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Quality audit
Quality audit experience for experience for
excellence in healthcare excellence
Yasmeen S. Alhatmi
Sultan Qaboos University Hospital, Al Khodh, Sultanate of Oman 113
Abstract
Purpose – To make an improvement on a larger scale and continuing along the path of quality
auditing, this paper aims to identify the steps taken towards excellence for patient care in Sultan
Qaboos University Hospital (SQUH).
Design/methodology/approach – SQUH, in the Gulf country Sultanate of Oman, has
enthusiastically entered the challenge of improving quality in healthcare while traveling towards
healthcare excellence. It began with the successful achievement of ISO 9001:2000 certification (May
2005) and re-certification (May 2008) and is now adopting accreditation standards.
Findings – Being a prominent 500-bed teaching research hospital in the country offering general and
distinguished specialized clinical services while adhering to continuing professional development, the
source of motivation derives from the hospital’s vision and mission, thus bringing the primary focus of
auditing to a peak. By performing internal quality audit, proper monitoring of conformity by
measuring the effectiveness to the stated intention in a cycle of continuous quality improvement (CQI)
is ensured.
Research limitations/implications – Traditionally, health prevention and cure have always been
the aim for the healthcare industry. Consequently it is the one industry that faces continuous pressures
to improve quality and the one with the fastest-growing interest in quality.
Originality/value – The paper puts forward a model that incorporates the fundamentals of quality
improvement through quality auditing step by step in a systematic manner and shows measurable
results.
Keywords Health services sector, ISO 9000 series, Quality audit, Quality management, Oman
Paper type Case study

Introduction
Sultan Qaboos University Hospital (SQUH) is situated in the gulf country, Sultanate of
Oman, employing Omani nationals and multi-nationality workers by contract at a ratio
of 40:60. As illustrated in the hospital mission statement, SQUH offers general medical
and distinguished specialized services enabling it to provide teaching to the students of
SQU College of Medicine and Health Sciences, continuing professional development of
healthcare professionals, and is a base for research and innovations in care for the
benefit of the community (SQUH, 2005). The source of motivation engines from the
hospital’s vision and mission, thus bringing the primary focus of auditing to a peak,
thus enabling Sultan Qaboos University Hospital to reach closer to achieving their
vision of excellence.

Accepting the quality challenge Clinical Governance: An International

Without a doubt, “quality” is a known essential ingredient of all customer service Journal
Vol. 15 No. 2, 2010
industries (Abdelhak, 2001). Traditionally, health prevention and cure has always been pp. 113-127
the aim for the healthcare industry. However recently it has become the industry facing q Emerald Group Publishing Limited
1477-7274
continuous pressure to improve quality and the one with the fastest-growing interest in DOI 10.1108/14777271011036364
CGIJ quality (Evans and Lindsay, 2005). Achieving quality in health care is dependent on an
15,2 effective and efficient monitoring system. No management system can be effective
without a suitable means of measuring its performance. Internationally recognized
standards require complying organizations to plan and implement processes of
monitoring, measurement, analysis and improvement, collected as evidence of their
management system. ISO 9000 (2000) has defined effectiveness as “the extent to which
114 planned activities are realized and planned results achieved“, and efficiency as “the
relationship between the result achieved and the resources used” (Beckmerhagen et al.,
2004). ISO 9001 standard states the requirements for implementation are “the
organization shall establish, document, implement, maintain, and continually improve
a quality management system in accordance with the requirements of the International
Standard” (BSI, 2000). By performing internal quality audit, the system can be
effectively monitored for conformity to the internationally recognized standards and
create a cycle of continuous quality improvement (CQI). Furthermore, not only should
the outcomes of audit be measured against the planned objectives, but the audit
process should encompass planning, reporting, follow-up and resource requirements,
including auditor skill and competency.
A recent research study by Juran demonstrates that 30 percent of hospital costs are
caused by poor quality of processes (Juran, 2003). This inevitably reflects as poor
quality of patient care. In 1910, Ernest Codman, MD, proposed a tracking system to
determine whether prescribed treatment was effective; a simple form of auditing. The
American College of Surgeons developed Minimum Standards for Hospitals in 1917
and began inspection audits the following year. W. Edwards Deming originated the
Deming Cycle (Bedi, 2006) commonly known as the PDCA cycle, in 1950, composed of
four stages: plan, do, check, and act; yet another method of self-auditing. In 2004, TQM
Magazine stated “quality in terms of healthcare is dependent on an effective and
efficient audit function” (Beckmerhagen et al., 2004). During the last two decades,
internal auditing of healthcare services has successfully introduced a team-oriented
culture, determining whether quality activities comply with planned arrangements,
whether these are implemented effectively, and whether these are suitable to achieve
objectives.

