Governing Regulation
Governing Regulation
Governing Regulation
STATEMENT
This is a controlled document. Unless stated otherwise, any unauthorized
electronically transferred copy or printed version of this document is considered
uncontrolled.
Table of Contents
Part Four Center for Healthcare Planning and Quality (CPQ) ................................................................. 23
33 Establishment of CPQ ................................................................................................................................... 23
34 Objective of CPQ ............................................................................................................................................. 23
35 Accountability of CPQ .................................................................................................................................. 23
36 Purpose of CPQ ............................................................................................................................................... 23
37 Powers and responsibilities of CPQ ....................................................................................................... 24
38 Relationship with the Agencies ................................................................................................................ 24
1 Title
This regulation is to be referred to as the DHCC Governing Regulation No. (1) of 2013
(the “Governing Regulation”).
2 Issue of Regulation
This Governing Regulation is issued in accordance with the Law.
3 Repeal of Regulation
This Governing Regulation repeals and replaces the DHCC Governing Regulation No. (1)
of 2008.
4 Hierarchy
(1) If there is any conflict between the provisions of this Governing Regulation and
any other Regulation approved by the Chairperson, the provisions of this
Governing Regulation shall prevail.
(2) In the event of any inconsistency between an earlier version of a Regulation and
an amended version of the same Regulation, the most recently amended version
of the Regulation shall prevail.
5 Commencement
This Governing Regulation comes into force on the date of its issuance by the
Chairperson.
6 Background
The vision of DHCC is to be the internationally recognized location of choice for quality
Healthcare Services and an integrated center of excellence for clinical and wellness
services, medical education and research. To assist in achieving this vision, there needs
to be a strong and transparent governance framework. No Entity or natural person may
operate within DHCC without an appropriate License or Miscellaneous Permit.
7 Purpose
The purpose of this Governing Regulation is to set out the governance framework under
which Licensees and Miscellaneous Permit Holders may operate within DHCC.
12 Amendment of Regulations
The Chairperson may, from time to time, approve amendments to this Governing
Regulation, or any of the other Regulations, taking into account the recommendations of
the DHCC Board of Directors, the Executive Body and the Agencies, as appropriate.
13 No discrimination
(1) The DHCA and any Agency, in exercising its powers and carrying out its
responsibilities under this Governing Regulation or any other applicable
Regulations shall not discriminate against any person on the basis of such
person’s:
(a) race;
(b) creed;
(c) color;
(d) national origin;
(e) ancestry;
(f) religion;
(g) sex;
(h) sexual orientation;
(i) marital status;
(j) age (including newborn status);
(k) handicap; or
(l) source of payment.
(2) Any Licensee and/or Miscellaneous Permit Holder, in conducting any activity or
providing any services in DHCC, shall not discriminate against any person on the
basis of any ground stated in subsection (1).
19 Definitions
Words in the singular include the plural and words in the plural include the singular.
Unless it is specifically stated otherwise in another Regulation, or unless the context
otherwise requires, the following definitions apply to all the Regulations within DHCC.
Academic and Research Council means the Academic and Research Council
established by Part Five of this Governing Regulation;
AED means the lawful currency of the UAE;
Affected Person means, with regard to the disclosure of information under Part Eleven
of this Governing Regulation, a person about whom the information to be disclosed
relates;
Agency means each or any of the boards, councils, registries and similar Entities
established under this Governing Regulation and includes the Appeals Board, Central
Governance Board, Licensing Board, Planning Council, Quality Council, Academic and
Research Council, Professionals Council, Registry of Companies and CPQ;
Animal Research means any systematic investigation, including research development,
testing and evaluation that involves the use of animals in research, with the objective of
developing or contributing to generalizable knowledge;
Appeals Board means the Appeals Board as established by Part Six of the Governing
Regulation;
Applicant means the applicant as defined in the specific Regulations that submits an
Application;
Application means an application for a License, a Provisional Approval Letter, or a
Miscellaneous Permit made under the specific Regulations;
Approved Continuing Healthcare Education Program, means a Continuing
Healthcare Education Program that has been approved by the Registry of Companies;
Approved Continuing Medical Education Program, means a Continuing Medical
Education Program that has been approved by the Registry of Companies;
Approved Education Operator means an Entity licensed by the Registry of Companies
to conduct Education Programs in accordance with the Education Regulation and the
applicable Rules, Standards and Policies;
Approved Education Operator means an Entity holding an Education Permit duly
issued by the Registry of Companies in accordance with the Education Regulation and
the applicable Rules, Standards and Policies;
Approved Non-Degree Granting Healthcare Program means a Non-Degree Granting
Healthcare Program that has been approved by the Registry of Companies;
Approved Research Operator means an Entity holding a Research Permit duly issued
by the Registry of Companies in accordance with the Research Regulation and the
applicable Rules, Standards and Policies;
Associated Person means with regard to an Applicant, any other person, including an
Entity, that is Closely Linked with such Applicant;
21 Headings
The headings used in this Governing Regulation are included for convenience of
reference only and shall be ignored in the construction or interpretation of this Governing
Regulation.
