Hospital Regulation - Dubai Health Authority

1 Health Regulation DepartmentHospitalRegulation2012 Hospital Regulation Health Regulation DEPARTMENT Dubai Health Authority 2012 Hospital Regulation Page 2 of 96 Ref. No. HRD/HRS/FRU001 Table of Contents Acknowledgment 6 I. Scope 7 II. Purpose 7 III. Definitions 7 IV. Acronyms 10 CHAPTER ONE: LICENSURE AND ADMINISTRATIVE PROCEDURES 11 1.

2 Registration and Licensure Procedures 12 2. Hospital Name 13 3. Final Inspection and Issuing the License 13 4. Management Responsibilities 15 5. Compliance Review 15 6. Application for License Renewal 15 7. Temporary Suspension of the License 16 8. Voluntary cancellation of the License 16 9. Null and Void License 16 10. Changes/Modifications Requiring DHA Approvals 16 11. Renovations and Additions to Hospital Building 17 CHAPTER TWO: Hospital DESIGN REQUIREMENTS 18 12. General Design Considerations 19 13. Operation Theatre 20 14. Critical Care 22 15. Airborne Infection Isolation (AII) Room 23 16. Emergency Area 24 17. Delivery Suite 25 18. Inpatient Service Areas 26 19. Outpatient Areas 27 20. Clinical Laboratory 28 21.

3 Diagnostic Imaging 29 22. Pharmacy 30 23. Allied Health 31 24. Administration Area 31 CHAPTER THREE: Hospital STANDARDS 32 Hospital Regulation Page 3 of 96 Ref. No. HRD/HRS/FRU001 CLUSTER ONE: PATIENT CARE 33 25. Patient Assessment 33 26. General Care 33 27. Outpatient Care 34 28. Surgical Care 34 29. Obstetric and Gynaecology 35 30. Anaesthesia and Sedation Care 36 31. Critical Care Services 37 32. Emergency / Casualty Services 39 33. Discharge / Transfer Planning 41 34. End of Life Care 42 CLUSTER TWO: DIAGNOSTIC SERVICES 43 35. Clinical Laboratory 43 36.

4 Diagnostic Imaging 43 37. Blood Bank 44 CLUSTER THREE: SUPPORT SERVICES 45 38. Nutrition Services 45 39. Laundry Services 45 40. Sanitary Services 46 41. External Services 46 CLUSTER FOUR: SAFETY 47 42. Patient Safety 47 43. Infection Control 47 44. Pressure Ulcer Prevention 51 45. Patients Falls Management Program 51 CLUSTER FIVE: MEDICATIONS MANAGEMENT AND PHARMACY 52 46. Medications Management 52 47. Pharmacy 52 CLUSTER SIX: PATIENT AND FAMILY RIGHTS 54 48. Patient s Rights and Responsibilities 54 49. Patient Education 55 50. Linguistic Diversity 55 51. Disabled People Rights 55 CLUSTER SEVEN: Health INFORMATION MANAGEMENT 57 Hospital Regulation Page 4 of 96 Ref.

5 No. HRD/HRS/FRU001 52. Health Records 57 53. informed consent 58 54. Telephone or Verbal Orders 59 55. Retention of Health Records 59 56. Health Record Management 60 CLUSTER EIGHT: ADMINISTRATIVE STANDARDS 62 57. Monitoring Quality of Service 62 58. Hospital Accreditation 63 59. Risk Management 63 60. Complaint System 63 61. Reporting Sentinel Events and Major Incidents 64 62. Mortality Cases Reporting 65 63. Data Collection and Statistics 65 CLUSTER NINE: LEADERSHIP AND MANAGEMENT STANDARDS 67 64. Governing Body 67 65. Medical Director 68 66. Director of Nursing Service 69 67. Hospital Technical Committees 69 68. Credentialing and Privilege System 70 CLUSTER TEN: HUMAN RESOURCES MANAGEMENT 71 69. Human Resource Practices 71 70.

6 Medical Staff Minimum Requirements 71 71. Healthcare Professionals Certification Requirements 72 72. Health Care Workers Immunization Requirements 72 CLUSTER ELEVEN: FACILITY MANAGEMENT 74 73. Hospital Safety Management Systems 74 74. Fire Safety 74 75. Hazardous Substances and Dangerous Goods 75 76. Waste and Environmental Management 75 77. Medical Equipment and Supplies 76 78. Emergency and Disaster Management 77 79. Security Management 78 Appendix 1: Ventilators Specifications 79 Appendix 2: Sample of Triage Criteria 80 Hospital Regulation Page 5 of 96 Ref. No. HRD/HRS/FRU001 Appendix 3: Sample of DAMA Form 83 Appendix 4: Patient Safety Solutions 84 Appendix 5: DHA Statistical Data Reporting Format 90 Appendix 6: DHA nursing staff ratio requirements for General Hospital 92 Appendix 7: Matrix for Staffing Decision Making 94 Appendix 8: Health Care Workers Immunization Recommendations 95 References 96 Hospital Regulation Page 6 of 96 Ref.

7 No. HRD/HRS/FRU001 Acknowledgment Dubai Health Authority (DHA) is pleased to present the DHA Hospital Regulation which represents a milestone towards fulfilling the DHA strategic objectives in providing A world class integrated Health system that ensures excellence in Health and healthcare for the Emirate of Dubai and promotes Dubai as a globally recognized destination for healthcare . This Regulation places an emphasis on facility design and services criteria with a focus on quality of services and safety of professionals based on the local and federal laws in addition to international accreditation standards. Therefore, this document provides a base for the Health Regulation Department (HRD) to assess the hospitals performance in Dubai and to ensure safe and competent delivery of services.

8 It will also assist the hospitals in developing their quality management systems and in assessing their own competence to ensure compliance with DHA regulatory requirements and the United Arab Emirates (UAE) federal laws. The Hospital Regulation was developed by the Health Regulation Department (HRD) in collaboration with Subject Matter Experts whose contributions have been invaluable. The Health Regulation Department would like to gratefully acknowledge those professionals and to thank them for their dedication to quality in Health and their commitment in undertaking such a complex task. The Health Regulation Department Dubai Health Authority Hospital Regulation Page 7 of 96 Ref.

9 No. HRD/HRS/FRU001 I. Scope This Regulation applies to every Hospital inclusive of both General and Specialty hospitals subject to licensure under the Dubai Health Authority (DHA) establishment law which includes governmental and semi governmental, private hospitals and hospitals operating in free zone areas. The DHA reserves the right to amend the Hospital Regulation stipulated herein without prior notice; the latest version of the Regulation shall be published in the DHA website II. Purpose The DHA is the sole responsible entity for regulating, licensing and monitoring all healthcare facilities and healthcare professionals in the Emirate of Dubai .

10 Through the development, establishment, and enforcement of this Regulation , which matches best practices for operating Hospitals, the DHA will ensure provision of the highest levels of quality and healthcare services at all times. III. Definitions Accreditation shall mean that process of evaluation conducted by international accredited organizations approved by the International Society for Quality in Health Care (ISQua) in which certification of competency and quality of service is given to a hospitals. Adverse Event shall mean any unanticipated, undesirable or potentially dangerous occurrence in a Health care organization. Assisted Reproductive Techniques (ART) shall mean the process of intercourse is bypassed either by insemination (for example, artificial insemination) or fertilization of the oocytes in the laboratory environment ( , in vitro fertilization).