Building an audit quality culture

ISO 9001:2000 certification was our starting point for getting establishing with an
effective quality management system and entering the road of healthcare excellence.
Documented processes, procedures and policies were developed and made up the
SQUH Quality Manual. Once documentation is established they generally remain
constant, but inevitably the environment will change. In order to meet the new
demands of the environment, continual improvement is a requirement. Auditing for
continual improvement provides valuable data that verifies improvement is taking
place and acts as a channel for further improvement. The ideal quality healthcare
environment is designed to provide the best possible services to patients and
customers in the best possible manner. Internal auditing allows monitoring of
processes, procedures and clinical service delivery and satisfaction. As a first step to
implement internal audit as a quality monitoring tool, a training phase was set to
include an in-house workshop presented by the ISO 9001:2000 Project Consultant.
This was specifically designed to train healthcare professionals in SQUH to be Quality audit
Internal Auditor/Change Managers and apply auditing tools and techniques to the experience for
ISO standards for effective auditing. Each department nominated a candidate
considered to have auditor characteristics which include being observant, inquisitive, excellence
knowledgeable, responsible and reliable, and possess interpersonal skills among
others. Being culturally sensitive and aware of such issues was felt to be of added
value, considering the culture diversified environment. 115

Audit process and design, styles and techniques

SQUH internal auditing was originally initiated to be carried out on its own system, by
its own people, conducting repeated self-inspections on various processes. Since the
hospital began cyclic auditing (June 2004), SQUH has designed, planned and
experienced different audit styles (vertical, horizontal, cross-functional, internal,
external), scopes (quality, health and safety, occupational health, clinical, risk, patient
safety), audit forms (improvement notes, nonconformity report (NCR), audit summary
report) and finally, different audit techniques (walk-the-process, checklist regulated,
activity oriented). A comprehensive list of audits conducted by SQUH internal auditors
matched with the type of audit and what it revealed, achieved and added-value
advantage is illustrated in Table I. The audit planner schedules areas to be visited
based on a deficiency, weakness or need in the hospital. Audits are designed with a
specific aim, targeted to achieve accordingly, be conducted as planned, with findings
ranging from observation to critical non-conformity; definitions (SQUH, 2005) are as
follows:
.
Critical. Serious non-conformity that affects/threatens life or life saving service or
product quality, delivered to patients.
.
Major. Strong evidence of main clause or main area within SQUH scope of main
process that is not covered as per requirement of standard (trend) or culture
(accepted norm).
.
Minor. A one-off or subjective evidence of failing to meet a certain sub-clause
within the implementation, or ineffective implementation, or not maintaining
documentation requirement.
.
Observation. Potential risk or practice that may lead to ineffective
implementation or may lead to a malfunction service or product quality in SQUH.

A designated time for proper closure and a re-visit is then scheduled and followed up.
Audit cycles represent the awareness and readiness of the hospital at the different
stages of ISO on the ladder towards excellence.

SQUH audit journey

To begin our journey, an assessment or gap analysis was conducted in September 2003
by the Project Consultant as an external audit evaluation. It compared the existing
activities, procedures, processes and clinical service delivery to the requirements of ISO
9001:2000 and the guidelines of ISO 9004:2000 suitable for healthcare service
organizations. The gap analysis has been a main reference throughout, indicating

