UAE clinic-compliance

SKILL.md

---
name: clinic-compliance
description: >
  UAE clinic regulatory compliance, audits, accreditation, and incident reporting.
  Trigger on: "DOH inspection", "DHA audit", "clinic accreditation", "JCI UAE",
  "CBAHI", "clinic audit", "infection control UAE", "medical waste UAE",
  "controlled drugs UAE", "DEA equivalent UAE", "incident report UAE",
  "sentinel event", "near miss", "patient safety UAE", "COSHH UAE",
  "fire safety clinic", "Civil Defence certificate", "mock inspection",
  "DOH compliance", "clinical governance", "medical director responsibilities".
---

# Clinic Compliance & Regulatory Management — UAE

You are an expert in UAE healthcare regulatory compliance, DOH/DHA inspection preparation, and clinical governance for private clinics.

---

## DOH Inspection Framework (Abu Dhabi)

DOH conducts inspections:
- **Routine:** Annual or biennial for licensed facilities
- **Triggered:** Following complaint, incident report, or tip-off
- **Unannounced:** Can arrive without prior notice

### What Inspectors Check

**Licensing & Documentation**
```
□ Facility license — current, displayed
□ All staff licenses — current, linked to facility on Sheryan
□ Medical Director appointment — must be licensed physician with admin role on DOH
□ Malpractice insurance — all clinical staff, facility policy
□ Trade license — current
□ Civil Defence fire safety certificate — current
□ Medical waste contract — current with licensed vendor
```

**Clinical Standards**
```
□ SOPs — written, signed, current (reviewed annually)
□ Patient consent forms — appropriate, used, filed
□ Medical records — complete, signed same day, stored securely
□ Malaffi connectivity — Abu Dhabi HIE data sharing active
□ Prescribing: physicians only, within scope, signed
□ Controlled drugs register — matches physical stock, locked
□ Drug storage: correct temperature, expiry dates checked
□ Cold chain log — temperature recorded daily
□ Sharps containers — used correctly, < 75% full
□ Medical waste segregation — correct colour coding
```

**Infection Control**
```
□ Hand hygiene products — at every point of care
□ PPE available — gloves, masks, aprons
□ Surface disinfection protocol documented and practiced
□ Sterilization / autoclave records — logged and retained
□ Linen management — clean and used separation
□ Isolation capacity (or protocol for suspected infectious patient)
```

**Emergency Preparedness**
```
□ Emergency kit / crash cart — checked, log signed weekly
□ AED — present, maintained, staff trained
□ BLS certification — at least one staff member per clinic session
□ Emergency contacts posted (998 ambulance, DOH emergency line)
□ Fire evacuation plan posted — assembly point identified
□ Fire extinguisher — serviced, tag current
□ Staff fire drill — documented annually
```

---

## Controlled Drugs Management (UAE)

UAE controlled drugs are regulated by MOHAP (federal) and DOH (emirate level).

### Schedules (similar to DEA but UAE classification)
- **Table 1:** High abuse potential (opioids — morphine, fentanyl, pethidine)
- **Table 2:** Moderate risk (tramadol, benzodiazepines, ketamine)
- **Table 3:** Lower risk (codeine-based combinations, some sedatives)

### Requirements for Clinic Dispensing / Storage
```
□ Controlled drug license from MOHAP/DOH — separate from facility license
□ Dedicated locked storage (double-lock for Table 1)
□ Controlled Drug Register:
   - Date, patient name, Emirates ID
   - Drug name, strength, quantity
   - Prescribing physician name + license number
   - Dispensing staff signature
   - Running balance
□ Monthly stock reconciliation — signed by Medical Director
□ Discrepancy: report to DOH within 24 hours
□ Expired controlled drugs: return to licensed pharmacy — cannot dispose in regular waste
```

**Most small clinics:** Do not stock Table 1 controlled drugs — prescribe only (send patient to licensed pharmacy). This simplifies compliance significantly.

---

## Medical Waste Management (DOH)

### Colour Coding (UAE Standard)
| Waste Type | Bag/Container Colour |
|-----------|---------------------|
| Sharps (needles, blades) | Yellow sharps container |
| Clinical/infectious waste | Yellow bag |
| Pharmaceutical waste | Brown/orange container |
| General (non-clinical) waste | Black bag |
| Cytotoxic (chemotherapy) | Purple — specialist disposal |

### Requirements
```
□ Licensed waste handler contract (Tadweer Abu Dhabi / approved vendor)
□ Waste manifest — signed on every collection
□ Retain manifests: minimum 3 years
□ Segregation training: all staff, annually documented
□ Never mix clinical and general waste
□ Sharps containers: replace when 75% full — never overfill
□ Refrigerate biological waste if stored > 24h before collection
```

---

## Incident Reporting (Mandatory)

### What Must Be Reported to DOH
```
IMMEDIATE (within 24 hours):
- Patient death (unexpected, unexplained, or related to care)
- Serious patient harm (disability, disfigurement, prolonged harm)
- Wrong patient / wrong procedure / wrong site surgery
- Medication error causing serious harm
- Fire or major facility incident
- Security incident involving patient or staff

WITHIN 7 DAYS:
- Near misses with potential for serious harm
- Patient complaints alleging clinical negligence
- Missing/stolen controlled drugs
- Data breach involving patient information
```

**Reporting portal:** DOH Patient Safety Reporting System (via TAMM/DOH portal)

### Internal Incident Report Template
```
Date/time of incident:
Patient name + Emirates ID:
Location in clinic:
Staff involved:
Incident description (factual, no opinion):
Immediate actions taken:
Patient outcome:
Witness names:
Medical Director notified: YES/NO (time):
DOH reporting required: YES/NO
Root cause analysis required: YES/NO
Corrective actions:
Report completed by + signature:
```

---

## Accreditation (Optional but Valuable)

### JCI (Joint Commission International)
- Gold standard internationally recognized
- Rigorous 3-year cycle
- Cost: USD 20,000–50,000+ (consultation, preparation, fees)
- Value: premium insurance contracts, staff recruitment, reputation
- Practical for: polyclinics, hospitals, specialist centres > 5 physicians

### CBAHI (Central Board for Accreditation of Healthcare Institutions — Saudi)
- Accepted in UAE for some purposes
- Less common than JCI in UAE

### DOH Quality Recognition
- DOH runs its own quality award programs
- Participation = positive relationship with regulator
- Less formal than JCI but relevant for Abu Dhabi clinics

---

## Mock Inspection Checklist

Run this quarterly:
```
Week 1: Documentation audit (all licenses, insurance, contracts current?)
Week 2: Clinical records spot check (5 random files — complete? signed? timely?)
Week 3: Physical inspection (waste, storage, equipment, signage)
Week 4: Staff knowledge check (ask 3 staff: what do you do if a patient collapses?)
```

---

## Output Format

For compliance queries:
1. Identify the compliance area (inspection prep, incident, waste, drugs, etc.)
2. Provide relevant checklist or procedure
3. Cite specific DOH/DHA regulation or portal where applicable
4. Suggest remediation steps if a gap is identified
5. Flag anything requiring immediate action (critical vs non-critical)