22 Time periods
References in Regulations to time periods are to be construed in accordance with the
Gregorian calendar. Whenever Regulations reference a period of time, such period shall
include every calendar day, except that:
(1) when the last day of the period falls on a Friday or a Saturday, the period shall end
instead on the next Sunday; and
(2) subject to subsection (1), when the last day of the period falls on a UAE or Dubai
public holiday, the period shall end instead on the next day that is not a UAE or
Dubai public holiday.
23 Gender
Pronouns indicating male gender are used to refer to persons of both genders.
25 Documents in writing
(1) Unless otherwise specifically stated, references in the Regulations to any
requirement for a document or notice to be submitted to the Registry of
26 Meaning of Person
Unless the context otherwise requires, any reference in the Regulations to a “person”
includes a reference to a natural person, and to a body corporate, limited liability
company, association or partnership and to the legal or personal representatives, legal
successors and lawful assigns of any such person.
27 Reference to sections
Unless otherwise specifically stated, references in a Regulation to a section and
subsection mean the section and subsection of that Regulation.
28 Objectives of DHCC
The objectives of DHCC are defined in Article (5) of the Law.
30 Chairperson
(1) The Chairperson is the Chairperson of the DHCA and has the responsibility of
undertaking the general supervision of DHCC and shall in particular, have the
authority set out in Article (9) of the Law.
(2) The Chairperson may delegate any of her prerogatives stipulated in Article (9) of
the Law to any member of the DHCC Board of Directors or to the Executive
Director.
32 Executive Body
(1) The Executive Body is established under Article (12) of the Law and is chaired by
an Executive Director. The Executive Body shall license and regulate all activities
in DHCC.
(2) The Executive Director reports to the Chairperson of the DHCA and has the
responsibilities and duties set out in Article (13) of the Law.
(3) The Executive Director may delegate any of his prerogatives stipulated in Article
(13) of the Law to any of the DHCA’s employees.
(4) Until the Executive Body is duly constituted all deemed reporting lines into the said
Executive Body shall be directly to the DHCA Board.
33 Establishment of CPQ
This Governing Regulation establishes the Centre for Healthcare Planning and Qual ity
(“CPQ”).
34 Objective of CPQ
(1) CPQ is an Agency which has been established to ensure the compliance and
enforcement of the clinical governance framework within DHCC.
(2) CPQ shall support clinical excellence and continuous quality improvement within
DHCC by serving as a center of excellence for:
(a) healthcare planning;
(b) healthcare policy and standard development;
(c) quality improvement; and
(d) regulatory services.
(3) To achieve its objective, CPQ is supported by the Agencies in accordance with
the terms of this Governing Regulation.
35 Accountability of CPQ
CPQ shall report on its activities to the Executive Body.
36 Purpose of CPQ
The purpose of CPQ is to:
(1) ensure compliance and enforcement of the clinical governance framework within
DHCC;
(2) provide the critical elements of the soft infrastructure that impact the Healthcare
Services provided by the Licensee registered in DHCC;
(3) provide or arrange for the provision of advice regarding strategy development
and clinical planning;
(4) provide or arrange for the provision of quality benchmarking and development of
Standards;
(5) provide or arrange for the provision of quality oversight systems;
(6) provide or arrange for the provision of advice for the development of Regulations
and Rules for the provision of Healthcare Services within DHCC by Licensees;
(7) collect Patient Health Information from Licensees in accordance with the Health
Data Protection Regulation to be used for quality oversight and future planning
purposes.
