ADMIN DEPARMENTOIN

Document Title: Governance and management Policy

Document Ref. Number: ERMC001 Version Number: 1.0
Approval Date: JUN 2024 Effective Date: JUN 2024
Page No.: Page 1 of 5 Next review: JUN 2029
Revision History Nill
Document owner: Department of Medical ERMC
Applies to: ADMIN Department ERMC

1. Purpose
The purpose of this policy is to establish a framework for governance and management at Enfeld
Royal Medical Center in alignment with the Department of Health (DOH) guidelines. This policy aims
to ensure high standards of care, patient safety, and operational efficiency.

2. Scope
This policy applies to all staff, management, and board members of Enfeld Royal Medical Center.

3. Definitions
• Governance: The framework of rules, relationships, systems, and processes within and by
which authority is exercised and controlled in the hospital.
• Management: The process of dealing with or controlling things or people, specifically within
the context of healthcare delivery and hospital administration.

4. Governance Structure
4.1 Board of Directors

• Responsible for the overall governance of the medical center.

• Ensure compliance with DOH regulations and standards.
• Approve strategic plans, budgets, and major policies.
• Regularly review performance and risk management reports.

4.2 Executive Management

• Led by the Chief Executive Officer (CEO).

• Responsible for the day-to-day management of the medical center.

Enfield Royal Medical Center – Abu Dhabi

(A Trademark of RCS Group of Companies)
 ADMIN DEPARMENTOIN

Document Title: Governance and management Policy

Document Ref. Number: ERMC001 Version Number: 1.0
Approval Date: JUN 2024 Effective Date: JUN 2024
Page No.: Page 1 of 5 Next review: JUN 2029
Revision History Nill
Document owner: Department of Medical ERMC
Applies to: ADMIN Department ERMC

• Implement policies approved by the Board of Directors.

• Ensure that staff adhere to regulatory and accreditation requirements.

4.3 Committees

• Establish various committees (e.g., Quality and Safety Committee, Audit Committee) to focus
on specific areas of governance and management.
• Committees report to the Board of Directors and provide recommendations for improvements.

5. Management Policies and Procedures

5.1 Strategic Planning

• Develop and maintain a strategic plan that outlines the vision, mission, and long-term goals of
the medical center.
• Engage stakeholders in the strategic planning process.

5.2 Risk Management

• Implement a comprehensive risk management program.

• Identify, assess, and mitigate risks to patient safety and organizational integrity.
• Regularly review and update the risk management plan.

5.3 Quality and Safety

• Establish a quality and safety management system.

• Monitor and evaluate clinical and non-clinical performance.
• Promote a culture of continuous improvement and patient-centered care.

5.4 Compliance

• Ensure compliance with all DOH regulations and standards.

• Conduct regular audits and inspections to identify areas for improvement.

Enfield Royal Medical Center – Abu Dhabi

(A Trademark of RCS Group of Companies)
 ADMIN DEPARMENTOIN

Document Title: Governance and management Policy

Document Ref. Number: ERMC001 Version Number: 1.0
Approval Date: JUN 2024 Effective Date: JUN 2024
Page No.: Page 1 of 5 Next review: JUN 2029
Revision History Nill
Document owner: Department of Medical ERMC
Applies to: ADMIN Department ERMC

• Maintain accurate and up-to-date records and documentation.

5.5 Human Resources

• Develop policies for the recruitment, training, and retention of staff.

• Ensure staff are qualified and competent to perform their duties.
• Provide ongoing professional development opportunities.

6. Accountability and Reporting

6.1 Performance Monitoring

• Regularly monitor and report on key performance indicators (KPIs).

• Use data to inform decision-making and improve service delivery.

6.2 Transparency

• Maintain transparency in governance and management practices.

• Communicate with stakeholders, including patients, staff, and the community.

6.3 Stakeholder Engagement

• Engage with patients, families, and the community to understand their needs and expectations.
• Incorporate feedback into the planning and improvement processes.

7. Review and Continuous Improvement

• Regularly review and update this policy to ensure it remains relevant and effective.
• Commit to continuous improvement in governance and management practices.

Enfield Royal Medical Center – Abu Dhabi

(A Trademark of RCS Group of Companies)
 ADMIN DEPARMENTOIN

Document Title: Governance and management Policy

Document Ref. Number: ERMC001 Version Number: 1.0
Approval Date: JUN 2024 Effective Date: JUN 2024
Page No.: Page 1 of 5 Next review: JUN 2029
Revision History Nill
Document owner: Department of Medical ERMC
Applies to: ADMIN Department ERMC

8. Approval and Implementation

• This policy is approved by the Board of Directors and is effective as of 19-06-2024.
• The CEO is responsible for the implementation of this policy.

Appendices

• Appendix A: DOH Regulatory Requirements

• Appendix B: Organizational Chart
• Appendix C: Committee Terms of Reference

Prepared by: AIMS

Approved by:

Enfield Royal Medical Center – Abu Dhabi

(A Trademark of RCS Group of Companies)