OUTPATIENT CLINICAL

SERVICES
STANDARD

Department: Quality Improvement Department

Document Identifier: SD/HCO/006/02
 STANDARD – OUTPATIENT CLINICAL SERVICES
1. PURPOSE
1.1 This standard defines the minimum requirements including licensing and service specifications to
ensure acceptable minimum levels of quality, performance, safety and reliability of Outpatient Clinical
Services operating in Dubai Healthcare City (DHCC) and its branches.
1.2 This Standard defines licensing criteria, qualified personnel and service requirements for the provision
of Outpatient Clinical Services licensed in DHCA and its branches.

2. SCOPE OF APPLICATION
2.1 This standard applies to Healthcare Operators and Healthcare Professionals currently providing or
intending to provide Outpatient Clinical Services licensed in DHCA and its branches.
2.2 This Standard does not apply to Inpatient Clinical Service providers and Healthcare Operators with
overnight services.

3. STANDARD
3.1 Licensure
3.1.1 Any DHCC Entity wishing to provide Outpatient Clinical Services shall be licensed by DHCA in accordance
with the requirements and procedures of the Dubai Healthcare City Authority (DHCA) Healthcare
Operators Regulation No. 4 of 2013, the Company Regulation No. 8 of 2013, the Commercial Services
Licensing Regulation No. 9 of 2013, the Standards defined herein, and all applicable regulations, rules,
standards and policies.
3.1.2 Each Entity at the time of applying for a Clinical Operating Permit to provide Outpatient Clinical Services
shall submit a clearly defined Clinical Functional Plan to DHCR which shall as a minimum detail:
3.1.2.1 the clinical objective(s) of the Healthcare Operator;
3.1.2.2 implementation timelines of the plan;
3.1.2.3 the planned target patient population;
3.1.2.4 anticipated patient numbers over the first three years of practice (by clinical type and
condition when appropriate);
3.1.2.5 number of planned treatment rooms/areas, consultation rooms, etc;
3.1.2.6 minimum and maximum number of practitioners and clinicians;
3.1.2.7 in-house support service delivery;
3.1.2.8 planned service(s) delivery;
3.1.2.9 compatibility of proposed clinical activities (for mixed services);
3.1.2.10 delivery methodology for patient centered care;
3.1.2.11 an assessment of risk associated with the proposed service(s) and risk management plan;
and quality assurance methodology.

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 STANDARD – OUTPATIENT CLINICAL SERVICES
3.1.3 Each Healthcare Operator intending to provide Multi-Specialty Clinical Activities shall demonstrate
capabilities to provide each Clinical Activity and related services with a similar level of quality, safety,
effectiveness and efficiency. Such Healthcare Operators shall ensure that there will be no negative
impact or overt risk associated with the delivery of any Clinical Activity or service upon that of any
other Clinical Activity or service.
3.1.4 In issuing a Clinical Operating Permit and in renewing a Clinical Operating Permit, DHCR shall assess the
appropriate ‘Category’ and ‘Clinical Activity(s)’ of the application for each Licensed Outpatient Clinical
Healthcare Operator.
3.1.5 Each Licensed Healthcare Operator that applies to significantly change, alter, add or remove Clinical
Services or Clinical Activities may be required to submit an updated Clinical Functional Plan.
3.1.6 Each Licensed Healthcare Operator will be assessed by DHCR to ensure the Clinical Functional Plan is
implemented.
3.1.7 Outpatient Clinical Services must be performed in a safe environment where the qualified personnel,
facilities, equipment, and if applicable, emergency drugs and equipment are immediately available.
3.1.8 Each Licensed Healthcare Operator providing Outpatient Clinical Services may not conduct any clinical
activity or commercial activity which is not encompassed within its already issued Clinical Operating
Permit. Such restrictions on additional activities extend to the retail of pharmaceuticals, para-
pharmaceutical products, medical or surgical equipment, cosmetics, etc.

