Our MISSION AND VISION - SEHA

Letter to Employees 

Dear Colleagues, 

Emiri Decree No. 10 of 2007, which established 

Abu Dhabi Health Services Company PJSC 

(SEHA), set out a number of goals and 

responsibilities of the new organization. 

Implied in these responsibilities is a duty of 

SEHA and its employees to always do the 

right thing when it comes to taking care of 

our customers and communities whom we 

serve. 

That is what these Standards of Conduct are about: 

knowing what the right thing is and then doing the right thing. 

As a healthcare worker, we know you take pride in what you do every day. 

You make a difference in people’s lives. There is great satisfaction in our work 

and we know you feel the same. 

You also know that our patients rely on us and their families entrust their loved 

ones to us and look to us to care for them in the same way they would if they 

had your skills and knowledge. The healthcare community is unique in this 

regard. We choose to apply the healing arts to serve others. It is a commitment 

to caring and our compassion that binds us together as colleagues and unites 

us in purpose. 

Our commitment to our patients means we have other obligations – to each 

other, to our partners, vendors and other parties who do business with us 

and our professional and other colleagues from other organizations and 

institutions who work in our corporate office and hospitals – and they to us. It 

also means that we must support one another as we render care, celebrate 

when we achieve a goal and at the same time make corrections or alert 

someone immediately when we have or become aware of a problem or an 

error. We cannot allow any of us to fail in our duty to our patients, as doing 

so may put them at risk and erode the trust which they have placed in us and 

which we have worked hard to earn. This will reflect poorly on our reputation, 

character and values and harm the pride we have in our organization and 

ourselves. 

behavioral rules we must apply every day in order to win the trust of those 

who have an interest in our company. Without exception, the Standards apply 

to every SEHA employee as well as all others who may work on behalf of or 

for the benefit of SEHA such as our vendors, suppliers, consultants, trainees, 

volunteers and our corporate board of directors. The Standards are a formula 

of necessary behavior to protect our patients and customers, their families, 

each other and each of our stakeholders. Unless we follow these Standards 

of Conduct we believe we cannot reach our mission of providing world-class 

healthcare. 

That is why we need to support each other in maintaining the Standards of 

Conduct. Never assume that something is someone else’s responsibility or 

that your manager or someone in a more senior position is aware of every 

situation you find concerning. We must all embrace the Standards and see 

that we each live up to its tenets. When in doubt, apply the following test: 

if you were to take an action that was questionable, would you like to see 

your picture and name in the newspaper the next day describing what you 

did Would the article praise your action or describe it as illegal, unethical or 

harmful to a patient, customer, a fellow employee or our stakeholders When 

in doubt, ask for guidance. We are all together in our mission and we succeed 

and fail as one. Our patients are relying on all of us. 

Our spirit as an organization comes from within each of us. I am proud to be 

a SEHA employee as I hope you are. We ask that you study these Standards 

of Conduct and make it part of your every-day work life. 

Sincerely, 

H.E. Saif Bader Haji Al Qubaisi 

Chairman 

Carl Vincent Stanifer 

Chief Executive Officer 

That is why we must exercise appropriate and ethical decision-making at all 

times and constantly focus on doing what is right and what is required of us. 

The Standards of Conduct outlined in the following pages describe the set of

Contents 

Purpose of our Standards of Conduct 

Our Mission and Vision 

Leadership Responsibilities 

Patient Care and Medical Treatment 

Outsourced Management of Hospitals and Services 

Medical Staff Rights and Obligations 

Patient Rights 

Conflicts of Interest 

Patient Information 

Work-Place Conduct 

Accurate Billing 

Medical Research 

Fraud and Misconduct 

Organisational Information and Property 

Accreditation and Regulatory Compliance 

Financial Accounts and Reporting 

Marketing and Advertising 

Regulatory Risk Management and Compliance Program 

Acknowledgment 

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3 

5 

7 

11 

15 

19 

23 

27 

29 

33 

37 

41 

45 

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53 

55 

57 

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PURPOSE OF OUR 

STANDARDS OF CONDUCT 

PURPOSE OF OUR STANDARDS OF CONDUCT 

Commitment and Common Purpose 

SEHA is committed to its employees, patients and shareholder, the Government 

of Abu Dhabi. As an organisation SEHA is made up of individuals bound by a 

common purpose and sharing a set of values and goals. The purpose of the 

Standards of Conduct is to identify and express on behalf of its employees 

those values and goals. It is what binds us together as colleagues, co-workers 

and individuals who wish always to do the right thing and as such build and 

maintain an organisation committed to the interests of its stakeholders. 

Guideline Relevant to our Work 

However, we believe that it is not enough to simply state general principles of 

how we must act. We must translate these general principles into guidelines 

that are relevant to our areas of work and responsibilities. We understand 

that every individual even when wanting to do the appropriate thing faces 

a multitude of conflicting choices in his or her work and the goal of these 

Standards of Conduct, along with the policies referred to herein, is to help 

guide us as to the proper actions which will be consistent with our agreed 

ethical standards, SEHA values and policies, strategic objectives and goals 

and the laws and regulations to which we are subject. 