43 Establishment of councils
To assist the Central Governance Board in carrying out its functions related to the provision
of Healthcare Services within DHCC, the following councils are established under this
Governing Regulation:
(1) Quality Council;
(2) Planning Council;
(3) Academic and Research Council; and
(4) Professionals Council.
44 Delegations
(1) The Central Governance Board may delegate its authority to approve and issue
Standards and Guidance to any council subject to any conditions it considers
appropriate in the circumstances.
(2) Where the Central Governance Board delegates its authority under this section,
the council to which such delegation is made shall ensure that the Central
Governance Board is fully informed before the approval and issue of any such
Standards and Guidance.
(3) Where such approval and issue has been delegated to a council, the Central
Governance Board may on review of such Standards and Guidance direct the
relevant council to adopt amendments to any such Standards and Guidance the
Central Governance Board requires.
46 Obtaining advice
In fulfilling its responsibilities under this Governing Regulation, the Central Governance
Board may seek advice from any source it considers appropriate.
50 Expertise of members
The Central Governance Board shall be composed of members who, collectively, have
expertise in the areas of:
(1) quality of Healthcare Services;
(2) Standards of practices of Healthcare Services;
Quality Council
56 Guidance
The Quality Council may issue Guidance for Licensees subject to the approval of the
Central Governance Board.
58 Obtaining advice
In fulfilling its responsibilities under this Governing Regulation and any other Regulations ,
the Quality Council may seek advice from any source it considers appropriate.
Planning Council
68 Guidance
The Planning Council may issue Guidance for Licensed Healthcare Operators subject to
the approval of the Central Governance Board.
70 Obtaining advice
In fulfilling its responsibilities under this Governing Regulation and any other Regulations
the Planning Council may seek advice from any source it considers appropriate.
74 Expertise of members
The Planning Council shall be composed of:
(1) healthcare professionals and Complementary and Alternative Medicine
professionals from different areas of Professional Practice with significant clinical
experience;
(2) Persons with significant administrative experience with healthcare operators;
(3) Persons with significant experience in Healthcare Services planning; and
(4) Persons with significant experience in the design, construction and equipping of
healthcare operators.
85 Obtaining advice
In fulfilling its responsibilities under this Governing Regulation, the Education Regulation
and the Research Regulation, the Academic and Research Council may seek advice
from any source it considers appropriate.
89 Expertise of members
The Academic and Research Council shall be composed of:
(1) 1 member with expertise in the educational requirements of a teaching hospital,
who shall be nominated by the teaching hospital within DHCC;
(2) 1 member with expertise in educational services provided within the region, who
shall be nominated by the Ministry of Higher Education of the UAE;
(3) at least 2 current members of the Research Ethics Review Committee;
(4) a person knowledgeable about research activities;
(5) members who have experience in the following areas:
(a) the provision of education activities within DHCC;
(b) the provision of services to meet regional educational needs;
(c) the research requirements of a teaching hospital from the perspective of
a healthcare professional;
(d) research undertaken by Licensed Healthcare Professionals;
(e) the undertaking of research activities within the region; and/or
(f) understanding applicable laws, regulations and rules governing medical
research.
95 Guidance
The Professionals Council may issue Guidance to Healthcare Professionals and/or
Complementary and Alternative Medicine Professionals, subject to the approval of the
Central Governance Board.
97 Obtaining advice
In fulfilling its responsibilities under this Governing Regulation and any other Regulations,
the Professionals Council may seek advice from any source it considers appropriate.
99 Membership
The Professionals Council shall consist of at least 3 members.
112 Register
(1) The Licensing Board shall maintain a Register or Registers identifying Licensed
Healthcare Professionals and Licensed Complementary and Alternative
Medicine Professionals. Any such Register may be held in electronic form or in
any other permanent manner, as appropriate.