Table I.
advantages
techniques and the
SQUH audit styles,
Audit name
Gap analysis assessment
Audit cycle 1
Audit cycle 1 follow up
Audit cycle 2
Pre-assessment audit health and
safety
Health and safety
Certification audit
Audit cycle 2 follow up
Audit cycle 3
Continuing assessment
Audit cycle 3 follow up
15,2
116
CGIJ
Type of audit Revealed/achievements Added value
External assessment Establishment of requirements External audit evaluation
Vertical Responsibility for own processes developed Strengths and weaknesses identified with
within departments departments
Vertical Proper closure of nonconformities/observations Intra-departmental issues closed with full
cooperation and awareness amongst staff
members, improving communication
Horizontal/cross- “Shared” processes across hospital encouraged Discovered areas such as target areas, support
functional discussion groups, transparency, effective areas, including cultural and environmental
improvements in areas of communication, considerations. “Areas not covered during this
developments and coordinated activities audit but felt to be important” included in Cycle 2
report form for future audit purposes or
references. Team leaders were matched, but not
from, the area of audit
External assessment Passed; 50 observations. Action plan prepared Areas of required improvement revealed in a
and implemented different implication compared to own internal
auditing findings
Checklist audit Monitored and organized by SQUH Health and Focused on hospital-wide safety such as
Safety Committee; performed by SQUH nursing hazardous materials, electrical, personal
staff; analyzed by QMD protection and fire. Statistics revealed areas that
need improved monitoring and awareness
External audit Passed; 3 NCRs, 17 observations. Prepared action Instigated SQUH to practice using more intense
plan as a guide of how to do proper closure and audit techniques, to include identifying root
go deep to root cause to improve causes. Encouraged departments to share
improvement ideas as best practice
Horizontal Proper closure through open communication Shared ideas for improvement, branching out to
lines between all involved parties new areas, leading to ideas for next audit cycle
(continuous improvement)
System/cross- A double aimed audit; systems, committees, Audit workshop measuring committee
functional hospital policies and previous NCR/observations. accomplishments against objectives; improved
Pathways focused on potentially high risk areas top management involvement; increased
versatility; wider audit approach; questionnaire
distributed
External surveillance Scheduled as planned December 2005, as per A means of determining whether the
audit plan organization has identified new or changed
competency needs
System/cross- Scheduled as planned January 2006, as per audit Joint decisions on important issues such as
functional plan hospital wide policy amendments, new
achievable objectives, shared best practices
areas of strength and weakness, improvement, documentation, communication and Quality audit
commitment required to reach the level of certification. experience for
excellence
Audit cycle 1
The first cycle of internal audits conducted at the hospital June 2004 took on a vertical
approach and covered all areas and processes randomly. Audits were limited to 117
activities going on within individual departments. The intent of this audit was to
identify existing or potential nonconformities and to recognize good work. Service or
products not conforming to the system, weak links in the system and opportunities for
improvement were raised, as well as positive findings of strong assets. In many cases,
root causes were identified and documented, thus creating a wider scope for
improvement. The closure rate reached 72 percent within two months.

Audit cycle 2
Conducted six months after the first cycle. This time it took on a horizontal approach,
focusing on cross-functional processes where shared activities are linked and audited
as a “process”. The idea behind it was to bring both the main areas and their relevant
support areas together for the purpose of discovering and identifying concerns as a
team, and resolving issues together. As an improvement to cycle 1, audit team leaders
were matched with related professional background, to but not from the area of audit.
Improvements were seen in communication, team development and coordinated
activities towards solutions, while revealing weaknesses and strengthening on
strengths. Even though issues raised proved to be more complex than in a vertical
audit and required more time to bring proper closure, an 86 percent closure rate was
reached within a four month period.

Pre-assessment audit
Conducted January 2005, Certification Audit took place May 2005 by external auditors
registered with British Standard Institution (BSI). SQUH responded by developing an
action plan corresponding to the reported nonconformity/improvement issues raised.
This was followed with 100 percent positive outcomes and closure, over the given
allotted time. SQUH gained official ISO certification in May 2005.

Audit cycle 3
Scheduled six months after cycle 2, this cycle was cross-functional on a larger scale.
Priority was given to processes with high-rate risk deficiencies or nonconformities
previously identified. The areas included cross-contamination and handling and
processing of the specimen. The hospital’s system processes were also audited during
this cycle, including supplier chain, committees, performance appraisal, and the
complaints system. This allowed for a much more detailed audit in areas where a
relatively longer time frame was given for necessary monitoring of the improvements
to the systems. Follow up to this audit found successful closure of many issues, with a
92 percent closure rate, within the proposed year.
CGIJ BSI surveillance audit (external)
15,2 Conducted December 2005, six-months after receiving certification by external BSI
auditors, as an ISO 9001:2000 requirement of certification. An action plan was
developed and followed up over the six months period for successful closure.

