Licensing Guidelines of Private Health Establishments

Directorate General of Private Health Establishments
Licensing Guideline of Private Health Establishments

September 2021
MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 1

Institution Name: Directorate General of Private Health Establishments
Document Title Private Health Establishments Licensing Requirements Form
Approval Process
Name Title Institution Date Signature
DG of Private
Dr Mazin Al Ministry of Dr Mazin Al
Written by Health Jan 2019
Khabouri Health Khabouri
Establishments
DG of Private
Health
DGPHE Establishments Ministry of DGPHE
Reviewed by Sept
DPEs & DG of Health DPEs
2019
Health Services
in Governorate
DG of Quality
Dr Qamra Al Ministry of Dr Qamra Al
Validated by Assurance Jan 2021
Sariri Health Sariri
Center
DG of Private
Dr Mazin Al Ministry of Dr Mazin Al
Approved by Health Jan 2021
Khabouri Health Khabouri
Establishments

Contents
Acknowledgement ..........................................................................................................................................6
Introduction: ...................................................................................................................................................7
Aims and Objectives: ....................................................................................................................................7
Chapter One (General Requirements) ......................................................................................................8
1. Records and Documents: ............................................................................................................... 8
2. Common area requirements: ........................................................................................................ 8
2.1 Parking………………………………………………………………………………………...8
2.2 Reception………………………………………………………………………………………8
2.3 Staffing………………………………………………………………………………………...9
2.4 Waiting area…………………………………………………………………………………..9
2.5 Consultation, observation & treatment room besides pertinent medical furniture &
equipments and instruments according to specialty……………………………………………10
2.6 Hand wash facility…………………………………………………………………………...11
2.7 Sterilization unit……………………………………………………………………………..11
2.8 Dirty utility unit……………………………………………………………………………..11
2.9 Waste storage unit…………………………………………………………………………..12
b. Toilets………………………………………………………………………………………..12
2.10 Security ……………………………………………………………………………………………………………………………………….12
Chapter two (Specific Requirements) .................................................................................................... 13
Occupational & Physiotherapy Clinics and Rehabilitation Centers: ............................................. 13
1. Introduction: .................................................................................................................................... 13
2. Description ....................................................................................................................................... 13
3. Basic Occupational Therapy Clinic Requirements ...................................................................... 13
3.2. Clinical Equipment……………………………………………………………………………14
3.3. Occupational therapy activities ……………………………………….. ................................ 14
4. Physiotherapy .................................................................................................................................. 15
4.1. Functional Areas………………………………………………………………………………15
4.2.Hydrotherapy Pool (optional)…………………………………………………………………15
4.3. Equipment……………………………………………………………………………………..16
4.4. Consumables…………………………………………………………………………………..16
5. Independent Rehabilitation Clinic or Rehabilitation Clinic attached within Medical Center 17
a. Models of care…………………………………………………………… ............................... 17
5.1. Rehabilitation Hospital……………………………………………………. ........................... 17
5.2. Rehabilitation Center………………………………………………………. .......................... 17
a. Functional Areas……………………………………………………...………………………18
b. Staffing………………………………………………………………………………………...18
c. Basic Equipment for Rehabilitation Centre………………………………………………..18
2. Optical Shop. ................................................................................................................................... 21
2.1 Refraction and eye examination room………………………………………………………21
2.2 Glasses Fitting room or optical lenses storage place……………………………………….21
2.3 Showroom……………………………………………………………………………………..22
2.4 Staff…………………………………………………………………........................................ 22
5.1. Speech Therapy Clinic:................................................................................................................ 23
5.1 Clinical Equipment……………………………………………….. .......................................... 23
5.2 Speech Therapy Activities……………………………………………………………………23
Appendix 1: .................................................................................................................................................. 24
Inspection Checklist for Required Records and Documents in the Facility .................................. 24
Appendix 2: .................................................................................................................................................. 25
Generic checklist for Clinics, Medical Centers and Polyclinics ...................................................... 25
GP Clinic Sketch.................................................................................................................................. 30
Appendix 3: .................................................................................................................................................. 31
Sterilizing Unite Sketch ...................................................................................................................... 31
31

Checklist for Sterilization, Dirty utility & Medical waste units Dental Unit /Clinic and
Polyclinic……………………………………………………………………………………………..32
Sterilization Unit Checklist…………………………………………... .......................................... 32
Dirty Utility and Medical Waste Units Checklist: ........................................................................... 34
Appendix 4: .................................................................................................................................................. 36
Occupational and Physiotherapy Clinic Sketch ............................................................................... 36
Appendix 5: .................................................................................................................................................. 37
Optical Shop Sketch ............................................................................................................................ 37
Extra Sketches of Specialized Clinics: Dental Clinics Sketch ......................................................... 38
Typical Room for X-Rays Sketch ...................................................................................................... 39
Typical Room for Mammography Sketch ........................................................................................ 40
Typical Room for CT scanner Sketch ............................................................................................... 41
Typical Room for MRI ....................................................................................................................... 42
Company/Camp Clinic Sketch ........................................................................................................... 43
First Aid/Site Clinic Sketch ................................................................................................................ 44
Extra Checklists for Specialized Clinics: Audiology Checklist ....................................................... 45
Checklist for Audiology Services ....................................................................................................... 45
Checklist for Psychology Clinic ......................................................................................................... 47
Dental Clinics Checklists .................................................................................................................... 48
Dental Clinic Sketch ............................................................................................................................ 51

