‫قطاع التنظيـم الصحـي‬

Health Regulation Sector

Document Type: Policy Ref No: HRS/HPSD/CP/1/2019 Version Number: 1

Document Title: Clinical Privileging Effective Date: 1/4/2019 Revision Date: 1/4/2022

Ownership: Health Licensing Department

Applicability: All Health Facilities Licensed by Dubai Health Authority

1. Purpose:

1.1. To align with Dubai Health Authority (DHA) strategic objective to position Dubai as a global

medical destination by introducing a value-based, comprehensive, integrated and high-quality

service delivery system.

1.2. To enable all health facilities under the DHA jurisdiction to adopt a standardized framework for

granting and revalidating the clinical privileging of their Healthcare Professionals (HP).

1.3. To ensure all HP have an acceptable level of knowledge, skills, training and competence consistent

with requirements set out by DHA and international best practice to promote safety and high

quality of care.

2. Scope:

2.1. All DHA licensed Healthcare Professionals.

3. Definitions/Abbreviations:

CPC: Clinical Privileging Committee

DHA: Dubai Health Authority

HF: Health Facility

HP: Healthcare Professionals

Clinical Privileging is the process of giving a DHA licensed Healthcare Professional (HP) permission to

carry out specific duties as per health facility scope of practice and licensure. This involves the review of

Clinical Privileging Page 1 of 7 HRS/HPSD/CP/1/2019

 ‫قطاع التنظيـم الصحـي‬
Health Regulation Sector

credentials and qualifications, training, competence, practical independence and experience.

Grandfathering An external competent entity which shall oversee and support a health facility to meet

the requirements in certain services.

Medical Director is a DHA licensed physician who holds responsibility and oversight of medical services

and clinical operations within a DHA licensed health facility.

Medical Practice Committee (MPC) refers to committee formed by virtue of Executive Council

Resolution No. (32) Of 2012 to regulate the practice of medical professions in the Emirate of Dubai.

Monitoring and evaluation is the process of continuous gathering of information and data to support

decision making and appraisal of clinical practice and patient outcomes.

Reappointment of Privileges is the process of reviewing the physician or health professional privileging

within a three (3) year timeframe.

4. Policy Statement:

4.1. The Health Facility (HF) shall have in place a standardized, objective and evidence-based clinical

privileging system to privilege DHA licensed Health Professionals (HP) to treat patients and/or

to provide other clinical services consistent with this Policy. The clinical privileging system shall:

4.1.1. Ensure all Physicians and HP undergo clinical privileging within a three (3) year

timeframe.

4.1.2. Assure granted privileges are supported by international benchmarks and best practices.

4.1.3. Include the review of clinical competence, malpractice, incident reporting and patient

outcomes.

Clinical Privileging Page 2 of 7 HRS/HPSD/CP/1/2019

 ‫قطاع التنظيـم الصحـي‬
Health Regulation Sector

4.1.4. Assist in benchmarking high quality and safe care and support the identification of

professional practices and services provided to patients and their carers.

4.1.5. Track the status of all granted privileges with supporting evidence.

4.1.6. Align to the needs of the Clinical Privileging Committee (CPC) which is the responsible

entity to authorise or deny clinical privileges.

4.2. Clinical privileges that are granted by the CPC shall adhere to titles mentioned in Professional

Qualification Requirements (PQR), or any privileges mentioned in DHA regulations, policies, or

standards.

4.2.1. Clinical privileges shall be granted consistent with UAE Federal Laws and Regulations.

4.3. Clinical privileges shall be granted consistent with the clinical needs, resources and capacity of the

services provided within the health facility to ensure the delivery of safe and high-quality

healthcare services.

4.3.1. To assist in clinical privileging, the health facility shall ensure it has in place a written

service specification for each service line that includes the following:

a. Service name, type and scope

b. Level of service provision and description

c. Service operational times

d. Minimum staffing and resource requirements

e. Risk management and business continuity arrangements

f. Management structure, oversight and reporting arrangements

g. Service performance metrics

h. Staff job descriptions

4.4. The Health Facility (HF) shall ensure it has in place an active CPC supported by written terms of

Clinical Privileging Page 3 of 7 HRS/HPSD/CP/1/2019

 ‫قطاع التنظيـم الصحـي‬
Health Regulation Sector

reference. Membership of CPC shall include but not be limited to the following staff for

comprehensive assessment:

4.4.1. Chairman: designated clinical Head of Department, changing on a yearly basis.

4.4.2. Medical Director/Clinical Medical Officer – clinical admin.

4.4.3. Specialty specific Head of Department /Lead Clinician.

4.4.4. Head of Nursing.

4.4.5. Quality leader.

4.4.6. Secretarial support.

4.5. HF with more than Twenty (20) staff may adopt a grandfathering approach for clinical

privileging.

4.5.1. Grandfathering shall only be undertaken once both entities have signed a Memorandum

of Understanding.