3.2 QUALIFIED PERSONNEL

3.2.1 Each Healthcare Operator providing Outpatient Clinical Services shall appoint qualified personnel and
maintain staffing levels as required to ensure reliable and consistent care in compliance with these
Standards, the Outpatient Clinic Quality Standards or the appointed accreditation organization’s
standards, the DHCA Quality Oversight Policies, and any other applicable regulations, rules and
standards.
3.2.2 Such Healthcare Operators shall have documented processes for determining its overall staffing needs,
by number and type of staff.
3.2.3 All Healthcare Professionals providing Outpatient Clinical Services shall be Licensed Healthcare
Professionals in DHCC.
3.2.4 All such Healthcare Professionals shall provide Outpatient Clinical Services within the scope of practice
and standards of proficiency for their licensed category.
3.2.5 Each Outpatient Clinical Service Healthcare Operator shall have in place management staffing, including,
but not limited to, an Administrator and a Clinical/Dental/Medical Director
3.2.6 The Administrator shall be responsible for the day to day management of the Outpatient Clinical
Services, the efficient coordination and management of appointments, contribute to the strategic

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 STANDARD – OUTPATIENT CLINICAL SERVICES
development of services, and be the principle representative in all dealings with external parties and
authorities.
3.2.7 The Administrator may be a Licensed Physician, a Licensed Nurse who is the Senior Nurse or an individual
with at least a Bachelor’s degree and three (3) years of relevant experience.
3.2.8 The Administrator shall ensure that an appropriate number of qualified, experienced and skilled Licensed
Healthcare Professionals are in attendance, and that there are adequate resources and capabilities to
supply all approved Clinical Services and Activities
3.2.9 The Administrator shall ensure that an appropriate number of trained nonclinical and support staff are
available consistent with Outpatient Clinical Services requirements.
3.2.10 The Administrator shall ensure the availability of administrative systems, information systems and
management capability, which systems may include, but not be limited to, financial reporting, a scheduling
system, billing systems, medical records system, purchasing and materials management, compliance
reporting, and quality improvement.
3.2.11 Each Licensed Healthcare Operator having more than one (1) person designated at the same time as an
Administrator, it shall have policies in place that clearly delineate the respective roles and responsibilities
of each of the Administrators.
3.2.12 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall appoint a
Clinical/Dental/Medical Director with full time responsibility for oversight of all clinical services to ensure
safe and quality healthcare service delivery.
3.2.13 The Medical Director shall be a Licensed Physician except where Clinical Services provided are restricted
to Clinical Support Services where a Licensed Allied Healthcare Professional practicing within the
approved service shall be the Clinical Director. The Dental Director shall be a Licensed Dentist.
3.2.14 The Clinical/Dental/Medical Director may be an Administrator.
3.2.15 The Clinical/Dental/Medical Director shall ensure that all relevant and required clinical policies,
standards and guidelines are adopted and complied with.
3.2.16 The Clinical/Dental/Medical Director shall facilitate and participate in the development of the Licensed
Healthcare Operator’s practice and clinical governance, with particular emphasis on clinical risk
management, clinical audit, medical records documentation, medical staff competencies and performance
evaluation.
3.2.17 If applicable, the Medical Director shall ensure that any visiting doctor is assisted by appropriate qualified
medical staff that can provide care to the patient when the visiting doctor is not available.
3.2.18 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall comprehensively and
clearly define in writing the qualifications of its Clinical/Dental/Medical Director, the Director’s clinical
and management responsibilities, and schedule of time during which the Director is to be physically
present at the location(s) of the Outpatient Clinical Service Healthcare Operator.

