Guidelines
 
Guidelines
Application
Accreditation Committee
Accreditation Report Form
 
  1. OBJECTIVES OF THE ACCREDITATION PROCESS
    The OMSB is the national body that certifies specialists in all branches of medicine and surgery, and family medicine. One of the OMSB's responsibilities is to survey and accredit residency programs to ensure the ability of these programs to assist residents in acquiring the knowledge and expertise necessary for specialty or subspecialty practice. The OMSB surveys and evaluates all residency programs in Oman in each of its recognized specialties and subspecialties. The accreditation process has as its major objectives:
 
  1. to improve the quality of postgraduate medical education;
  2. to provide a means for objective assessment of residency programs;
  3. to provide guidance in the development of new residency programs
  4. to assist the scientific committees chairmen and program directors in reviewing the conduct and educational quality of their programs.
    To achieve these objectives, essential elements in each aspect of a program have been identified which must reach established accreditation standards before the program can be accredited. The accreditation process examines each program using information obtained through the use of questionnaires and an on-site visit made by a team of surveyors experienced in postgraduate medical education and familiar with the standards of the OMSB
   
  2. ORGANIZATION OF THE OMSB WITH RESPECT TO ACCREDITATION
    2.1. The Accreditation Committee
      Responsibility for accrediting OMSB residency programs is delegated to the Accreditation Committee. This Committee is composed of a chair, vice chair and other members. All members are appointed for a three-year term that is renewable.
The role of the Accreditation Committee is:
   
  1. To recommend policies, standards, and criteria related to the accreditation process of residency programs.
  2. To arrange periodic review and assessment of accredited residency programs through on-site surveys and internal reviews.
  3. Assess applications for accreditation of new residency programs or for modification of accredited programs.
  4. To determine the category of accreditation granted to each residency program. To develop, maintain, disseminate, and review its policies and procedures.
     
    2.2. Specialty Committees
      The Accreditation Committee is assisted in its work by the scientific committee of each of the specialties. The role of a scientific committee in the accreditation process is:
   
  1. To develop and review periodically the specific standards of accreditation for programs in the specialty or subspecialty;
  2. To develop and review periodically the specialty-specific portions of the pre-survey questionnaire, which is used to obtain information on programs applying for accreditation and on programs to be surveyed or otherwise reviewed;
  3. As requested by the Accreditation Committee, to nominate individuals from the specialty or subspecialty to conduct external reviews of specific programs and to participate in regular surveys.
      The development and monitoring of the content of the documents "Specific Standards of Accreditation for Residency Programs" in the specialty or subspecialty and the specialty-specific portions of the pre-survey questionnaire are a major responsibility of the respective specialty committees. Guidelines provided by the specialty committee are particularly important in evaluating the structure and organization of the program as well as the adequacy of resources, the academic content and the evaluation processes of the specialty or subspecialty. Such guidelines also assist accreditation committees to determine the resources required to initiate and sustain a residency program in the specialty or subspecialty.
     
  3. Training Centers
    All training centers must be accredited by OMSB accreditation committee/ department whether for core /mandatory rotations or elective rotations.
    3.1 Sites for All Rotations
      All sites must demonstrate a commitment to education and quality patient care. The following requirements will assist OMSB in developing, maintaining and evaluating the quality of sites for all rotations. It is the responsibility of the OMSB accreditation committee, each residency program scientific committee and each hospital director to:
     
  1. Maintain and continuously update records of each site including the length of the rotation and the number of residents involved;
  2. Maintain written agreements with each site;
  3. Ensure that there are goals and objectives for each program using each site and that all sites comply with approved objectives and standards as appropriate;
  4. Ensure that there is a rotation supervisor.
  5. Ensure that there is appropriate evaluation of each rotation by each program;
  6. Ensure that all sites are evaluated during the internal review of the program
      At the time of the survey, the role of the Accreditation Committee will be to ensure that the hospital has an appropriate system in place to maintain and evaluate the quality of the rotations in all sites in all programs.  Sites will be visited at the time of a regular survey or at the time of internal review.  Strengths and weaknesses of the sites will be noted
       
  4. Accreditation Requirement of the Training Centers
   

Accreditation of health institutions as training centers requires that they meet the following requirements:-
    4.1 The Training Faculty
     
  1. There must be qualified faculty for training according to the international standards by the authorized Scientific Committee. 
  2. The residents must be totally under the supervision of the training faculty to assure the residents' participation in the scientific activities.
  3. The training faculty must carry out Instructional activities, for example, rounds in the training centers, lectures, seminars…etc. and preparing this in an organized way according to specialties
    4.2 Basic Services
      A. Hospitals
       
  1. Main Specialties
  2. A&E
  3. Out-patient clinics
  4. Operation Rooms
  5. ICU
  6. Diagnostic Laboratory
  7. Radiology Department
  8. Pharmacy & Nutrition
  9. Medical Records
  10. Sufficient, on call rooms for residents
  11. Communication
  12. Any other requirements of the Accreditation Department.
      B. Health Centers
       
  1. Out-patient clinics
  2. Diagnostic Laboratory
  3. Radiology Department
  4. Vaccination Department
  5. Health Instruction Department
  6. Pharmacy & Nutrition
  7. Medical Records
  8. Communication
  9. Meeting & Teaching Rooms if available
  10. Any other requirements of Accreditation Department
    4.3 Training and Educational Resources.
     
