt Team 02 03. 04 05 Written by Reviewed by Approved by Document Development DGQAC Team Minister of Health Team 9, Related Documents: 9.1 Document Request Form (Referred to: MoH/DGQAC/F/001/Vers.01).. 9.2 Document Validation Checklist (Referred to: MoH/DGQAC/F/002/Vers.01). 9.3 Document Distribution Form (Referred to MoH/DGQAC/F/003/Vers.01). 9.4 Master Document List (Referred to MoH/DGQAC/F/004/Vers.01), Page 16 of 25& Policy & Procedure of Document Development MaH/DGQAC/P&P/001/Vers01 Effective Dat: April 2016 Review Date: Apel 2019 10. References: | Title of book/ journal/ articles/ Website Author Year of Page publication A Guide to Nursing Management Marriner- 1988 Tomey, A Clinical Protocols are Key to Quality Health Heymann, T | 1994 Pages Care Delivery. International Journal of Health | 14-17 Care Quality Assurance Dietionary.Com Douglas, H. | 2016 http:/dictionary.reference.com/browse/institution Documentation Management System Director 2015 General of Khoula Hospital Directorate Documentation Management System Director 2015 General of Royal Hospital Directorate Documentation Management System | Sohar Hospital [2015 Documentation Management System Sultan Qaboos | 2015 University Hospital Document & Records Management Policy NHS England | 2014 Document Version Control and Naming National 2014 Convention Guidance Health Service Page 17 of 25: Mol¥/DGQACIPRPIOOI/Ve.01 Policy & Procedure of Document Development Elective Date Apri 2016 Reviow Date: Apri 2019 Title of book/ journal/ articles/ Website ‘Author Year of Page publication Management and Organizational Behavior Mullins, LJ | 1991 ‘Organizational Audit (Accreditation UK): King’s Fund | 1990 Standards for an Acute Hospital Centre Policy Document Development and Review CQ University [2014 Policy for the Development and Management of | Royal 2014 Knowledge, Procedural and Web Documents, | Cornwall National Health Services Hospital Policy Management Framework http:/iwww.bac- | Library & 2015 lac.ge.ca/eng/about-us/policy/Pages/policy- Archives ‘management-framework.aspx Canada Procedure Development Process Procedure ‘Athabasca | 2009 University The Royal Marsden Hospital Manual of Clinical | Pritchard,AP | 1992 ‘Nursing Procedure. &Mallett,J The Royal Marsden Hospital Manual of Luthert, JM& | 1993 Standards of Care. Robinson, L Page 18 of 25€ Policy & Procedure of Document Development Mol/DGQACIP&PICON/Vers 01 Effective Date: April 2016 Review Date: April 2019) Appendix 1: First Page Institution Name: Document Title: Approval Process Name Title Institution Date Signature Written by Reviewed by Validated by Approved by Page 19 of 25€ Policy & Procedure of Document Development Efetive Dat: April 2016 MaH/DGQACIPRPICOI/Vers 01 Review Date: April 2019 Appendix 2: Main Elements of the Document Development Ly 5: Introduction: This section is a brief summary of the document. Scope: This section is a brief statement specifying the persons, department(s), or program(s) that will be affected by the document. Purpose: This section is a brief statement explaining the objective(s) of developing the document. Policy (if any): This section is a brief statement which can be used to guide the parties which mention in the scope, in order to implement the document. Definition (if any): This section lists the meaning of words that might be uncommon to potential users of the document. (Beside each definition to mention the reference number if any). Procedure: This section explains the steps to be followed specifying what to be done, when, who shall do, why, and how it can be done (as applicable). Responsibility: This section lists all the individuals (or groups) who are responsible for implementing the document and their duties in the implementation of the document. Document History And Version Control Table: Document history and version control is used to record detail of minor and major amendments (see Appendix 6 for details). Page 20 of 25‘ MotDOQACiPeROO1/Ver.01 Policy & Procedure of Document Development Effective Date: Apel 2016 Review Date: pl 2019 9. Related Documents (if any): This section lists any document (can be departmental, hospital or ministerial document) that is related to the written document. 