Chapter 1: Governance

Chapter 1: Governance

1.1 Policy Statement

ARmed for Medical Training and Consultancy (LLC–OP.C, Abu Dhabi) shall maintain a comprehensive governance framework that clearly defines accountability, responsibilities, and reporting mechanisms for all CME/CPD activities. The governance structure ensures that:

  • All activities are compliant with the Department of Health (DOH) Abu Dhabi CME/CPD Quality Assurance Standards.
  • Education is independent from commercial influence.
  • Activities are aligned with the organization’s CME/CPD mission and DOH health priorities.
  • Documentation is ready for audit-ready and maintained for the required 6-year retention period.

DOH Reference: Provider Accreditation Criteria requires accredited providers to demonstrate mission, planning, integrity, and independence in CME/CPD activities.

1.2 Rationale

  • DOH Standard for CPD: mandates that providers maintain institutional policies reflecting leadership’s commitment to high-quality, evidence-based CPD.
  • DOH Healthcare Education Standards: emphasize the creation of a dedicated CME/CPD unit with defined reporting lines.
  • Activity Development Guide: highlights that CME planning must begin with practice gap analysis, validated by a governance body, and aligned to measurable changes in competence, performance, or outcomes.

Thus, a robust governance framework is essential for ensuring educational integrity, alignment with regulatory priorities, and continuous quality improvement.

1.3 Governance Structure

1.3.1 Chief Executive Officer (CEO)

  1. Strategic Leadership
  • Define and oversee the strategic direction of the organization in alignment with DOH Abu Dhabi healthcare priorities.
  • Ensure that CME/CPD activities contribute to national health workforce development and patient safety.
  • Approve annual business and training plans.
  1. Governance & Accountability
  • Ensure that the organization maintains a robust governance framework with clear reporting lines and accountability.
  • Provide oversight for the Scientific Director, CPD Officer, QA Officer, and IT/LMS Officer.
  • Represent the organization at the Board and regulatory level.
  1. Regulatory Compliance
  • Maintain compliance with DOH CME/CPD Quality Assurance Manual and all relevant UAE laws.
  • Ensure proper documentation, reporting, and audit-readiness of CME/CPD activities.
  • Sign off on final DOH accreditation reports and submissions.
  1. Resource Allocation
  • Approve budgets for CME/CPD activities, staffing, and IT/LMS infrastructure.
  • Secure funding and partnerships to sustain and expand organizational growth.
  • Ensure adequate human resources and capacity-building for staff and faculty.

 

  1. Quality & Risk Oversight
  • Ensure implementation of Quality Assurance policies (internal audits, CAPA, risk management).
  • Monitor organizational risks and ensure effective mitigation.
  • Promote a culture of continuous quality improvement and ethical practice.
  1. Final Approval Authority
  • Approve all policies, SOPs, and official documents before release.
  • Provide final approval of CME/CPD activity portfolios, accreditation applications, and reports to DOH.
  • Oversee decisions on conflicts of interest and commercial support agreements.

1.3.2 Scientific Director

  • Holds ultimate accountability to DOH for CME/CPD compliance.
  • Approves all activity content prior to delivery.
  • Provides annual governance and compliance reports to DOH.
  • Approve CME/CPD policies, manuals, and annual activity plans.
  • Validate alignment with DOH health priorities and population need.
  • Review evaluation data and ensure corrective actions are implemented.
  • Approve faculty eligibility and review COI disclosures.
  • Guarantee documentation and audit readiness.

1.3.3 CME/CPD Coordinator

  • Leads daily operations of CME/CPD activity planning and logistics.
  • Maintains the official CME/CPD database (attendance, evaluation results, certificates, faculty CVs).
  • Manages learner communication, registration, and reporting to DOH.
  • Ensures records are stored securely and compliant with data privacy rules.

1.3.4 Scientific Committee (changeable according to activity)

  • Validates need assessments and educational gap analyses.
  • Approves activity design, learning objectives, and methodologies.
  • Reviews curriculum relevance, scientific rigor, and faculty performance.
  • Encourages innovation (simulation, blended learning, e-learning) .

1.3.5 Reporting Lines

CME/CPD Coordinator → Scientific Committee → Scientific Director → CEO → DOH.

This structure ensures traceable accountability and clear escalation pathways for compliance issues.

1.4 Conflict of Interest (COI) Governance

1.4.1 Policy

All individuals in control of educational content (planners, faculty, reviewers) must disclose all financial relationships from the past 24 months with ineligible companies.

DOH Requirement: The provider must collect, review, mitigate, and disclose relevant financial relationships before the start of each activity.

1.4.2 Procedures

  1. Collection: COI Disclosure Forms required annually and per activity.
  2. Review: Oversight Committee reviews each disclosure to identify relevant relationships.
  3. Mitigation: If relevant, mitigation strategies (e.g., peer review, change of faculty, content review) are documented.
  4. Disclosure: Learners are informed of all relevant financial relationships, with the statement:

“All relevant financial relationships have been mitigated.”

  1. Prohibition: Logos, trade names, and product group messages are not allowed in educational content.

1.5 Escalation Pathways

1.5.1 Internal Escalation

  • Stage 1: Coordinator identifies non-compliance, logs into CAPA (Corrective Action/Preventive Action) register.
  • Stage 2: Scientific Director reviews and assigns action.
  • Stage 3: Oversight Committee monitors CAPA closure.
  • Stage 4: CEO is informed of unresolved or serious issues.

1.5.2 External Escalation

  • Serious breaches (e.g., commercial bias, inaccurate reporting, unethical practices) are reported to DOH within 10 working days.
  • DOH reserves the right to conduct random or complaint-driven audits at any time.

1.6 Documentation Control

  • Versioning: All documents carry identifiers, version numbers, and effective/review dates.
  • Retention: Attendance records and activity planning files kept for 6 years.
  • Storage: Hard copy (signed) + secure digital repository.
  • Access: Restricted on a need-to-know basis.
  • Audit-readiness: Providers must make documents available to DOH upon request.

1.7 RACI Matrix for Governance

Function

CEO

Scientific Director

Scientific Committee

Coordinator

QA

Policy Approval

A

R

C

I

C

Needs Assessment Validation

C

I

A/R

R

I

Faculty Approval

C

R

A

I

I

Content Approval

A

C

R

I

I

Evaluation Review

C

R

A

R

I

DOH Reporting

A

I

I

R

C

(A = Accountable, R = Responsible, C = Consulted, I = Informed)

1.8 Annual Review

The Governance Framework is reviewed annually by the Oversight Committee.
The review includes:

  1. Compliance Audit: Benchmark against latest DOH standards and policies.
  2. Effectiveness Audit: Assess meeting frequency, attendance, and closure of action items.
  3. International Benchmarking: Compare with ACCME best practices.
  4. CQI Plan: Update governance processes to integrate lessons learned from audits and evaluations.
  5. DOH Submission: Updated governance framework submitted to DOH upon request.

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