Audit cycle 4
118 Took place March 2006 and focused on high traffic areas; those affecting a large
volume of customer/patients on a daily basis. The kitchen, laundry and outpatient
clinic were audited during this cycle, involving a detailed look into the process of
service delivery, specifically targeting the health and safety aspect. Remarkably, the
majority of points raised as opportunities for improvement resulted in immediate
actions, and with the timely cooperation from top management, proper closure was
possible. Awareness had reached a high level among staff members of SQUH, thus
making such immediate improvement actions possible. Follow up audit found 100
percent successful closure within the proposed three months.

Health and safety internal audits

Integrated with quality audits, under the direction of SQUH Health and Safety
Committee, the first cycle began early 2008, immediately following OHSAS training.
The specific focus of hospital safety for staff and patients included infection control,
fire safety, personal protection, equipment, hazardous substances, storage, electrical,
housekeeping and maintenance issues. The new design of SQUH audits since 2008 is
one team leader with two lead auditors under the themes quality and health and safety.
It has proven to be quite effective in capturing both patient safety and occupational
safety during one audit.

Audit cycles 5-9

Between the period of October 2006 and March 2009, regular internal quality audits
took place with the theme of CQI as the focus. Integrated Health and Safety audits
began immediately following a certified OHSAS lead auditor training with 16 staff
members of multi-healthcare disciplines; surgeons, nurses, pharmacists, clinical
technicians, and engineers. The main themes included eliminate waste, reduce risk, and
improve workflow.

Audit analysis
Internal auditing quickly became a way of SQUH culture; SQUH top management,
quality and all the departments working together in joint harmony, creating an
atmosphere of positive growth and development, specifically tailored to the needs of
shared processes. DD Sharma defines quality audit system as “a systemic and
independent examination to determine whether quality activities comply with panned
arrangements, whether these arrangements are implemented effectively and whether
these are suitable to achieve objectives” (Sharma, 2001). SQUH audit plan is constantly
adjusted accordingly in relation to how findings and requirements dictate, based on
self-departmental audits, number and types of nonconformities raised, status of
readiness, and size and division of departments.
Statistically, the number of nonconformities found in cycle 1 compared to cycle 2
was a tremendous difference. The number dropped from approximately 400 to less
than 50 between the first few cycles. “Inconsistency in documentation” and Quality audit
“insufficient record of calibration” were the categories found to have the highest values experience for
of nonconformance during cycle 1, likely due to the immaturity of the quality
management system (QMS) at that time, as compared to “improper handling” and excellence
“patient/result delays” discovered to be the highest nonconformities in the audit trail of
cycle 2. Likewise, cycle 3 found similar trends to cycle 2 although the numbers were
drastically reduced. Additionally, cycle 3 showed weaknesses of “inconsistent process 119
documentation” and “communication”. Cycle 4 displayed trends towards patient/staff
“safety” and “satisfaction”.
Compiled statistics from the cycles showed an improvement to the categories
identified as weak in previous cycles by the fact that they occurred less frequently or
not at all. An important point to stress here is the new approach in cycle 2 of
identifying root causes to bring about change was emphasized and proven to be
effective on a much larger spectrum. One of the risks SQUH faced over and over was
having the same nonconformity turn up within the hospital after some time had
elapsed. Yet by identifying root causes and spreading awareness of the corrective
action throughout the hospital, the chances of re-occurrence was significantly reduced.
The indicating factors for the decrease in the trend point to the increased awareness
among staff, improved communication, and the continuous quality improvement joint
activities occurring across the hospital. During audit closure there has always been full
cooperation and awareness from staff members and top management, which is an
achievement in itself.

Audit findings – evidence for improvement

There are two areas to be considered when auditing for improvement. Initially we audit
the data analysis results, corrective and preventive actions documented and the output
from Management Review, conducted biannually. If evidence of change is found, we
then look for evidence of the change indicated in the process or system. Without
change to the process or system, events will recur over and over again, resulting in no
improvement. However, if change is apparent in results and the system or process has
been adjusted accordingly, this is a measurable improvement. The second area to be
considered is verification of actual changes taken place. In addition to re-analyzing new
data collected, this may be done more thoroughly by reviewing documentation and by
interviewing area staff for awareness and compliance.
During the period from 2006 to 2008, an audit analysis was conducted to find trends
in the hospital. The overall achievements included hospital-wide improvement in
important areas such as communication, documentation and awareness. The top ten
trends found are included on Table II. These findings acted as the seeds that led the
hospital to adopt accreditation standards because of their specific design and
applicability to healthcare organizations, in particular, the trends found in SQUH over
a four-year period of auditing against ISO standards.