10. Attachment (if any): This section lists any related forms, charts, auditing tools ete...that will be included with the document. 11, Reference (if any): This section lists all references that were used for writing/ supporting the document. The document writer should use the table in appendix 3). Page 21 of 25Policy & Procedure of Document Development MoH/DGQACTPAPIOOLVers OL Effective Date: April 2016 Review Date: April 2019) Appendix 3: Reference Table References Title of book/ journal/ articles/ Website ‘Author Year of publication | Page Page 22 of 252 L POLIO PRETO haat i it Effective Date: April 201¢ Policy & Procedure of Document Development Eten Due 0 Appendix 4: Document Development Procedure Flowchart Identify need for Document teen | Documents, the document's Fill Document Request =>" ™ (Tn tnetitational Documents} | OMaPSsesiondepanment | End of Process © <—No Im National Documents: i a =>" pcoae ! Yes ‘tn tnstitutionat Documents | Concemed Departments/section | tn National Documen >| Concerned Directorate {In Institutional Documents: | QME&PS section/department = In National Documents: Concerned Directorate at HQ ‘tn Institutional Documents: | QM&PS section/department | In National Documents: \_ Degac in Institutional Documents: 5 DG Direcorate/Director of 1 Hospital {In National Documents: Yes | Concemed Directorate at HQ {In Institutional Documents: QM&PS section/department In Institutional Documents: MEPS seetionidepartment In National Documents: | Concerned Directorate at HQ Update every 3 years/when required Im National Documents: Concerned Directorate at HQ Page 23 of 25Mol/DGQACIPAPIOOIVers OL ’ Policy & Procedure of Document Development Efective Date: April 2016 Review Date: April 2019, Appendix 5: Coding System 1, ‘The following numbering tables are explaining the contents of the Coding style (Document Header). The required information should be added accordingly: Tnsert Institution Logo TA/ DO/DT/ DN/ Vers... 1A: Institutions Acronym DO: Document Owner DT: Document Type DN: Document Number Vers. No: Version Number Review Date: Month/ Year Effective Date: Month/ Year 2, Numbering for Institutions Acronym (IA) & Document Owner (DO): to follow the approved abbreviation in each institution. 3. Numbering for Document Type (DT) Policy POL Process PRS Procedure SOP Protocol PRT GUD F Manual ~ | MNL — ‘Job Description JOD ‘Audit Tool AT Page 24 of 25MoHDGQACIP&P/OO1/Vers.O1 Policy & Procedure of Document Development Effective Date: April 2016 Review Date: April 2019, Appendix 6: Document History and Version Control Table 1, All documents should contain a document history and version control table on the final page (before any appendices). 2. In the case of forms a document history and version control table should be kept also, however this may be best kept separately ina secure drive by the document owner. 3. The details of the table as shown below: Document History and Version Control Version Description of Amendment Author Review Date o1 Initial Release Written by Reviewed by Approved by Page 25 of 25,Document Request Form MoH/DOQACIF/OO1/VersO1 Effective Date: April 2016 Review Date: April2019. Institution Name: Directorate General of Quality Assurance Centre, MoH Document Title: Document Request Form Written by Reviewed by Validated By Approved by Name Document Development Team DGQAC Team Dr. Ahmed Bin Salim Al-Mandhari HLE Dr. Ahmed Bin Mohammed Al-Saidi Title DGQAC DG of DGQAC Minister of Health Approval Process Institution Date Signature Ministry of Health Pe a Ministry . i ofHealth 79 “ Ministry of Health mx Ministry of Health vQ oe yr Page | of 2Document Request Form MoH/DGQACIPIOONVersO1 [Eetive Date: April 2016 Review