  1. The medical Library which includes but not limited to:-
    1. The latest editions of the essential textbooks.
    2. The new edition of the index medicine.
    3. Medical Journals & Periodicals.
  2. Medical electronic Library
  3. The availability of adequate number of modern instructional aids.
  4. Lecture halls equipped with audiovisual aids.
  5. Medical Librarian.
    4.4 Accreditation Process of Training Centers.
      4.4.1 The Accreditation Committee will visit the training centers which apply for their accreditation for the first time.
      4.4.2 The Accreditation Committee will pay periodical visits to the training centers and programs in the first quarter of the training year for evaluation. However, the first visit for the purpose of accreditation or emergency visit may be at any time
      4.4.3 After fulfilling the accreditation conditions, the Accreditation Committee will study the accreditation requirements specific to each specialty separately in the training centers.
      4.4.4 The OMSB will review the implementation of the program systematically.
      4.4.5 The OMSB will evaluate the center and the scientific program every 3 years, or less if the OMSB deems it necessary, to continue accrediting them
       
  5. Accreditation Requirement of the Training Program and Faculty:-
   

The Training Programs are

  1. Emergency Medicine
  2. Anesthesia
  3. Child Health
  4. Dermatology
  5. FAMCO
  6. General Surgery
  7. ENT
  8. Obstetrics & Gynecology
  9. Internal Medicine
  10. Microbiology
  11. Biochemistry
  12. Hematology
  13. Histopathology
  14. Psychiatry
  15. Radiology
  16. Other added by the decision from the Board of Trustees.

For accrediting a training program, it must fulfill the following general requirements and also the requirements pertaining to each specialty.
    5.1. Curriculum
      5.1.1

Aims & Objectives
      5.1.2 Outline of rotations both core and elective for all training years
      5.1.3 Didactic lectures and conferences for all years
      5.1.4 Determining graded responsibility for every training year.
      5.1.5 The duration of training program
      5.1.6 The participating and accredited Training Centers by the OMSB and the resources used.
      5.1.7 The members of the teaching faculty
      5.1.8 Admission criteria of the program
      5.1.9 Number of resident posts available annually in the program for training residents according to the available resources and international standards.
      5.1.10 The required examinations if available
      5.1.11 Surgical techniques and procedures if applicable
      5.1.12 Research requirements if applicable.
    5.2. The Training Supervisor
      5.2.1 There must be one Program Director responsible for the training program. There also must be one assistant to the Program Director in every training center assisting the Program Director
      5.2.2 The Program Director together with his assistants and the teaching faculty are responsible for general administration of the program and providing a suitable academic environment for the trainees.
      5.2.3 The Program Director and his assistants must be holders of specialty certificate and they must have enough experience and broad knowledge in the specialty in addition to their administrative abilities.
    5.3. The Training Faculty
      5.3.1

There must be a sufficient number of training faculty in all training centers and they must have the qualifications which enable tem to supervise and teach all trainees of the program.
      5.3.2 The ration of the training faculty to the trainees must be 1 consultant : 3 trainees according to international standards
      5.3.3 The training faculty should dedicate enough time for the training & teaching processes.
      5.3.4 The training faculty must allow the trainees to attend lectures and conferences conducted by the program and they should be at least 2 hours / week
      5.3.5 The training faculty must dedicate a stated time for academic training and participate in the time designated for academic training.
      5.3.6 The training faculty must make sure that the trainees education and training have priority over the clinical services.
      5.3.7 The training faculty must show interest in teaching and training processes in the OMSB
      5.3.8 The training faculty  must provide a suitable environment for trainees attendance at conferences and they must encourage research.
      5.3.9 The training faculty must encourage the trainees to participate in clinical discussions and clinical rounds
      5.3.10 The training faculty must be evaluated periodically by the residents.
    5.4. The Qualifications of the Training Faculty
      5.4.1 Members of the training faculty must be holders of specialty certificate of the training program.
      5.4.2 Members of the training faculty must be experienced in the field of academic and clinical teaching.
    5.5. Number of the Trainees
      The OMSB will decide the required number of trainees in each specialty program in keeping the teaching resources available for instructing the trainees in the training centers (for example, number of patients, the availability of clinical materials used in instruction, the training faculty to the trainees ratio, the budget available, and the efficiency of the training faculty) by coordinating with the authorized institutions and bodies.
    5.6. Other Requirements for each Specialty:-
      5.6.1 A trainee's shift must not exceed consecutive 24 hours and the trainee should make sure that he/she hands over his/her patients to the next training group.
      5.6.2 The trainee may submit shift requests to the Chief Resident 2 weeks before the beginning of the rotation and the Chief Resident will look into his/her request.
      5.6.3 The monthly working schedule must be distributed among the trainees at least one week prior to the beginning of the rotation and must be sent to OMSB office in the training center.
      5.6.4 The trainee must not take more than one in house call every 4 days
      5.6.5 Weekend call must bee one day long – 24 hours – only
      5.6.6 The trainee must not permitted to take more than one home call every 3 days
     