Acknowledgement
DGPHE would like to thank and appreciate the great efforts of all the staff from different
healthcare institutions who participated in writing up this document and in particular the
following staff:
Name of Employee Institution / Directorate / Department

Dr. Mazin Al-
Director General of Private Health Establishments, MoH.
Khabouri
Dr Hamed Al Adawi Consultant, Director General of Private Health Establishments, MoH.
Ex-Head of Assessing and Licensing Private Health Establishments

Dr Hamood Al Harthi
Department, Director General of Private Health Establishments, MoH.
Head of Quality Control and Patient Safety, Director General of Private

Dr Munira Al Hashmi
Health Establishments, MoH.
Senior staff Nurse, Director General of Private Health Establishments,
Aida Al Hanai
MoH.
Senior Specialized Nurse, Director General of Private Health
Maha Al Maskari
Establishments, MoH.
Senior Dental Surgeon Director General of Private Health
Dr Manal Issa
Senior Dental Technician t, Director General of Private Health
Abdullah Al Riyami
Quality Specialist, Director General of Private Health Establishments,
Rawan Al Amri
MoH.
Head of Information and Statistics Section, Director General of Private
Waheed Al Maskari
Health Establishments, MoH.
Ex-Senior Radiographer, Director General of Private Health
Asial Al Habsi
Senior Radiographer, Director General of Private Health
Ahmed Al Rashidi
Senior Laboratory Technician, Director General of Private Health
Abbass Al Lawati
Ex-Senior Staff Nurse, Director General of Private Health
Salha Jafer
Araffaa Al Sheibani
Asad Al Toubi Physiotherapist, Institute of Health Sciences, MoH.
Samia Faqir Al Raisi
Azaa Al Maskari Audio Technician, Al Nahdah Hospital, MoH.

Introduction:
The Directorate General of Private Health Establishments (DGPHE) provides this document as
guidance to the general requirements of private health establishments; it also states the common
area requirements, and lists the Ambulatory clinics or outpatient clinics. Ambulatory clinics or
outpatient clinics are medical facilities that perform procedures that do not require an overnight
stay in a hospital or care facility. This document outlines the general guidelines of these facilities
that need to be considered when establishing a stand-alone ambulatory clinic.
For further in depth criteria and reference; please consult the website of The International
Health Facility Guidelines: https://healthfacilityguidelines.com/
Aims and Objectives:

1. To provide a standardized guideline of the general and specified requirements for a private
health facility.
2. To ensure that all private health care establishments follow a recognized guideline when
preparing their facilities
3. To provide checklists and sketches helping in internal as well as external auditing.

Chapter One (General Requirements)
1. Records and Documents:

Documentation is essential. There should be for each patient a medical record in an approved
electronic system (Appendix 1)
2. Common area requirements:
2.1 Parking
a. There should be enough parking spaces for expected patients and allocated marked
parking for the disabled.
2.2 Reception
a. Handicap accessible entrance level access or with a ramp and hand rails.
b. Corridors must be at least 1.5 meters in width to allow wheelchair users to maneuver
easily doors of consultation room should be at least 1.2 meters wide to allow for
wheelchair access. A wheel chair should be kept either at entrance or reception of the
facility for those who may need assistance.
c. The facility should be adequately ventilated with temperature-controlled air-conditioning
for the comfort of both patients and staff.
d. Wheel chair/bed for disabled patient’s facility.
e. Reception counter height must be wheelchair accessible.
f. Electronic medical record (EMR) facility in each medically used room including
reception for registration.
g. Price list approved by MOH.
h. Patient’s Right and Responsibilities (Arabic and English Languages) clearly displayed.
i. Pedal bins in all rooms; one with black bag for general waste and the other one with
yellow bag for medical waste (150 micron thickness).
j. It is essential to ensure that suitable access to every type of clinic for people

with special needs, i.e. users of wheelchair, people with difficulty walking,
people with a sensory disability such as visual or hearing impairment, people
with learning difficulties.
2.3 Staffing
a. Licensed medical staff & paramedic staff according to DGPHE requirements.
b. There should be admin staff, receptionist, accountant, cleaners etc. registered with
DGPHE according to Ministry of Labor requirements.
c. Staff files should have the following records Continues Professional Development (CPD)
certificates, vaccination certificates, contract signed by both sides, copy of license.
2.4 Waiting area

a. Waiting areas with a space large enough to not allow crowding and with an allocated
space for wheelchair users.
b. Any fabric (chairs, curtains etc.) in the facility should be of non-porous material easy to
clean and disinfect (general point to be applied to all facility rooms).
c. The facility should ensure that there is proper signage to ensure smooth flow of patients
and each room or area should be appropriately labeled with a clear display in Arabic and
English.
2.5 Triage room

