Bespoke Health Consultancy
A UAE Medical Director is legally accountable for the clinical governance of the facility named on their licence. This briefing covers the six duties inspectors will test against, the governance artefacts you must maintain, the DHA and DoH expectations that differ from other jurisdictions, and how to protect your personal licence when acting as MD.
The MD role in the UAE is a personal, licensed appointment — accountability cannot be delegated.
DHA and DoH both expect a working clinical governance system, not just documentation.
MDs should hold a monthly evidence review and a quarterly clinical governance committee.
Personal licence protection depends on documented dissent and escalation when governance is compromised.
Six duties every UAE MD is judged against
Regulators do not test MDs on personality — they test them on evidence. Six duties recur in every inspection: policy oversight, incident management, clinical audit, professional standards, patient safety and complaints learning.
Each must be evidenced with dated artefacts. Absence of dated evidence is treated as absence of the duty.
Clinical governance artefacts you must maintain
- Live incident register with root cause analysis on serious events - Rolling clinical audit calendar with closed-loop actions - Morbidity and mortality reviews recorded and signed off - Complaints log with actions and lessons - Policy library with review dates and version control - Clinical KPI dashboard reviewed monthly
DHA-specific expectations
DHA inspections are unannounced. NABIDH real-time privacy audits (April 2025 update) check EMR consent documentation during the visit. MDs must ensure consent forms and EMR access controls are live, not template.
EJADAH KPI reporting across 30 therapeutic indications is the MD's responsibility to sign off. Personal PQR 2025 status must remain current.
DoH-specific expectations
DoH inspections are announced but structured. JAWDA PC V9/2026 and PC V1 (Q3 2026) quarterly submissions require MD sign-off. PXS 2026 patient experience survey compliance is mandatory for outpatient facilities and reports up to the MD.
Malaffi integration issues will be attributed to the MD as clinical governance owner, even if technically caused by the EMR vendor.
Protecting your personal licence
Where an owner or CEO overrules a governance recommendation, document the dissent formally — minuted, dated and communicated in writing. UAE MDs have lost licences in cases where they failed to record objections to clinical decisions they disagreed with.
Never sign off KPI or audit returns you have not personally verified.