4.5.2. The nominated facility to perform grandfathering shall have sufficient and competent

health professionals who are licensed by DHA or another competent health regulator in

the UAE.

4.5.3. Grandfathering shall be free from any conflicts of interest that may affect the issuance

of privileges.

4.6. HF with less than Twenty (20) staff shall obtain clinical privileging through their Medical

Director.

5. Responsibilities of the CPC:

The CPC shall be responsible for:

5.1. Documenting a transparent policy and decision-making process for the appointment,

Clinical Privileging Page 4 of 7 HRS/HPSD/CP/1/2019

 ‫قطاع التنظيـم الصحـي‬
Health Regulation Sector

reappointment or revocation of clinical privileges.

5.2. Determination and review of clinical privileges within their health facility.

5.3. Documenting its decisions and review dates.

5.4. Assuring there is no conflict of interest between applicants seeking privileges and committee

members.

5.5. Ensuring the scope and complexity of the privileges being sought are inline the health facility

scope and capabilities.

5.6. Assuring licensed Physician or HP documentation (credentials, qualifications, training,

competence, independence and experience) is sufficient to grant privileges as per international

benchmarks.

5.7. Obtaining periodic reports from the heads of units/departments to assure privileges granted

support the HP efforts to assure high quality and safe care.

5.7.1. Reporting shall be aligned with the HF documentation and records management system.

5.8. Issuing final decision to approve or deny clinical privileges.

5.9. Revoking HP clinical privileges at any time where there is justifiable reason that is supported by

documented evidence. Revocation of privileges shall be determined by the CPC and include the

following of scenarios:

5.9.1. Falsified or inaccurate documentation.

5.9.2. Serious underperformance.

5.9.3. Ongoing and unresolved ethical concerns.

5.9.4. Ongoing or unresolved staff or patient complaints.

5.9.5. Final malpractice decision determined by the Medical Practice Committee

5.9.6. Final negative decision determined by the Courts.

Clinical Privileging Page 5 of 7 HRS/HPSD/CP/1/2019

 ‫قطاع التنظيـم الصحـي‬
Health Regulation Sector

5.9.7. Contract Termination by the Health Facility or resignation of staff.

5.9.8. Termination of licensure by DHA.

6. Responsibilities of Applicants:

6.1. All applicants shall complete and submit an application form to the CPC on the privileges being

sought and reasons for review and consideration.

6.1.1. The application form shall include the privileges being sought and reasons.

6.2. All applicants shall provide evidence of their qualifications including registration and/or

equivalent training, experience and current competence for clinical privileges being sought. This

includes but is not limited to the following documents:

6.2.1. Active DHA license according to their scope of practice.

6.2.2. Relevant and up to date evidence of Continuing Professional Development (CPD)/
Continuing Medical Education (CME) as per the Unified Healthcare Professional
Qualification Requirements (PQR).
6.2.3. Clinical log book and approved privileges from the previous health facility.
6.2.4. Evaluation letter from the medical trainer if under supervision.
6.2.5. At least two supporting references (clinical expertise) must be submitted to CPC.

6.3. Applicants shall not apply for the clinical privileges prior to DHA licensure

6.4. Renewal of clinical privileges shall be sought three (3) months prior to the end of the three (3)

year period for clinical privileging.

6.5. The process of Renewal of clinical privileges after three (3) years should include the submission

of up-to-date documentation to justify the extent of privileges.

6.5.1. Applicants shall extend / re-apply for clinical privileges once all requirements

determined by the CPC have been satisfied.

Clinical Privileging Page 6 of 7 HRS/HPSD/CP/1/2019

 ‫قطاع التنظيـم الصحـي‬
Health Regulation Sector

7. References:

7.1. Alberta Health Services (2015). Guide to Medical Staff Credentialing, Clinical Privileging and

Appointment. Available at:

https://www.albertahealthservices.ca/assets/info/hp/phys/if-hp-phys-clinical-privileging-

guide.pdf (accessed at 6/8/2017).

7.2. Australian Council for Safety and Quality in Health Care (2002). National Guidelines for

Credentials and Clinical Privileges. Available at:

https://safetyandquality.gov.au/wp-content/uploads/2012/01/guide_cred_clin_priv.pdf

(accessed at 6/8/2017).

7.3. Health Authority of Abu Dhabi (2010). HAAD Standards for Clinical Privileging Framework.

Available at:

https://www.haad.ae/HAAD/LinkClick.aspx?fileticket=0IOZiGY_ERU%3d&tabid=819

(accessed at 6/8/2017).

7.4. Joint Commission International Accreditation Standards for Hospitals (2017). Staff

Qualifications and Education (SQE). 6th Edition.

7.5. Decree of the Executive Council no. (32) of 2012 concerning the regulation of practicing health

professions in the Emirate of Dubai.

Clinical Privileging Page 7 of 7 HRS/HPSD/CP/1/2019