In facilities with multiple consultation rooms a triage room is recommended where the vital
signs, temperature and body weight of the patients can be recorded. In single General
Practitioner clinics the triage room is not a requirement and the equipment will be in the
consultation room.
Equipment list:
a. Vital signs monitor with appropriate cuff sizes for pediatric, Adult, obese patients.
b. Digital Thermometer
c. Floor weighing scale with height measurement

d. Glucometer
2.5 Consultation, observation & treatment room besides pertinent medical furniture &
equipments and instruments according to specialty
a. Rooms should not be less than 3x3 meter
b. Paper roll on top of the examination bed: medical grade blanket, pillow and pillow case.
foot stool.
c. Partition between beds for privacy
d. Weighing and height scale.
e. Stethoscope, BP apparatus manual/electronic with range of cuffs, specimen collection
trolley, individually wrapped tongue depressors & torch etc.
f. Resuscitation set including crash cart.
g. PPE (Gloves, Apron, Mask)
h. Oxygen cylinder and peak flow meter.
i. Nebulizer machine with its’ kit
j. Suction apparatus with disposable catheter tips
k. Portable IV stand
l. Spirit swabs, dry cotton balls, antiseptics solution in container
m. Disposable tray or bowl for used speculums and instruments
n. Alcohol based hand rub (60-70%)
o. Sharps container which is of MoH standard and placed above the ground Appendix 2.
2.6 Blood Collection (Phlebotomy): Where blood collection is done a separately room,
especially labs equipped with a Phlebotomy chair, stool, and stainless-steel Phlebotomy
cart.

2.7 Hand wash facility
a. Should be sited close to where clinical procedures are carried out, easily accessible and
not sited behind curtain rails, trolleys or chairs.
b. Large enough to contain and reduce splashes and allow staff to perform accepted hand
hygiene techniques.
c. All hand washbasins should be with mounted dispensers for antimicrobial soap and paper
towels, water tap and soap dispenser should be elbow operated or with sensor. Soap
dispenser should not be refillable.
2.8 Sterilization unit

a. Assigned staff & dedicated room (lockable), at least minimum of 2.5 x 2.0 meter for
clinic and 2.5 x 3.0 meter for polyclinic with air conditioner and exhaust fan.
b. Steam autoclave class B, autoclave tape and wrapper (if there are instrument sets),
pouches, marking pen. ultrasonic washer or cleaner (if required)
c. Double sink with elbow operated tap or sensor.
d. Hand washing facility
e. Sharp container, instrument brush, enzymatic solution with detergent, chemical indicator
(either class 5 or 6)
f. Test log book, to document the result of the tests (Bowie-Dick, Biological and Chemical
indicator).
g. Instrument cabinet for storing sterilized sets.
h. Personal Protective Equipments (gloves, apron, safety goggle, face mask, hair and shoe
cover).
i. Maintenance document file (maintenance and calibration of the equipment) Appendix 3
2.9 Dirty utility unit

a. At least 2 x 2.5 m2 with 2 sinks. One for hand washing, the other one for washing the
mops and disposal of dirty water. Hooks should be installed to hang the cleaning

materials such as mops and brushes. A lockable cabinet or rack to store the cleaning
items.
2.10 Waste Management

a. Dedicated room at least not less than 2 x 2 m2 and be shared with the clinic/polyclinic or
hospital and should have a lock.
b. Appropriate waste cans to collect clinical and general waste shall be placed in all
functional clinical areas and include:
 General waste 20 liters.
 Clinical waste (yellow/red)
 Sharps container wall hung or on trolley.
c. Toilets
a. Toilets facilities must be provided for patients, staff and visitors. At least one toilet must
be wheelchair accessible; all with hand washing facility.
2.11 Security
a. CCTV according to ROP requirement and specification

Chapter two (Specific Requirements)
This chapter explains the requirements of specific specialized clinics.
Occupational & Physiotherapy Clinics and Rehabilitation Centers:
1. Introduction:
The design of the physical setting of the rehabilitation unit needs to be able to provide a safe
and accessible environment that fulfills and achieves the purpose of rehabilitation. The
equipment used requires to be assessed for safety and is deemed sufficient to achieve the
purposes and goals of rehabilitation.
2. Description
A rehabilitation center or allied health facility must provide a minimum of physiotherapy
services in combination with either Occupational therapy or Speech Therapy services. This
may sometimes be accompanied by complimentary medicine services like acupuncture,
Ayurveda etc.
a. In an occupational therapy clinic, a minimum of two treatment/consultations
rooms must be present. The following is essential for each room
b. Space area not less than 9 square meters (3m x 3m). Larger rooms should be
allocated for group therapy no less than 25 square meters (5 m x 5 m). Group
therapy should include 4-6 clients only Appendix 4.
c. Privacy must be ensured.
3. Basic Occupational Therapy Clinic Requirements

a. Pediatric treatment areas must be child friendly
b. Should have a washing facility for the toys and other items that will need cleaning and
disinfection.

c. Each clinic must include at least one therapist with a bachelor degree in health science
majoring in occupational therapy.
d. Physiotherapy clinicians must not deliver occupational therapy services.