Date: April2019 Document Request Form Section A: Completed by Document Requester 1, Requester Details Name Institute Department The Purpose of Request: [Develop New Document 1, Document Information Document Title Document Code Date of Request Mobile Email [1] Modification of Document Section B: Completed by Document Controller Approved Cancelled 1 Forward To: Comment and Recommendation: Name Signature Cancelling the Document Date Stamp Page 2 of 2( J Document Validation Checklist Mol/DGQACTF/002/VersO1 Effective Date: March 2016 Review Date March 2019 Institute Name: Directorate General of Quality Assurance Centre, MOH Document Title: Document Validation Checklist Name Written by Document Development Team Reviewed by DGQAC Team Validated by Dr. Ahmed Bin Salim Al-Mandhari Approved by HE Dr. Ahmed Bin Mohammed Al-Saidi Title DGQAC DG of DGQAC Minister of Health Approval Process Institution Ministry of Health Ministry of Health Ministry of Health Ministry of Health Date Signature DO sant ee ay aw a Page 1 of 2z 5 MotvDoQACrFION2/Ver.01 Document Validation Checklist ffestive Date: Mach 2016 Review Date March 2019, Document Validation Checklist Document Title: Document Code: No Criteria Meets the Criteria Comments Yes No N/A Approved format used Clear ttle - Clear Applicability 12 Index number stated 13 Header/Footer complete 14 Accurate page numbering 15 Involved departments contributed 16 Involved personnel signature/approval 19 Clear Stamp 2. Document Content 2.1 Clear purpose and scope 22 Clear definitions 23 Clear policy statements (if any) 3. Well defined procedures and steps 3.1 Procedures in orderly manner 3.2 Procedure define personnel to carry out the step 3.3 Procedures define the use of relevant forms 3.4 Procedures is defined ina flowchart 3.3 Responsibilities are clearly defined 3.6 Necessary forms and equipment are listed 3.7 Forms are numbered 3.8 References are clearly stated 4. General Criter 4.1 Policy is adherent to MOH rules and regulations 42 Policy within hospital/department scope 43. Relevant policies are reviewed 44 Items numbering is will outlined 45 Used of approved font type and size 4.6 Language is clear, understood and well structured Recommendations ..... For implementation... More revision... To be cancelled Reviewed by: sesessueeeiensnne — Reviewed by Page 2 of 2Document Distribution Form MoH/DGQACI003/Vers Ot Effective Date: April 2016 Review Date: Apel 2019 Institution Name: Directorate General of Quality Assurance Centre, MoH. Document Title: Document Distribution Form Approval Process Name Document Development Team Written by Reviewed by DGQAC Team Dr. Ahmed Bin Salim Validated by Al-Mandhari H.E Dr. Ahmed. Bin Mohammed Al-Saidi Approved by Title DGQAC DG of DGQAC Minister of Health Institution Date Signature Ministry of Health ) fe ae Ministry of Health we fp (a ! E ‘ Ministry of Health A 6 x ye Ministry of Health Page | of 2Pe ens Mol/DGQACIFI003/Vers Ot Document Distribution Form Effective Date: April 2016, Review Date: Apel 2019 Document Distribution Form Document Title Document Number No Name Title Signature Date Page 2 of 2Master Document List MoH/DGQACIF/004/Vers OF Effective Date: April 2016 Review Date: April 2019 Institution Name: Directorate General of Quality Assurance Centre, MoH Document Title: Master Document List Approval Process Name Written by Document Development Team Reviewed by DGQAC Team Validated By Dr. Ahmed Bin Salim Al-Mandhari Approved by HE Dr. Ahmed Bin Mohammed ALSaidi Title DGQAC DG of DGQAC Minister of Health Institution Date Signature Ministry Vyiky of Health jp MY Ministry ofHealth 6 eo ve ( Ministry of Health a Ministry E of Health 9. Page | of 2i MoH/DGQACIP/O04/Vers 01 Master Document List Effective Date: April 2016 Reviow Date: Aptil 2019, Cc Master Document List Document Title Version Date Reasons for Name of Document Date Document Number Created/Modified _Creation/Modification _ Custodian/Creator_ Reviewed status Page 2 of 2