  6. Freezing & Revoking Accreditation of Training Centers and Training Programs
    The OMSB has the right to Frees & Revoke accreditation from the training center and training programs if they do not fulfill the accreditation requirements and conductions according to the following steps’
    6.1. Freezing the Accreditation
      6.1.1 Based on the recommendation of the Accreditation Committee, the President of the Executive Board will issue a warning letter of freezing the accreditation to the center's administration or the training program to correct the deficiencies. The centre or program correct the deficiencies and then submit a request for a re-evaluation within 6 months from the date of issue of the warning letter..
      6.1.2 If the period of warning ends without correcting the deficiencies for freezing the accreditation of the center, the training program will continue for another six months until the deficiencies are corrected and the Accreditation Committee will evaluate the centre or the training program again
    6.2. Revoking the Accreditation
      6.2.1 In case the above mentioned freezing of accreditation period ends without correcting the deficiencies, the accreditation will be revoked.
      6.2.2 Revoking accreditation may result in not allowing the admission of new residents and transferring all residents to other centers.
      6.2.3 Re-accreditation of the centre or the training program will be based on a letter from the center's administration or the training program that shows the correction of deficiencies and application for re – accreditation
      6.2.4 Revoking accreditation may be immediate, especially in case of severe deficiencies in the centre or the training program and if the deficiencies cannot be corrected within a short period
     
  7. The Accreditation Process
    The accreditation process is based on a system of regular surveys of the residency programs on a three year cycle. However, the survey will be done annually initially, until the programs are well established. The primary purpose of a survey is to provide the Accreditation Committee and the Executive Board and Board of Trustees of OMSB with a first-hand evaluation of each accredited program and the extent to which it meets the standards of accreditation. The accreditation committee will send a team of surveyors to assess the Specialty Program and Training Centers.
    7.1. Regular Surveys
      There are a number of checks and balances in the survey and accreditation of residency programs with respect to the accuracy of information and the process of deliberations and decision-making. In brief:
      7.1.1 The training centers provides the pre-survey information which will include a covering letter from the Head of Department indicating that the faculty approves and supports this program plus covering letters from the Hospital Directors of the major teaching institutions or training centers indicating support of the program
      7.1.2 The accreditation committee reviews the documentation and provides comments prior to the survey;
      7.1.3 The surveyor examines the program in interviews with the chairman and program director, teaching staff, residents, and with the residency program committee. In addition, the surveyor tours the facilities and reviews the resources available to the program;
      7.1.4 The surveyor meets with the chairman and the program director prior to the departure of the survey team to clarify any issues;
      7.1.5 The surveyor submits a written report
      7.1.6 The Accreditation Committee reviews the pre-survey documentation, the survey report and recommends the category of accreditation
      7.1.7 The accreditation committee will submit the report to the Executive Board and the Board of Trustees for approval
      7.1.8 The Board of Trustees will notify the Specialty Program and the training centers of the status of accreditation
     
   
     
    7.2. Internal Review of Residency Programs
      Direct responsibility for the quality of the specialty programs rests with the scientific committee, the chairman and program directors. The internal review, which is considered to be an integral component of the accreditation process, should be conducted annually. It is intended as a mechanism to assist residency program in maintaining its quality and to provide the accreditation committee, chairman and program directors with valuable information about the strengths and weaknesses of their programs. This in turn enables the scientific committee to take corrective measures before the next OMSB survey. It is recommended that repeat internal reviews be conducted on programs with serious identified weaknesses
      7.2.1. The Objective of the internal review are
       
  1. To assess the strengths and weakness of each program
  2. To consider and evaluate all residency education training centers, including elective experiences
      7.2.2. The internal review team for each program should include
       