(2) Each such Register shall include the names and business addresses of
Licensed Healthcare Professionals and Licensed Complementary and
Alternative Medicine Professionals, and such other particulars, including the
scope of the License, any conditions or restrictions imposed upon a License by
the Licensing Board from time to time.
135 Establishment and membership of Complaints Panel and Fitness to Practice Panel
(1) The executive director of CPQ shall establish a Complaints Panel comprising a
pool of panelists who collectively have experience in matters relating to the
quality of care and licensure of healthcare professionals or Complementary and
Alternative Medicine professionals, healthcare operators, education providers or
research operators.
(2) The executive director of CPQ shall appoint a chairperson of the Complaints
Panel to be chosen from the panelists in the Complaints Panel.
(3) The chairperson of the Complaints Panel shall, from time to time, appoint a
Fitness to Practice Panel to review complaints against a Licensed Healthcare
Professional, a Licensed Complementary and Alternative Medicine Professional,
a Licensed Healthcare Operator, an Approved Research Operator or an
Approved Education Operator.
(4) A Fitness to Practice Panel shall comprise of at least 3 and no more than 5
panelists. There shall be at least 1 healthcare professional who is a member of
the Professionals Council and 1 non-healthcare professional on each panel.
(5) A person may not be a member of the Fitness to Practice Panel if the person
has:
(a) been involved in any earlier investigation of the matter;
(b) been involved in undertaking or supervising any Competence Program
in respect of the Licensed Healthcare Professional concerned; or
(c) an interest in the outcome of the matter or is in a position of conflict in
respect of the Licensed Healthcare Professional or Licensed
Complementary and Alternative Medicine Professional concerned.
(6) A member of a Fitness to Practice Panel is appointed on the terms and
conditions determined by the chairperson of the Complaints Panel for that
member.
(7) A member of a Fitness to Practice Panel is entitled to receive the fees that are
fixed from time to time by the Executive Body in accordance with the applicable
Policy and such fees may vary for different classes of cases.
150 Penalties
(1) A Licensee and/or Miscellaneous Permit Holder shall be subject to Penalties
where the Licensee and/or Miscellaneous Permit Holder has:
(a) not complied with a requirement set out in this Governing Regulation;
(b) not complied with a requirement of any of the other Regulations; or
(c) not complied with a requirement of a Rule, Standard or Policy.
(2) Penalties may only be imposed by the Licensing Board and Appeals Board or
the Registry of Companies in accordance with the applicable Regulations, Rules,
Standards and Policies.
Part Eleven
Management and Disclosure of Information
2 Qualifications of members
The following persons are disqualified from being members of an Agency:
(1) a person who is an undischarged bankrupt;
(2) a person who has been convicted of an offence punishable by imprisonment for a
term of 2 years or more, or who has been sentenced to imprisonment for any
other offences unless that person has obtained a pardon, served the sentence or
otherwise suffered the Penalty imposed on the person.
4 Term of appointment
(1) Of the initial appointees to Agencies, the Executive Body shall appoint:
(a) half the members to a term of 2 years each; and
(b) half the members to a term of 3 years, including the chairperson.
(2) In the case that there are an uneven number of members to be appointed, the
majority of members shall be appointed for the term of 2 years.
5 Reappointment of members
A member is eligible to be reappointed to the Agency unless he has held office for 6
consecutive years. In such an event, the member shall not be reappointed immediately
unless the Executive Body consents in writing to his reappointment and holding office for
more than 6 consecutive years, provided that such reappointment shall only be for 1
further term.
6 Resignation of members
A member of an Agency may resign from office by tendering a signed written notice to the
chairperson of the Agency.
7 Vacation of office
A member of an Agency ceases to be a member of an Agency if that Agency is
disestablished by amendment to this Governing Regulation.
12 Role of secretary
The secretary shall have the following responsibilities:
(1) to keep a written record of all Agency meetings and of all actions taken by it, and
any decisions and any recommendations made;
(2) at the direction of the chairperson, distribute the agenda for each meeting no less
than 3 business days prior to such meeting;
(3) responsibility for ensuring that the minutes of each meeting are distributed to the
members of the Agency within 3 business days following each meeting;
(4) responsibility for maintaining a register of members’ interests as disclosed under
clause 16 in this Schedule; and
(5) any such additional duties as the chairperson may from time to time prescribe.