Example 1 – average length of stay in ICU

Through audit, average length of stay for patients admitted to the intensive care unit
(ICU) was noted to be higher than other similar ICU average days in the other
countries. An indicator was set to reduce the ICU average length of stay (ALOS) by 50
 15,2

120
CGIJ

Table II.

standards)
SQUH continual
improvement audit

with ISO 9001:2000

checklist (in accordance
Training, awareness, Customer satisfaction Analysis of data Continual improvement
Customer focus (5.2) Quality objectives (5.4.2) competency (6.2.2) (c), (d) (8.2.1) (8.4) (8.5.1)

Customer surveys Performance reports by New staff orientation Review of complaint log Customer Evidence of a decrease in
departments program complaint undesirable results or an
satisfaction increase in desirable
results? i.e. incidence,
complaints, NCRs
Internal staff surveys Measurable key Up-to-date training Corrective action to Customer Regular meetings
performance/clinical records, employee customer complaint feedback, (minutes, agenda) where
indicators progress reports surveys continual improvement
results are discussed
Documentation and Organizational charts, Evidence that training Customer survey Management Improved process: faster,
awareness of departmental quality met learning objectives review output better quality, more
complaints manual demonstrated by post reliable, cost controlled,
training lecture increased efficiency, i.e.
patient waiting time,
pharmacy dispensing
time
Top management Identified process Demonstration of skills by Recognition as a result Forums or focus
awareness through ownership audit or observation of receiving compliment groups
interview
percent in 12 months within SQUH medical ICU population, or reduce by 3.5 days for Quality audit
ventilated patients, whichever is greater. Relevant data was gathered from our hospital experience for
information system (HIS) and calculated on a monthly basis. The number of ICU
patient days is divided by the number of ICU discharges each month. Audit revealed a excellence
number of factors obstructing reducing ALOS (see Figure 1).

Example 2 – improvement process of chlorahexadine 2 percent 121

During internal audit it was noticed that the solution used for skin prep (antiseptic)
was Chlorahexadine 1 percent, while the internationally recognized standards (CDC,
JCI) stated use of Chlorahexadine 2 percent is an acceptable practice. Bloodstream
infections, which include catheter-related bloodstream infections (CRBSI), are a costly
subset of nosocomial infection (NI) associated with a poor prognosis and high costs
(Tacconelli et al., 2009). A nurse, as opposed to an infection control nurse ordered 2
percent solution immediately. A typing error of 20 percent versus 2 percent was not
detected and request went to tender as 20 percent. Purchasing proceeded with the
order, searching for a strength that does not exist resulting in time loss. In the
meantime, 1 percent solution ran out and needed to be re-ordered. This was a great
financial strain having ordered both solutions as urgent requests. Furthermore, SQUH
is forced to revert back to using an antiseptic 10 percent solution with 1 percent iodine
for a short period, which is much less effective than 1 percent estimated costs
(Tacconelli et al., 2009) ranging from France: length of stay (LOS) £ cost per day in
ICU (9.5 2 14 LOS £ e813), Germany: (4.8 2 7.2 LOS £ e1,500) and Italy: (12.7
days £ e1,026.4) are illustrated in Table III.

Example 3 – improvement in waiting time in pharmacy

In 2005, during an external audit, it was observed pharmacy had a long waiting time
for patients collecting their medications. The wait was measured by interviewing
patients in the waiting area and auditing medication log. The wait ranged from 3 hours
and longer. This was reported as non-compliance in providing patient satisfaction
according to ISO 9001:2000 standard clause 7.1 – Customer Satisfaction. Additionally,