3.1. Office for Occupational Therapist
a. Desk with 2 chairs, one for the Occupational Therapist and one for the patient.
b. Examinations couch with pillow and medical blanket for patient’s privacy.
c. Suitable storage area for documents.
3.2. Clinical Equipment:

a. treatment tables (wooden or Hi Low)
b. At least one standardized Occupational Therapy Assessments material (SOP).
c. Large mirror
d. Swiss (exercise) ball
e. Hand weight set
f. parallel bars or railing
g. Stackable steps
h. Hand exercise balls
3.3. Occupational therapy activities At least 20 occupational therapy activities must be available
that may include:
a. Range of Motion Arc
b. Therapeutic cones
c. Fine motor activity tools and pegboards
d. Sensory brushes and relevant sensory products
e. Cognitive development tools
f. Gross motor developmental tools
g. Weighted pencils

4. Physiotherapy
4.1. Functional Areas:

In addition to the main areas mentioned above, the following should be applicable where
physiotherapy service is to be provided:
a. Individual treatment areas (patient privacy).
b. Gym with facilities appropriate for the level of service to be provided.
c. Equipment storage room
d. Ice making facilities
4.2. Hydrotherapy Pool (optional):

The need should be carefully considered.
a. Recommended pool size is 7.5m x 4.5m generally the length should be one and a half times
the width.
b. Recommended depth is 0.8m at the shallow end and the maximum of 1.5m at the deep end.
c. The pool floor should contain no steps as gradient is to be provided
d. Steps are the accepted method of entry and exit
 May be used to provide functional training
 Should be placed at both ends of the pool
 Should not intrude into the working space of the pool
 A pool hoist should be provided
e. Temperature of the pool should be maintained at 30 degree C to 35 C. The ambient
temperatures should be lower than water for comfort of pool side staff and patients
f. Lighting should allow the pool floor to be seen and should minimize glare of the surface of
the water
g. Non-slip surface should be used for pool surroundings.
h. Space considerations should include waiting patients, staff and accessibility for multiple
wheelchairs.

i. Changing facilities and showers should be provided for both staff and patients (male/female)
size will be dependent on pool size.
j. Adequate emergency call points should be provided. These should be accessible from the
concourse area and within the pool.
k. Storage facilities (pool specific) should be provided within the area:
 Therapy equipment
 Consumables and pool supplies
 Pool aids
 Staff lockers
4.3. Equipment:
This will be dependent on population being treated at the clinic whether pediatric, geriatric,
women health, general etc....
4.4. Consumables:
a. PPE (apron, gloves etc.)
b. Disinfectant (cleaning) available in all areas

5. Independent Rehabilitation Clinic or Rehabilitation Clinic attached within Medical Center
Clinics should include facilities of one profession only. The clinic should be specific for that
particular profession.
a. Models of care:
Facilities for rehabilitation services will vary greatly, depending of the professions involved.
They will range from large purpose designed, central facilities to basic small bedside services.
5.1. Rehabilitation Hospital:
The hospital should include facilities for both outpatients and inpatients. It should allow the
facilities to be utilized by both groups of patients. The inpatients should be accommodated
with-in the vicinity. They will be expected to attend rehabilitation services on a daily basis.
The design of the facility could provide areas of common utilization to both units.
a. Functional Areas:
 Entrance, reception area and waiting areas.
 Patient therapy areas which may be shared
5.2. Rehabilitation Center:

Centers should include facilities for outpatients only. These should be of multiple professions
including physiotherapy. Day care may be included, however patients utilizing day care facilities
(more than 4hours treatment) should be provided with a resting area. Rehabilitation centers
should provide a minimum of 1 consultation room per profession and 3 treatment rooms (2.5m X
2.5m each) in total depending on the number of professions included. In addition a gym (4.5m X
4.5m minimum size) should be included

a. Functional Areas:
 Patient therapy area. A minimum of 1 consultation and treatment room (with a minimum size
of 2.5m X 2.5m) or (3.5m X 3.5m)
o In any clinic (one treatment room can be substituted by a gym (minimum size 3.5m X
4.5m) in a physiotherapy clinic).
 Floor finishing is essential that it is nonslip and does not create a drag for patients using
walking aids and wheelchairs
 The height of light switches need to accessible
 Handrails on both sides of the corridors are recommended
 Duress alarm system should be located at reception and treatment areas (especially in the
case of a hospital)
 Call systems should be provided in all individual treatment rooms including the gymnasium.
b. Staffing
 Each clinic should have at least 1 full time therapist with BSc from an approved academic
institution.
 Physiotherapists may choose to develop certain skills in the area of advanced practice that
has been performed by other professions such as dry needling, chiropractic, spinal
manipulation, cupping therapy and osteopathy techniques. These skills require extra training
beyond those obtained in the undergraduate or immediate post-graduate training. Permission
for which should be sought through request for privileges beyond those normally granted.
c. Basic Equipment for Rehabilitation Centre

The following is a list of some of the equipment to consider for starting a private physiotherapy
clinic or rehabilitation centre according to the scope of the clinic or the center

 Devices for Tests and Measures
• Goniometers
• Tape measures
• Grip dynamometer
• Manual muscle testing dynamometer
• Reflex hammer
• Neurological testing instruments
• Blood pressure cuff
• Stethoscope
• Thermometer
 In-House Educational Materials

• Anatomical posters
• Health education posters
• Skeleton (optional)
• Anatomical Models (optional)
 Basic Treatment Room Equipment

• Treatment tables: wooden plinths
• Treatment tables: high-low adjustable
• Mat table
• Treatment room cabinets, chairs
• Large mirror for visual feedback
• Exercise steps with different sizes
• Linens: gowns, towels, sheets, pillows, pillowcases, blanket, etc.
• Step stools
• Therapist stools on wheels