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 STANDARD – OUTPATIENT CLINICAL SERVICES
3.2.19 If applicable, each Outpatient Clinical Service Healthcare Operator shall appoint a Licensed Nurse as the
Senior Nurse to support the Administrator and/or Clinical/Dental/Medical Director in creating clinical
protocols and guidelines, leading the nursing practice at the Outpatient Clinical Service Healthcare
Operator, managing the nursing staff component, ensuring nursing staff’s competencies, and developing
the Outpatient Clinical Services’ nursing practice.
3.2.20 All Licensed Healthcare Professionals shall be currently certified in basic life support (BLS).
3.2.21 Each Licensed Healthcare Operator shall determine the associated clinical risk in the provision of the
Outpatient Clinical Services provided and ensure the availability of adequately trained and certified
Licensed Healthcare Professionals in resuscitation procedures such as Advanced Cardiac Life Support
(ACLS) and Pediatric Advance Life Support (PALS) as appropriate.
3.2.22 In addition to current certification, a reasonable level of proficiency by certified BLS, (ACLS and PALS as
appropriate) Healthcare Professionals must be maintained for readiness and preparedness to provide
unified collaborative emergency services.
3.2.23 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall ensure qualified
individuals to oversee the planning and implementation of the facility management program to reduce
and control risks in the care environment.
3.2.24 If applicable, the roles and responsibilities of any student personnel attending the Licensed Healthcare
Operator, must be clearly defined and clarified in writing. Approval shall be obtained from DHCR to have
a trainee or student attending the Licensed Healthcare Operator.

3.3 PATIENT MANAGEMENT

3.3.1 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall manage patients care in
accordance with these Standards, the Outpatient Clinic Standards and all other applicable laws,
regulations, standards and policies.
3.3.2 A patient shall be accepted for healthcare services based on whether the Licensed Healthcare Operator’s
scope of clinical activities, services and availability of suitably qualified and licensed healthcare
professionals can meet the patient’s needs.
3.3.3 Patients who are at undue risk for complications or who are not eligible for Outpatient Clinical Services
shall be referred to an appropriate facility for further management and care.
3.3.4 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall have a process for
obtaining findings from relevant outside assessments and incorporating them into the patient
assessment process. Assessment findings shall be integrated and documented in the patient’s record and
readily available to those responsible for the patient’s care.
3.3.5 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall have effective and
efficient scheduling processes to minimize cancellation and delays, and reducing waiting times.

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3.3.6 Appropriate and effective clinical laboratory, radiology and imaging services must be provided. If on-site
services are not utilized, written contractual agreements shall be in place from accredited ancillary
services to provide support and services.
3.3.7 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall make provisions for
appropriate and separate facilities for care and management of pediatric patients.
3.3.8 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall ensure that all patients
are provided with relevant information at every phase of management making sure that the patient
and/caregiver fully understands the information given. It shall also foster a safe environment in which
questions are welcomed and feedback provided.
3.3.9 Each Licensed Healthcare Operator providing Outpatient Clinical Services prior to referral or transfer of
a patient shall ensure that the patient or their representative is informed and educated about his or her
follow-up care, treatment, and services. When appropriate the patient shall be informed in the presence
of the responsible person who is to escort and provide care at the home.
3.3.10 Standardized handover communication processes for correct information handling between internal and
external parties must be in place to ensure safe, efficient and effective patient care. Critical information
must be verified so that both parties (sender and receiver) have the same understanding of the patient
or environment condition.

3.4 HEALTH INFORMATION MANAGEMENT

3.4.1 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall comply with DHCA
regulations, policies and standards for the management of patient health information and medical
records.
3.4.2 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall ensure the confidentiality
of patient health information as per the provisions of the DHCA Health Data Protection Regulation Numb
(7) of 2013.
3.4.3 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall plan and design
information management processes to meet internal and external information needs. It shall ensure that
the data and information needs of patients are met timeously in a format that satisfy user expectations
and with the desired frequency.
3.4.4 Standardized diagnosis codes, procedure codes, symbols, abbreviations, and definitions must be used.
3.4.5 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall effectively manage the
collection of health information. It shall also retrieve, disseminate, and transmit health information in
useful formats.
3.4.6 Written documents, including policies, procedures, and programs, are managed in a consistent and
uniform manner.