Figure 1.
Top “10” quality audit
trends from September
2006 to October 2008
CGIJ
Audit finding raised on ALOS Corrective action taken for proper closure
15,2
1 Culturally unable to rationalize bed occupancy Introduce ICU ambulance for transporting
statistically (community culture) leading to bedpatients from SQUH to peripheral hospital ICU,
mismanagement. in the case of no available ICU beds
Physicians prefer to admit to high dependency Train physicians/nurses end-of-life skills (Care
122 beds at ward level than to send to nearby of the Critically Ill) to educate community,
hospital with ICU bed counsel high-risk/ICU patients and relatives.
Patient’s file entrees are reviewed periodically.
Overcome language barrier by training
specifically Omani nurses/physicians (in Arabic)
2 No step-down unit (high dependency unit) to Introduce step-down unit for transition between
make transition from ICU to ward level ICU and ward level
Staffing ratio low Review of staffing to remedy the crisis
management between 3:30-7:30 (Registrar)
Introduce ICU outreach teams * (google search)
3 Other contributing factors which may increase Perform extubation as soon as possible
the risk of infection and other complications Practice non-invasive ventilation (when level of
(chest from injected saline rather than using a consciousness is normal) on ward level while
nebulizer, insufficient physiotherapy, providing central line insertion training
inadequate beds, poor acceptance by community Introduce sedation scoring with training
of awareness/education) Starting patient on spontaneous modes of
ventilation as soon as possible
Replace routine use of instilled saline with
nebulization to reduce chest infection risk
Introduce mobilization of patients passive/
supportive/active movements for patients
unable, to encourage improvement in muscle,
immune system and psychological state.
Reduce complications of bed rest (UTI, gastro
problems) – currently ordering hoists and
stretch chairs. Increase support staffing
(physiotherapists)
Table III. Reduce healthcare associated infections
Average length of stay through Joint Commission International ( JCI)
(ALOS) in ICU, SQUH IPSG No. 5

internal audit reported a similar noncompliance in outpatient clinic measuring waiting

time to see the doctor. Pharmaceutical staff used Ishikawa (fishbone), customer
satisfaction survey and complaints filed against pharmacy on medication waiting time
as tools to determine the affecting factors. Improvements were made using Ishikawa
fishbone diagram (see Figure 2).

Challenges and obstacles

Resistance to change stemmed from staff not believing that certification could be
achieved. We faced difficulty in getting people to understand that auditing is not about
criticizing the person; it is about the compliance to established processes and
procedures. SQUH adopted the concept of transparency and continuously promotes a
“no-blame” culture reducing the risk of spreading a negative and apprehensive
approach to auditing and encourages process ownership.
 Quality audit
experience for
excellence

123

Figure 2.
The Ishikawa fishbone
diagram
CGIJ Lack of awareness in certification (ISO) requirements also posed communication
15,2 barriers. A total of 100 percent awareness training was first introduced early January
2004, covering the majority of staff (1,350 in number then). Training is repeated
periodically to ensure all staff are updated and aware (1,900 current number) and help
maintain the momentum of awareness throughout.
Different cultural backgrounds played a significant part in the challenges faced.
124 Being a multi-cultural society and workplace with an Omani national ratio of 40:60 to
expatriate contract staff, standards of practice varied widely from professional to
professional. It took time to achieve harmony so we would all speak the same language;
the language of quality. Audit channeled the ultimate focus of patient care to follow
internationally recognized policies and guidelines adopted in SQUH, while fully
supporting expatriate experience, skills and expertise.
SQUH auditors’ limited experience in report writing, ISO clause familiarity and time
management, was an obstacle during early audit cycles, however this improved
significantly over time with audit experience and process ownership of the audit
design and methodology.
The loss of momentum felt throughout the hospital in the documentation phase was
a challenge SQUH underwent during the project. One logical attribution to this would
be the decision SQUH took to have the quality manual electronic as a means to
controlling documentation, as per ISO requirements, clause 4.2.3. This process required
enormous dedication from SQUH staff in weekly reviewing and revising existing
documentation or by creating the detailed documentation necessary, as per ISO
requirements.
The risk of a nonconformity re-occurring in the same or a different area of the
hospital was a major concern, although with the introduction, monitoring and
subsequent sharing of corrective/ preventive action, this too has improved quite
considerably.

