Dubai Health Authority — Health Regulation Sector policies for licensed facilities and professionals (audit, communicable disease, sentinel events, advertising, Medical Director, fitness to practice, privileging, clinical governance, consent, telehealth),
chapter by chapter

Fitness to Practice Policy ss 4.1-4.12Fitness to practice

Applicants over 65 or with impairing conditions must provide a medical fitness document; non-compliance or impairment may lead to licence suspension or revocation.

Health Data Protection and Confidentiality Policy PP-11 s 4 (rectification)Health data protection

Data subjects' requests for rectification of health data must be addressed within 5 working days.

Health Data Protection and Confidentiality Policy PP-11 ss 3-4Health data protection

Entities processing protected health information in Dubai must comply with data protection laws, ensuring lawful processing and confidentiality obligations in contracts.

Hospital Accreditation Policy s 4.2-4.3Hospital accreditation

Hospitals must achieve ISQua IEEA accreditation within 24 months and provide proof during annual licence renewals.

HP-03 ss 4.1-4.25Inspection and audit

DHA conducts various inspections and facilities can only operate post-final inspection; staff must cooperate and self-inspect quarterly.

HP-03 ss 4.16-4.24Violations and appeals

Facilities have 30 days to appeal administrative violations and may pay fines in installments per Executive Council resolutions.

HP-10 ss 4.1-4.7, Appendices 1-3Communicable disease notification

Facilities must report all communicable disease cases to DHA Preventive Medicine within specified timeframes via IDNS/SALAMA, ensuring confidentiality of patient information.

HP-10 ss 4.1-4.7, Appendix 3 (Group 3 diseases)Communicable disease notification

Appendix 3 diseases must be reported to DHA Preventive Medicine within 5 working days through IDNS/SALAMA.

Medical Advertisement Standard ss 5-9, Appendix 2Medical advertising on social media

Medical advertisements on social media must include a licence number, require Medical Director approval, and adhere to strict claims substantiation and consent protocols.

Medical Director Policy s 4Medical Director

Every DHA-licensed facility must have a Medical Director ensuring ethical practices, reporting requirements, and documentation standards.

Medical Director Policy s 4.2.1(e)Ethics training

All staff must receive annual training on medical ethics, which must be recorded.

Mortality and Morbidity Standard s 5.5, Appendices 1-2Quarterly facility report

Facilities must submit quarterly reports detailing healthcare concerns, implemented solutions, morbidity analysis, and key performance indicators.

Mortality and Morbidity Standard ss 5.3-5.6, 8.8Mortality reporting

Facilities with inpatient beds must report all mortalities within 35 days and review cases in a committee to implement corrective actions.

NABIDH Breach Notification Policy ss 3.3.1-3.3.11Breach notification

Healthcare facilities must notify NABIDH of breaches within 48 hours, train employees, audit security, and report incidents, maintaining records for 25 years.

Sentinel Events Standard ss 5.3, 6.1-6.2Sentinel event governance

Facilities must conduct annual patient safety staff training, track sentinel events, and report findings to the clinical governance committee.

Sentinel Events Standard ss 5.5-5.11Sentinel event notification

Facilities must notify DHA of sentinel events within 48 hours, initiate root cause analysis, and secure evidence until investigations are complete.

Transfer of CD and SCD Policy HP-22 ss 4.1-4.7Controlled drug transfers

Controlled and semi-controlled drugs can only be transferred under specific conditions, requiring authorization and documentation from overseeing pharmacists.

NABIDH Breach Policy s 3.2.27-retRecord Retention — Breach investigation reports

Breach investigation reports must be retained for 25 years following completion, as mandated by DHA's record retention policy.

Clinical Governance Manual ss 10.2-10.3, 12.5Clinical governance

Healthcare facilities are required to implement clinical governance frameworks and submit specific reports to DHA within set timeframes.

Clinical Laboratory Accreditation Policy ss 4.2-4.3Laboratory accreditation

Clinical laboratories must be accredited by recognized bodies and comply with standards for proficiency testing and reference materials within two years of licensure.

Clinical Privileging Policy ss 4.3-4.16Clinical privileging

A clinical privileging committee must be established to grant, renew, and revoke privileges based on defined criteria and applicant qualifications.

Clinical Trials Policy ss 4.4, application formClinical trials

Clinical trials require DHA Scientific Research Ethics Committee approval, informed consent, periodic progress reports, and serious adverse event reporting to DHA.

DNR Policy ss 4.1-4.5Do not resuscitate

DNR requests require agreement from three consultants and cannot be denied if requested by the patient.

Emergency Medications Policy ss 4.4-4.6Emergency medications

Controlled drugs cannot be exchanged between facilities; DHA Drug Control reviews emergency medication requests within 5 days, valid for 3 months.

Emergency Services Facilities Policy ss 4.2-4.4Emergency services facilities

Emergency services must provide access regardless of insurance plans, report incidents to DHA, and comply with Dubai Health Insurance Corporation policies.

Medications Disposal Policy ss 4.1-4.13Medication disposal

Facilities must ensure pharmaceutical waste management, check for expired medications monthly, and follow specific disposal protocols for narcotics and controlled drugs.

NABIDH Subject of Care Rights ss 3.4Subject of care rights

Patients using NABIDH can request investigations for breaches, must be informed of any breaches, and notified of accesses to their health data.

Patient Referral and Transfer Policy s 4.4Referral and transfer

Patients must receive emergency care regardless of health insurance and should be referred to secondary or tertiary care within 5 working days.

Telehealth Policy s 4.1Telehealth

Telehealth services need DHA licensing, patient consent for information transfer, compliance with relevant standards, and may not store health data outside UAE.

NBS Guideline s 5.1Physical examination

Newborns must receive a comprehensive physical examination by a qualified medical professional within 24 hours of birth.

NBS Guideline s 6.3.7Specimen retention

Dried blood spot cards must be retained for one year for quality assurance, while presumptive positive cards are stored indefinitely under controlled access.

NBS Guideline s 7.4Hearing screening

Healthy newborns must undergo hearing screening within 48 hours of birth, ideally after 12 hours.

NBS Guideline s 8Critical congenital heart disease screening

Pulse oximetry screening for critical congenital heart disease must occur between 24 and 36 hours of age, or as close to discharge if before 24 hours.

NBS Guideline ss 5.2, 6.1Informed refusal

Parents must sign a refusal form for newborn screening, which a physician countersigns and uploads to the newborn's electronic medical record.

NBS Guideline ss 5.2, 6.2Blood spot screening

Newborns must undergo dried blood spot screening within 24-48 hours of birth, with follow-up samples if discharged early, as mandated by Cabinet Resolution 15/2020.

NBS Guideline ss 6.3.1-6.3.6Results and follow-up

Parents must be notified of normal newborn screening results in 14 days; time-critical positives require physician evaluation within 24 hours of laboratory reporting.

NBS Guideline s 6.3.7 (dried blood spot cards)-retRecord Retention — Newborn screening dried blood spot cards

Newborn screening dried blood spot cards must be retained for one year, while presumptive positive cards are kept indefinitely following specimen receipt.