• Variety of bolsters, wedges, supports
• Gait belt
 Basic Rehabilitation Modalities

• Hydro-collator with hot packs
• Ice production modalities
• Ice packs, Ice massage cups
• Ultrasound machine with gel warmer
• Multiple mode electrical stimulator as per required
• Paraffin bath
• EMG biofeedback (optional)
 Exercise machines
• Treadmill
• Upper Body Ergometer
• Upright / Recumbent Bike
• Various sports performance equipment:
• sport specific equipment
• Supine shuttle-style leg press machine
• Multi-purpose, multi-joint, adjustable resistive machine

2. Optical Shop:
2.1 Refraction and eye examination room

a. Refraction chair unit, adjustable up and down.
b. Auto refractometer with Kerato-meter, working and gives accurate results.
c. Lensometer, Auto or manual.
d. LCD screen or chart projector should be adjusted and placed 3 meters in front of the
examination chair, on same eyes level of the patient.
e. Phoropter or lenses trial set with trial frame.
f. Streak Retinoscope, working and in good condition.
g. Pen torch.
h. Color Vision examination book.
i. Hand washing basin with elbow operated tap or sensor.
j. Steps of hand washing poster.
k. Wall mounted dispenser with antimicrobial soap (soap should be non-refillable (in bottle or
sachet).
l. Wall mounted paper towel dispenser with paper towel.
m. Adjustable lightening of the room for maximum dimming and brightness.
n. Signage on the door ( Examination Room)
o. MOH private establishment license certificate and copy of the Optometrist license should be
displayed clearly in the facility.
2.2 Glasses Fitting room or optical lenses storage place

a. Should be placed in the end of the shop and separated from the refraction room.
b. Should have all required fitting instruments like edger machine, drilling, lens polishing,
fitting tolls etc.
c. Lenses storage place.
d. This room should be cleaned and tidy all the time.
e. Exhaust fan for lens coloring odors clearing.

f. Water supply- hand washing basin with elbow operated tap or sensor. Steps for hand washing
poster. Wall mounted dispenser with anti-microbial soap and wall mounted paper towel
dispenser with paper hand towel.
2.3 Showroom:
a. Reception and waiting area.
b. Cash and dispensing counter.
c. Cabinet to display contact lenses and related products.
d. Wall mounted sunglasses or optical frames display.
e. Drawers display to showcase and store optical frames.
f. Room should be clean and tidy all the time Appendix 5.
2.4 Staff:
a. Licensed MOH Optometrist is a must to run the optical shop
b. Optometrist should wear white lab coat and wear his license ID card.
c. All eye testing and refraction should be done by the Optometrist.
d. All medical advices and information should be given by the Optometrist.
e. Salesperson should be familiar with the types of sun-glasses, optical lenses and frames.
f. Dispensing optician or glasses lenses fitter should have the required knowledge of lenses
fitting and dispensing.
g. Cleaner with knowledge of optical shops cleaning and glasses lenses handling.
Note:
 Hand washing facility is a must.
 Fitting Room should be separated from refraction room and it is optional as the
fitting maybe done somewhere else.
 Optometrists should wear a lab coat with their license ID.
 The Private establishment license should be clearly shown in the examination room.

5.1. Speech Therapy Clinic:
a. In Speech therapy clinic, a minimum of two-treatment / consultations room must be
present if no special procedures are to be carried out in the clinic. The following is
essential for each room
b. Equipment storage spaces (preferably vertical) to store rehabilitation tools.
c. Staff allocation each clinic must include at least one therapist with a bachelor's degree in
health science majoring Speech Therapy.
5.1 Clinical Equipment:

a. Mirror
b. At least one standardized Speech and Language Assessment materials to be utilized.
c.
d. Suitable therapy materials including visual, auditory, and cognitive stimulating materials.
e. Oral-motor exercises kits.
f. Augmentative and Alternative Communication Tools.
g. Small supply of food/ liquids items to test swallowing.
h. Syringes (No needles).
i. Consumables: Gloves, face masks, tongue depressors and sanitizing wipes must be available
and accessible in all areas
5.2 Speech Therapy Activities

a. Strength and skills activities for oral-motor disorders.
b. Cognitive rehabilitation.
c. Aural rehabilitation.
d. Articulation, speech and language delay therapy activities.
e. Cognitive development tools and tasks.
f. Feeding activities and materials.