Outcome of change
Stage I
A total of 26 months into the project, and having achieved ISO 9001:2000/08
certification, the following outcomes were observed as the many factors which helped
SQUH to overcome the resistance of change, such as: ISO team members are from
within the institution, thus creating an advantageous perspective of teamwork,
encouragement and sharing of enthusiasm. Change Management training was given as
an introductory tool for preparation of resistance to change and how to manage it.
Process Ownership defined in SQUH as the one whom understanding controlling and
improving the process. By awarding process ownership to the experts or specialists of
their field, when audit is conducted, they are able to measure what they see against
what is documented, removing any animosity, therefore inadvertently reduces the
resistance to change. Additionally, we have gained a positive change in the way we
think, work, and relate to one another. Continuous improvement is evident through
commitment, teamwork and continuous audit evaluation. The “cycle of fear of change”
is being broken down whereas the auditor is now greeted with a smile instead of
anxiety and SQUH staff are now fully aware that by developing their vision of
excellence and, most importantly, creating and implementing a realistic plan to achieve
that vision, is a potential improvement in itself. Corrective and preventive actions are Quality audit
surfacing and are being identified through audit as “trends”, encouraging open experience for
feedback and the sharing of continual improvements, while promoting a blame-free
environment. Furthermore, audit reveals strengths and weaknesses, which is always a excellence
starting point to identify variations in practices across physicians, particularly with
regard to the cost and success rate of treatments. “Best practices” are being shared and
adopted throughout the hospital, promoting even better patient care and patient 125
satisfaction. All departmental quality indications are on an upward trend. SQUH
internal auditors are engaging in self-departmental audit in order to improve
performance in certain aspects of care by identifying existing non-conformities or
potential risk. This openness enhances awareness, not only intra/inter-departmentally,
but throughout the hospital in general. In addition, majority of staff are now familiar
with the criteria of standards being audited in their areas, having a friendlier and
stronger coordinated effect on environment.

Maintaining the improvement cycle

Stage II
One month following JCI Accreditation Mock Survey (April 2009), SQUH staff have
implemented numerous departmental improvement processes as part of internal
quality audit closure, based on Plan-Do-Check-Act (PDCA) model used to develop, test
and implement proposed changes rapidly by using a “trial and learning” approach.
Performance and outcome measures are monitored over time to test and refine these
processes when needed. Audits are done diligently and findings are presented and
results of improvement projects in departmental meetings as well as monthly hospital
board meetings to share. Internal communication has improved up, down, left and
right. Physicians are beginning to be provided with names of patients whose care did
not meet the standard for follow-up purposes. Hospital-wide key performance
indicators are being developed, in order to enhance teamwork and motivate
performance improvement. Whenever individual performance were evaluated, the data
was blinded to avoid a blaming or punitive culture. Goals of 100 percent compliance for
process measures and achievable benchmarks for outcome measures have been set.
“Focus on Prevention” has been nominated for the Audit Theme of 2010; a total quality
management (TQM) principal. Furthermore, the hospital has realized that until
methods are instituted to prevent the recurrence of problems, long-lasting results
cannot be achieved. SQUH Quality Team Award, presented in recognition of a team’s
outstanding contribution to accomplishing quality improvement based on audit
findings. Additionally, a questionnaire on auditor skill, technique and manner was
sub-sequentially designed and distributed during auditing on three occasions.
Additionally, to improve service performance, process owners are encouraged to run
departmental audits to identify waste and activities of non-added value (Figure 3).

Conclusions
As an improvement on a larger scale and continuing along the path of auditing for the
purpose of improvement, the next step for Sultan Qaboos University Hospital is to seek
healthcare accreditation. In our quest to improve patient outcomes and satisfaction,
accreditation can only enhance the journey of continual improvement towards
CGIJ
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126

Figure 3.
SQUH improvement
process for chlorahexadine
2 percent

excellence and provide concepts, methods, tools and advice for attaining a total quality
culture. In conclusion, and on behalf of the Sultan Qaboos University Hospital of
Oman, this experience has essentially been a practical approach to implementing
quality audit, where much has been achieved, but much more remains to be done.

References
Abdelhak, M. (2001), Health Information: Management of a Strategic Resource, 2nd ed.,
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About the author

Yasmeen S. Alhatmi is Deputy Director in the Quality and Development Directorate of Sultan
Qaboos University Hospital in Sultanate of Oman and is a certified ISO, OHSAS and IOSH lead
auditor. Yasmeen S. Alhatmi can be contacted at: yaz4me2@yahoo.ca

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