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3.4.7 All Licensed Healthcare Professionals involved in the care of patients should have access as necessary to
patients’ health information to plan, provide and document the care delivered.
3.4.8 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall ensure that all patient
Health Information is documented on official forms with the Healthcare Operator’s name.
3.4.9 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall ensure documented
evidence in a patient’s medical record of any referrals to external healthcare services, Informed Consents
(if applicable), and related healthcare management and outcomes to maintain continuity of care.
3.4.10 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall meet all requirements for
timely and regular submissions of data and information to DHCR as per applicable DHCA regulations,
standards and policies.
3.4.11 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall report clinical and
managerial performance measures to Department Director to monitor and improve patient care and
outcomes as defined in DHCA Performance Measures Policy.

3.5 PATIENTS RIGHTS AND RESPONSIBILITIES

3.5.1 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall provide patients and
families with information regarding the DHCA Patients’ Rights and Responsibilities in accordance to
Schedule Two of the DHCA Governing Regulation Number (1) of 2013. This information shall also be
displayed in English and Arabic throughout all Outpatient Clinical Service Healthcare Operators for
patients and visitors to review.
3.5.2 Each Licensed Healthcare Operator providing Outpatient Clinical Services is responsible for providing
processes that support patients’ and families’ rights during care.
3.5.3 Patient consent to treatment shall be obtained through a process defined by each Licensed Healthcare
Operator and carried out by trained staff in a manner and language the patient can understand in
accordance to the DHCA Informed Consent Policy.

3.6 MINIMUM FACILITY REQUIREMENTS

3.6.1 To obtain and maintain a Clinical Operating Permit, each Licensed Healthcare Operator providing
Outpatient Clinical Services shall meet and comply with DHCA regulations, standards and policies for
minimum facility requirements.
3.6.2 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall comply with the minimal
facility requirements of the most current FGI Guidelines for Design and Construction of Hospitals and
Outpatient Facilities. The design shall make provision for accessible, efficient, and safe clinical care in a
secure, supportive and functional environment.
3.6.3 Each Licensed Healthcare Operator providing Pediatric services shall ensure appropriate provisions for
the separate management of pediatric patients and the needs of parents/caregivers.

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3.6.4 All examination rooms, dressing rooms, and reception areas are built and maintained in a manner that
ensures patient privacy during interviews, examinations, treatment, and consultations.
3.6.5 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall ensure that treatment
areas are of adequate size to allow for the presence of necessary equipment, patient and staff. It must
also allow for the presence of emergency personnel and equipment and the safe care and transfer of the
patient in case of a medical emergency.
3.6.6 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall ensure sufficient waiting
area spaces throughout the facility with layouts sensitive to specific cultural needs.
3.6.7 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall have suitable and secure
storage space for consumables, equipment, pharmaceutical drugs/products and medical records.
3.6.8 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall have sufficient and
appropriate equipment, instruments and supplies in compliance with applicable DHCR regulations,
policies, standards and procedures.
3.6.9 Appropriate radiological and laboratory equipment and support must be available either on site or
outsourced.
3.6.10 Radiological equipment shall be registered and licensed by the Federal Authority for Nuclear Radiation
(FANR).
3.6.11 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall maintain a written
preventive maintenance program for all equipment and related procedures.
3.6.12 If applicable, each Licensed Healthcare Operator shall have valid written agreements for contracted
services (e.g. hazardous waste removal, laboratory services, laundry, cleaning, sterilization, food services).
It shall have a process to assure that contracted services are monitored for quality and patient safety.
3.6.13 Utility systems must be routinely inspected, maintained, and improved.
3.6.14 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall have an Emergency
Management Plan to effectively and efficiently organize its communications, resources, clinical and
support activities, utilities, safety and security, and staff responsibilities.

3.7 QUALITY OVERSIGHT AND ACCREDITATION

3.7.1 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall be subject to the quality
oversight policies and standards of DHCR.
3.7.2 Each Licensed Healthcare Operator providing Outpatient Clinical Services is required to successfully
meet the applicable Outpatient Clinic Quality Standards and to obtain certification of successful
completion of the Quality Survey performed by the Quality Department of DHCR within (2) years of
commencing operations, and maintain such certification throughout the term of its Clinical Operating
Permit in accordance with the requirements of the DHCA Healthcare Operators Regulation number (4)
of 2013.