Appendix 1:
Inspection Checklist for Required Records and Documents in the Facility
Sr Not
Required Records Met Comments
No. Met
1. Valid MoH facility license
2. Valid municipality license
3. Valid civil defense certificate
4. Valid medical laundry contract
5. Valid appropriate Be’ah contract (medical waste contract)
6. Staff files:
 Copy of contract and offer letter
 Qualifications and CV
 Copy of staff license
 BLS/ACLS certificate
 Signed job description
 Annual appraisal
 Induction/orientation for new staff
 Training record including CPD of all medical personnel
according to OMSB requirements
7. Minutes of meetings records
8. Vaccination records
9. Nurses duty roster record
10. PPM records
11. GCC infection control manual latest addition
12. Standard operation procedures (SOP)
13. Inoculation policy
14. Medical record and referral policy

Appendix 2:
Generic checklist for Clinics, Medical Centers and Polyclinics

Name of Private Health Establishment:
Location: Full Address and GPS

Names and designations of the Health
Establishment Staff during inspection:
S. No Items General Specifications Met Not Met Comments

1. Entrance Adequate Allocated Parking
Allocated Parking for Disabled
Ramp for Disabled Patients
CCTV
Emergency Exit (push to open
operated)
2. Reception Waiting area- Non-fabric chairs
Adequate Air Ventilation
Receptionist (Omani)
Patient’s Right and Responsibilities
(Arabic and English Languages)-
Visible
Approved Price List from DGPHE
(for the most common procedures).
Suggestion/Complaints email
Notice Board
Approved Networked Electronic
Medical Record system
Wheel Chair/Bed for Disabled
Patients
Pedal Dust Bin for General Waste
with Black Bag
3. Male and Female Hand Washing Basin with Elbow
Toilets Operated Tap or with Sensor
Wall Mounted Dispenser with Non-
Refillable Liquid Soap

Wall Mounted Paper Hand Towels
in Dispenser
Pedal Dust Bin for General Waste
with Black Bag
4. Consultation Room signage
Rooms Room size at least 3×3m
Doctor’s Table and Non Fabric
Chair
Patient’s and attendant Chairs (Non
Fabric)
Examination Bed/Couch with IV
Stand Bed Sheet Medical Blanket,
Pillow and Pillow Case and Paper
Roll on Top of the Examination Bed
with foot stool and partition
PPE (Gloves, Apron, Mask)
Alcohol based Hand Rub (60-70%
Alcohol)
Disinfectant Wipes
Hand Washing Hand Basin with
Elbow Operated or Sensor
Steps of Hand Washing and Hand
Rub Poster
Wall Mounted Dispenser with
Antimicrobial (e.g. Chlorhexidine
4%)
Paper Hand Towels in Dispenser
General Waste Pedal Dust Bin with
Black Bag
Waste Pedal Bin with Yellow Bag
for clinical waste (with biohazard
label)
5. Treatment Room signage
Observation or Staff Table and Non-Fabric Chairs
Procedure room for staff and patients including
attendant

Examination Bed/Couch with IV
Stand Bed Sheet Medical Blanket,
Pillow and Pillow Case and Paper
Roll on Top of the Examination Bed
with foot stool and partition
Vital Signs Monitor (e.g.
Sphygmomanometer with SpO2
monitor)
Glucometer
Thermometer with disposable cover
Nebulizer Machine and masks with
different sizes
Medication Fridge with Thermometer
and Temperature Graph/Chart
Lockable Medications
Cupboard/Cabinet with Checklist
with Expiration Dates
Secured Oxygen Cylinder with Flow
meter and humidifier (in Stand or
Transport Trolley)
Suction Machine with disposable
catheters
Fully Equipped Crash Cart with
Content Checklist with Expiration
Date of the Contents
Dressing/Suturing Sets
Dressing/Cannulation Trolley
(Stainless Steel Trolley)
Weighing and Height Scale
Alcohol Based Hand Rub (60-70%
Alcohol)
Operational ECG Machine
Approved Secured Sharp Container
(e.g. Wall Mounted) at waist level
Spill Kit
Alcohol Swabs
Splint (Different Sizes), Cervical
Collar, Cuff and Collar and
Triangular Bandage
PPE (Gloves, Apron, Mask)

Examination Light
Disinfectant Wipes for furniture
Hand Washing Basin with Elbow
Operated Tap or with Sensor
Steps for Hand Washing and Hand
Rub Poster
Wall Mounted Dispenser with Non
Refillable Antimicrobial Soap (e.g.
Chlorhexidine 4% - Soap
Wall Mounted Paper Towel
Dispenser
General Waste Pedal Dust Bin with
Black Bag
Waste Pedal Bin with Yellow Bag
for clinical waste (with biohazard
label)
Required Records and Documents in the Facility
Documents required Met Not Met Comments
1. Valid MOH License
2. Valid Municipality License
3. Valid Civil Defense Certificate
4. Valid Laundry Contract
5. Valid appropriate Be’ah Contract (Medical

Waste Contract)
6. Staff Files
 Copy of license
 BLS/ACLS Certificate
 Induction/orientation for new staff
 Training records including CPD of
all medical personnel.
8. Vaccination Records

9. Nurses’ Duty Roster Record
10. PPM Records
11. GCC Infection Control Manual latest Edition
13. Inoculation Policy
14. Medical Record and Referral Policy
*Crash cart items should be kept based on MOH crash cart guidelines.
*All clinical rooms including the sterilization unit and rooms/ where medication are kept should
be well ventilated with AC on all the time.
Date of Inspection:
Comments:-
Names of Inspectors Signature

GP Clinic Sketch

Appendix 3:
Sterilizing Unite Sketch

Checklist for Sterilization, Dirty utility & Medical waste units Dental Unit /Clinic
and Polyclinic
Date of Visit:
Name of the Reporter:
Sterilization Unit Checklist:

1. Sterilizati Staffing:
on Room  Trained staff for
sterilization,
autoclaving and
packing of sterilized
items.
Dedicated room:
 At least Minimum of
2.0 x 2.5 meter for
clinic.
 2.5x3.0 meter for
Polyclinic
Signage
Lockable
Air Conditioner (AC)
Exhaust fan
Steam Autoclave Machine-
Class B
Ultrasonic washer or cleaner (if
required according to the
service)
Two Sinks
Sink with Elbow
Operated Tap for
Instrument Cleaning
 Hand wash Basin with

Elbow Operated Tap for
Hand Washing
Steps of hand washing poster
Wall Mounted soap dispenser
with Antimicrobial Soap (e.g.
Chlorhexidine 4%)
Disinfectant for instruments,
surface impression and suction
Blood spill kit with instruction
to use
Paper napkin one side poly
coated
Disposable patient bibs with
absorbent cellulose cover
Wall Mounted paper towel
dispenser with paper towel
Waste Pedal Bin with black
bag
Waste Pedal Bin with yellow
bag for medical waste
Enzymatic Solution with
Detergent
Sharp container
Instrument Brush/es
Chemical indicator (class 5 or
6)
Biological Indicator and
Incubator
Bowie-Dick Test
Autoclave tape and wrapper (if
there are instrument sets)
Marking pen
Rack or Cabinet
Distilled water
Personal Protective
Equipments (gloves, apron,
safety goggle, face mask, hair
and shoe cover).
Pouches Different Sizes–(either

self-sealing or sealed with
sealant)
Log book – to document the
result of the tests
Maintenance document Record
for autoclave machine
Lockable
Dirty Utility and Medical Waste Units Checklist:

2. Dirty Cleaning Staff:
Utility  With waste management
Room knowledge and proper training.
Other
items  Contract between the staff and
facility
Dedicated room at least Minimum of 2.0
x 2.5 m.
Signage
Lockable
Exhaust fan
2 Sinks
 Floor mop sink with Elbow
Operated Tap
 Hand wash Basin with Elbow

Operated Tap
Hand wash basin with elbow tap or
sensor
Steps of hand washing poster
Wall Mounted soap dispenser with
Antimicrobial Soap (e.g. Chlorhexidine
4%)
Wall Mounted paper towel dispenser
with paper towel
Waste Pedal Bin with black bag

Detergent

Dusting clothes
Color Coded Mops and brush/es
Hooks or wall mounted holders
Double bucket Mop trolley
Rack or Cabinet
Rubber gloves (Heavy Duty)
Caution Wet Floor sign
Waste Dedicated room Minimum of 2 x 2 m.
1. Storage Signage
Lockable
Valid Be’ah Contract

Appendix 4:
Occupational and Physiotherapy Clinic Sketch

Appendix 5:
Optical Shop Sketch

Extra Sketches of Specialized Clinics: Dental Clinics Sketch

Typical Room for X-Rays Sketch

Typical Room for Mammography Sketch

Typical Room for CT scanner Sketch

Typical Room for MRI

Company/Camp Clinic Sketch

First Aid/Site Clinic Sketch

Extra Checklists for Specialized Clinics: Audiology Checklist
Checklist for Audiology Services

Date of Visit:
6. Room Set Up/ Test Environment

Room signage
Room size at least 3×3m
Hearing assessment is conducted in a quiet room where
ambient noise is less than 35dB.
Provide access and comfort for patient with physical
disability.
The clinic provides visual and auditory privacy for
consultations in accordance with the individual privacy needs
of clients.
Testing cabin should be sound proof with certificate from
manufacturer.
Testing room, equipment, instruments, and anything that will
come in contact with clients are cleaned before every client.
Safety alarm to ensure patient’s safety.
Alcohol based Hand Rub (60-70% Alcohol).
Disinfectant wipes.
General Waste Pedal Dust Bin with Black Bag.
9. Tests and procedures* YES NO Remarks
Detailed case history.
Otoscopy.
Pure tone audiometry with masking.
Acoustic Immitance test (Tympanometry + acoustic reflex)
Special testing (OAE, ABR, ASSR, EcoG).
Paediatric testing (BOA, VRA, Play Audiometry).
Cochlear Implant fitting and programming.

Make medical referral when needed.
10. Hearing aid fitting and evaluation YES NO Remarks
Proper selection of hearing aid type according to client’s
needs.
Taking impression using a safe procedure to avoid injury, and
using appropriate instruments and materials.
Proper ear mould selection according to client’s needs. (e.g.
mould/RIC/open fit)
Ear mould modification and tube changing. (e.g. adding
vent/changing dome/hooks).
Hearing aid fitting and adjustment (acoustic/electroacoustic)
Aided testing.
Real ear verification and/or coupler measurements.
Provide counselling regarding hearing aid care, use, and
control
Explain realistic expectation and hearing aid limitation
Implement a rehabilitation plan that includes follow up to
check hearing aid use and effectiveness, and verify hearing
aid performance.
11. Balance Testing YES NO Remarks
Video-nystagmography (VNG).
Caloric test.
Positional tests.
Vestibular Evoked Myogenic Potential (VEMP).
Vestibular rehabilitation exercise.
*Minimal Qualification Required:

- Diploma or equivalent for basic audiometry and tympanometry.
- BSc or equivalent and or MSc for diagnosis, advanced testing, and rehabilitation.
- Ear mould course for making moulds.
*Assessments are conducted using recognized test procedures.
Names of the inspection team: Signature
Name of director of the health institution: ____________________________________

Signature ___________________

Checklist for Psychology Clinic
Date of Visit:
Narcotic and Psychotropic Medications Checklist
S. No General Specification Met Not Met Comments
1. Approval letter from pharmacy

2. Locked DDA Cupboard with
alarm and light
3. DDA Keys with Nursing In-
charge
4. Narcotic and Psychotropic
Prescriptions and Registers are
kept in Secured
Cupboard/Cabinet
5. MOH Narcotic and Psychotropic
Guidelines
6. Proper documentation based on
narcotic and psychotropic
guidelines.