  1. Chairman and members of the accreditation sub-committee, program director and chairman of the program scientific committee
  2. To Chairman or program director from another specialty
  3. Members of the accreditation committee should also be included
      The review team should have available all documentation regarding the program. A series of interviews must take place with the chairman program director, teaching staff, residents, and with the scientific program committee. Visits to individual sites should take place as appropriate. All residency education sites and elective experiences should be reviewed by the internal review team. There should be a careful assessment of the quality of the program, based on the general and specific standards of accreditation as outlined by the OMSB
      A separate written report from the residents in the program should be included. This report should be prepared by the resident representative(s) commenting on:
     
  1. strengths of the program,
  2. weaknesses previously identified in the program and the residents’ perception of how well these have been dealt with,
  3. Any other significant changes in the program since the last review.
      The written report of the internal review should include the strengths and weaknesses of the program and specific recommendations for continued development and improvements. This report should be submitted to the Accreditation Committee Chairman and Executive Board. The report should then be circulated to the members of the scientific committee and discussed at their meeting
      Internal review reports of all programs are to be provided to the survey team prior to the regular OMSB survey to enable them to assess the efficacy of the internal review process.
       
    7.3 External Reviews.
      In addition to the regularly scheduled surveys, the Accreditation Committee may, from time to time, request that an external review of a residency program be conducted when there are serious concerns regarding the ability of the program to meet the standards of accreditation.
         
  8. CATEGORIES OF ACCREDITATION
    Each program considered by the Accreditation Committee is granted an accreditation status or category of accreditation outline below:
   
  • New program are given “New approval
  • Continuing program without deficiencies are given “Full Accreditation”.
  • Programs that have deficiency may be given accreditation with warning or probationary accreditation.
     
    8.1. Approval
      Programs that are considered to meet the general and specific standards of accreditation and which have no major weaknesses identified are granted approval
    8.2. Conditional Approval
      When a program is considered to meet the general and specific standard of accreditation and have some weaknesses that can be corrected within 1 year before the next scheduled survey, it is granted provisional approval. It then becomes the responsibility of the scientific committee to correct the weaknesses in the program within the first year.
The Accreditation Committee may mandate follow-up of a program with conditional approval by means of a regular survey
    8.3. Probation Status
      When major and/or continuing weaknesses have been identified which bring into question the ongoing accreditation of the program, the program will be placed on probation for one year. Residents and applicants to the program, must be advised immediately by the program director of the status of the program. Within one year of such notice being given, regular survey will be conducted.
    8.4. Freezing Accreditation of Training Centers and Training Programs
      The OMSB has the right to freeze accreditation from the training centre and training programs if they do not fulfill the accreditation requirements and conditions according to the following steps:
      8.4.1 After the program has been on probation for one year with continuing deficiencies which have not been corrected, a notice of intent of freezing will be sent.
      8.4.2 The specialty program corrects the deficiencies can submit a request for a re-evaluation within one year from the date of issue of the warning letter.
      8.4.3 New residents will not be accepted in the program.
    8.5. Withdrawal of the Accreditation
      8.5.1 A program on "Freeze status" for one year without correcting the deficiencies, withdrawal of the accreditation will take place
   

 

 8.5.2 If a program is on "Withdrawal Status" all residents will have to be transferred to other programs if available.
      8.5.3 Re-accreditation of the centre or the training program will be based on a letter from the training program that shows the correction of deficiencies and application for re – accreditation.
      8.5.4 Revoking accreditation may be immediate, especially in case of severe deficiencies in the training centre or the training program and if the deficiencies cannot be corrected within a short period.
    8.6. New Approval
      An acceptable application for a new program is granted new approval. After 3 years of a resident being enrolled in the program, the accreditation committee can change the category to full accreditation category if the program is established.
    8.7. Application For Accreditation Of New Programs
      The specialty program requesting accreditation of a new residency program should follow the following steps:
      8.7.1 The new residency program must apply by means of a special forms supplied by the OMSB
      8.7.2 To be accredited, a program must comply with the OMSB Program and Training Center “General Standards”.
      8.7.3 Recommend specific standards of accreditation for the specialty and sub-specialty.
      8.7.4 Accreditation Committee will appoint a new program sub-committee to consider the application.
      8.7.5 Accreditation will be granted on the basis of an assessment of the resources to be provided within the program and the capability of the program to provide a complete education program in the specialty or sub-specialty as well as the manner in which these resources will be utilized for the residency education.
      8.7.6 Completed application forms and a covering letter from the Head of Department of the proposed specialty indicating that the faculty approves and support this program plus covering letter from the Hospital Directors of the major teaching institutions or training centers indicating support of the program must be submitted to OMSB
         
       
 


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