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3.7.3 Prior to commencing operations under its Clinical Operating Permit, each Outpatient Clinical Service
Healthcare Operator shall have in place written policies and procedures required for safe and effective
operation in compliance with the accreditation standards of the approved accreditation agency and all
applicable regulations, policies and standards.
3.7.4 All policies and procedures shall be consistent with the applicable provisions of the DHCR applicable
Regulations, Rules, Standards and policies and all other applicable Rules.
3.7.5 The policies and procedures shall include provision for regular review as well as making provision for
training of all staff of the Outpatient Clinical Service Healthcare Operator, both prior to and subsequent
to its becoming an Outpatient Clinical Service Healthcare Operator, on the content of the policies and
procedures.
3.7.6 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall appoint/assign
appropriate individual(s) to monitor, review and manage the quality of services provided in accordance
with the requirements of the DHCA Healthcare Operators Regulation number (4) of 2013 and all
applicable standards.
3.7.7 Each Licensed Healthcare Operator providing Outpatient Clinical Services shall establish and approve a
program for Quality and Safety that includes both patient and staff, and includes its Risk Management
and Quality Improvement activities.
3.7.8 All staff members shall continuously participate in risk management and quality improvement activities.
3.7.9 Each Outpatient Clinical Service Healthcare Operator shall report all sentinel events to the Department
Director as per the applicable DHCA Sentinel Event policy.
3.7.10 Each Outpatient Clinical Service Healthcare Operator shall plan for preventing and controlling infections
in accordance to the applicable Outpatient Clinical Quality Standards and/or other applicable standards,
policies and procedures.
3.7.11 Each Outpatient Clinical Service Healthcare Operator shall formulate policies and procedures that clearly
outline the management of medical emergencies and care. The Healthcare Operator shall ensure that
staff is educated and proficient in activation of the emergency plan to perform with confidence and
efficiency in responding to changes in a patient’s condition. This shall include documented evidence of
training and mock emergencies.

4 DEFINITIONS
4.1 DHCA: the Dubai Healthcare City Authority established under Article (4) of the Law, and comprises the
Chairperson, the DHCC Board of Directors and the Executive Body.
4.2 DHCC: Dubai Healthcare City.
4.3 DHCR: is the regulatory arm of Dubai Healthcare City Authority. An independent licensing and regulatory
authority for all healthcare providers, medical, educational and other business operating within DHCC.
4.4 FGI: Facility Guidelines Institute

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4.5 Informed Consent: a process of communication between a person and a physician or other healthcare
professional that results in the person’s authorization or agreement to undergo a specific medical
intervention. It includes the principle that a physician has a duty to inform his or her patients about the
nature of a proposed or alternative treatment, procedure, test, or research, including the risks and
benefits of each alternative and of not receiving it. An informed patient can then make a choice which
procedure, if any, to undergo.
4.6 License: means a license issued by the Licensing Board with regard to healthcare professionals and
Complementary and Alternative Medicine professionals or a license or permit issued by the Registry of
Companies with regard to companies, including Clinical Operating Permits, Non-Clinical Operating
Permits, Research Permits and Education Permits.
4.7 Outpatient Clinical Services: a Healthcare Operator providing any type of medical, day surgical, clinical
diagnostic, dental and clinical support service(s) that does not include an overnight stay.

5 REFERENCES
5.1 American College of Rheumatology, 2013 – 2016 Strategic and Functional Plans, USA.
5.2 Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care. Centre for
Disease Control, USA, 2011.
5.3 Healthcare Facilities Regulation - Outpatient Care Facilities, Ministry of Health, 2013, UAE.
5.4 Outpatient Clinic, Robert Carr, 2014. Accessed on 14th January 2016
https://www.wbdg.org/design/outpatient.php.
5.5 Outpatient Services Implementation Standard, Queensland Health, Australia, 2010.
5.6 Rehabilitation Agency/ Outpatient Physical Therapy Accreditation – Standards and Checklist, American
Association for Accreditation of Ambulatory Surgery Facilities, 2014.

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