Dental Clinics Checklists
1. Dental Operatory Room
S.N Items Specification M NM comments
1.1 General
1.1 Dental cabinet Made of suitable material
(metallic or laminated
wood) with suitable
top(Granite, Laminated
wood or acrylic)
1.2 Equipment
Complete Dental System ( Minimal Requirements )
1.2.1 Dental Chair - Auto- zero positioning
movable arm rest
-Foot controlled chair
movement
1.2.2 Dental Operating Light Shadow-less halogen lamp
illumination
1.2.3 Dental Unit with the following:
Air rotor turbine
Electric motor
Ultrasonic (piezometer) scaler
3 in 1 air -water syringe with outlets (one for
the operator and one for the assistant)
Clean Water System With non-retraction valve
Cuspidor Spittoon With intermittent wash
linked with cup filler with
automatic levelling and
separate water
system(operator and
assistant control)
Salivary ejector
High volume suction
Adjustable bracket table
1.2.4 Hand pieces
High speed turbine hand-piece

Low speed Contra-angle hand-piece
Low speed Straight hand-piece
Ultrasonic scaler hand-piece
1.2.6 Tips:
Autoclavable stainless steel tips for the 3 in 1
syringes
Autoclavable stainless steel tips for the high
volume suction
Autoclavable scaler tips
Autoclavable Scaler tip remover
1.2.7 Compressor To be in a separate room
1.2.8 Suction machine Noise reduced
1.2.9 Mobile instrument cabinet
1.2.1 Mobile stools
0
1.2.1 Polymerization Light Unit Specific for dental
1 applications with build in
radiometer for monitoring
the light intensity
1.2.1 Intra -Oral / Dental X - Ray Unit (if Applicable)
2 has the following:
Intra -Oral / Dental X - Ray Developer / Digitizer
X -Ray viewing box
Lead apron
Thyroid collar
1.3 Instruments
Diagnostic
1.3.1 Full set of diagnostic instruments
Oral Surgical
1.3.2 Full set of oral surgical instruments
Extraction Forceps
1.3.3 Upper and lower for adult
Upper and lower for child
Elevators
Full set of elevators

Conservation
1.3.4 Full set of dental conservative instruments
Periodontal & Scaling
1.3.5 Full set of instruments used in scaling and
periodontal procedures
2. Dental Consumables
Disposable items:
2.1 Disposable syringes, cotton, gauze… etc.
Endodontic Materials
2.2 Full set of endodontic materials
Conservative Materials
2.3 Full set of conservative materials

Dental Clinic Sketch

Licensing Guidelines of Private Health Establishments

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Directorate General of Private Health Establishments

Licensing Guideline of Private Health Establishments

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 1

Document Title Private Health Establishments Licensing Requirements Form

Name Title Institution Date Signature

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 2

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 4

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 5

Name of Employee Institution / Directorate / Department

Ex-Head of Assessing and Licensing Private Health Establishments

Head of Quality Control and Patient Safety, Director General of Private

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 6

Aims and Objectives:

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 7

1. Records and Documents:

2. Common area requirements:

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 8

2.4 Waiting area

2.5 Triage room

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 9

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 10

2.8 Sterilization unit

2.9 Dirty utility unit

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 11

2.10 Waste Management

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 12

This chapter explains the requirements of specific specialized clinics.

Occupational & Physiotherapy Clinics and Rehabilitation Centers:

3. Basic Occupational Therapy Clinic Requirements

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 13

d. Physiotherapy clinicians must not deliver occupational therapy services.

3.2. Clinical Equipment:

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 14

4.1. Functional Areas:

4.2. Hydrotherapy Pool (optional):

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 15

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 16

5.1. Rehabilitation Hospital:

5.2. Rehabilitation Center:

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 17

c. Basic Equipment for Rehabilitation Centre

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 18

 In-House Educational Materials

 Basic Treatment Room Equipment

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 19

 Basic Rehabilitation Modalities

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 20

2.1 Refraction and eye examination room

2.2 Glasses Fitting room or optical lenses storage place

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 21

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 22

5.1 Clinical Equipment:

5.2 Speech Therapy Activities

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 23

Inspection Checklist for Required Records and Documents in the Facility

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 24

Generic checklist for Clinics, Medical Centers and Polyclinics

Location: Full Address and GPS

S. No Items General Specifications Met Not Met Comments

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 25

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 26

MoH/DGPHE/F/013/Vers.002 Effective Date: Jan 2021 27

Required Records and Documents in the Facility

Documents required Met Not Met Comments