13 Retention of information
All the Agency’s records including but not limited to:
(1) written procedures;
(2) membership lists;
(3) lists of occupations/affiliations of members;
14 Meeting procedures
Each Agency shall adopt procedural rules to govern conduct, which shall include at least the
following:
(1) It shall meet regularly upon the call of the chairperson of the Agency, at such
times and places as the chairperson shall designate;
(2) At least 1 meeting each year shall be a face to face meeting, where the majority of
members shall be present at DHCC;
(3) All meetings shall occur with the physical presence of all participating members.
provided, however, that:
(a) meetings may take place via teleconference or such other means as
determined by the Agency that allow all of the members to participate in
the meeting at the same time; and
(b) votes of the Agency may be taken without a meeting, via e-mail, provided
that all of the members of the Agency concur in the vote and that e-mail
concurrence is received from all of the members within 72 hours following
the delivery to them of the proposed votes via e-mail by the chairperson;
(4) A majority of the members of the Agency then in office shall constitute a quorum
for the transaction of all business; and
(5) All meetings of the Agency shall be deemed to have been duly called and
regularly held, and all decisions, resolutions and proceedings of the Agency shall
be deemed to have been duly authorized, if attended by a majority of the
members of that Agency then in office, unless a larger number is required with
regard to any meeting or any action at a meeting under any applicable law,
Regulation, Rule or Standard in effect from time to time in DHCC.
16 Disclosure of interests
(1) A member of an Agency who is interested in a transaction shall, as soon as is
reasonably practicable after the relevant facts have come to the member’s
knowledge, disclose the nature of the interest to the Agency.
(2) Subject to clause 18 of this Schedule, a member of an Agency who makes a
disclosure under this clause shall not:
(a) take part, after the disclosure in any deliberation or decision of the
Agency relating to the transaction;
(b) be included in the quorum when a vote on the decision is to be taken; or
19 Meaning of transaction
A transaction means:
(1) the exercise or performance of a function, duty or power; or
(2) an arrangement, agreement or contract to which the DHCA is a party; or
(3) a proposal that the DHCA enter into an arrangement, agreement or contract.
1 Patient rights
As a Patient you have the right to:
(1) know by name the physician, nurse and other staff members responsible for your
care;
(2) talk openly with your physician about your diagnosis, the treatment prescribed for
you, the prognosis of your illness, and any instruction required for follow up care;
(3) request that your physician communicate in terminology you may reasonably
expect to understand;
(4) have your request courteously received and properly considered as quickly as
circumstances permit;
(5) be informed of the reason why you are given various tests and treatments, and
who the persons performing such tests and treatments are;
(6) be informed of the general nature and inherent risks of any intended procedure
before you give your consent;
(7) change your mind about any procedure for which you have given consent, to
refuse treatment and to be informed of the medical consequences of this action;
(8) expect your personal privacy to be respected to the fullest extent consistent with
the care prescribed for you and applicable UAE laws;
(9) expect all communications and other records pertaining to your care to be kept
confidential to the extent required by law;
(10) request through your attending physician a second opinion by another physician,
to change physicians, or to change hospitals and/or facilities;
(11) participate in ethical discussions that arise in the course of your care including
issues of conflict resolution, and participation in investigational studies or clinical
trials;
(12) have impartial access to the medical resources of the healthcare facility indicated
for your care without regard to race, color, creed, national origin, age, gender or
handicap;
(13) refuse to participate in medical training programs and research projects;
(14) care and treatment in a safe environment;
(15) have pain managed in a compassionate manner;
(16) be informed about the outcomes of care, including unanticipated outcomes;
(17) have unhindered access to your medical information, and to request for copies of
the relevant medical records; and
(18) expect that confidentiality in your medical information and records will be
maintained by your physician, nurses and other staff members involved in your
care, healthcare provider and healthcare facility.