Shared Responsiblity 

We also recognize that we have a shared interest in ensuring that our fellow 

colleagues and our partners with whom we contract to assist us in carrying out 

our functions act in accordance with these Standards. It is therefore necessary 

that in addition to helping us understand what we are supposed to do, we 

receive the proper amount and type of training and education, tell someone 

when we observe someone who is not following our shared Standards (or 

systems which might encourage others not to follow the Standards), take an 

action when we see something that is wrong and determine why and how we 

can continually improve our consistency with the Standards. 

Condition of Employment and Association 

Because we believe that these Standards of Conduct are critical to achieving 

our mission and vision, they are a condition of employment and association 

with SEHA and each of us, whether a director, officer, employee or contracting 

partner must sign an Acknowledgment that we have read, understand and 

will reflect these Standards in our daily work and services to SEHA and our 

patients. 

1 

Abu Dhabi Health Services Company PJSC ( SEHA ), Standards of Conduct 


2

Our 

MISSION AND VISION 

OUR MISSION AND VISION 

SEHA was formed by the Government of Abu Dhabi in 2007 after it made 

a transformational decision to provide world-class healthcare to the citizens, 

residents and visitors of Abu Dhabi and the Middle East region. 

The creation of SEHA (along with Health Authority – Abu Dhabi, the health 

regulatory framework, the National Insurance Company - Daman and the 

health insurance laws) was one of the key steps in this plan. This therefore 

is SEHA’s mission: to continuously improve customer care to recognized 

international standards. 

In order to realise our mission, we must believe in and demonstrate the 

following values, which are at the core of our Standards of Conduct: 

• SEHA is an ethical organisation, meaning that before we take any action we 

ask ourselves “is this the right thing to do” 

• SEHA is a patient-centered organisation, meaning that before we take any 

action we ask ourselves “is this what is best for the patient (or our patients 

in general)” 

• SEHA is an innovative organisation, meaning that before we take any action 

we ask ourselves “is there a better way of doing things” 

Where we are required to take an action or make a decision in our work which 

is not referred to in the Standards, we may use these values to guide us as to 

the proper action or decision. 

While each of our SEHA corporate office and healthcare facilities or business 

entities (including Ambulatory Healthcare Services Division, Al Ain Hospital, 

Al Gharbia Regional Hospital, Al Rahba Hospital, Corniche Hospital, Mafraq 

Hospital, SEHA Dialysis Services, SEHA Revenue Cycle Management Services, 

Sheikh Khalifa Medical City and Tawam Hospital) may have its own identifiable 

mission and vision and expression of ethical principles, these must all be 

consistent with and support the principles expressed above. In this way we 

can ensure that through our collective efforts we will achieve our goal to 

become a world-class healthcare organisation. 

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4

LEADERSHIP RESPONSIBILITIES 

LEADERSHIP RESPONSIBILITIES 

The Standards of Conduct apply to every SEHA employee. However, because 

of their special position within the organisation, SEHA leadership consisting of 

directors, officers, department heads, supervisors and managers must lead 

by example and demonstrate every day and in every action consistency with 

not only the letter but the spirit and intent of the Standards. 

Leadership Standards 

Managers must, in fulfilling this obligation, ensure that those under their 

responsibility: 

• Comply with the Standards of Conduct 

• Have the necessary resources, training and information to be able to 

perform their tasks in accordance with the Standards 

• Feel able to come to their manager to discuss any issues regarding the 

Standards, including potential non-compliances by the employee or another 

person 

• Create and encourage an environment in which proper ethical and legal 

conduct exhibited by the Standards is the standard way of conducting their 

everyday activities 

Management of Our Valued Staff 

In managing their team and carrying out the work of their department, 

managers must always ensure that their team has the necessary information 

to make decisions, seeks advice and information from other departments on 

a timely basis, practices transparency in decisions and the information on 

which such decisions are based and demonstrates teamwork both within and 

across departments. 

Managers must treat their employees with respect, courtesy and with a view to 

the professional and personal development of employees. The success of SEHA 

depends on allowing each employee to utilize his or her talents within their job 

scope to the fullest extent possible along with the appropriate freedom and 

responsibility to act within such job scope. SEHA human resources maintains 

policies regarding performance management and career development and 

managers must understand and apply these policies in respect of employees 

they manage. 

5 

Special training and educational programs for managers of the corporate 

office are provided by the Human Resources Department to ensure that our 

managers have excellent leadership skills and have the tools and guidance to 

be able to achieve these requirements. Leadership training is also provided to 

the managers of our SEHA healthcare facilities through their respective Human 

Resources Departments. Any manager who feels that he or she needs or would 

benefit from additional training, advice or assistance in relation to managing 

staff are encouraged to contact their Human Resources Department to discuss 

with one of our human resources professionals the resources available to 

them. 

Abu Dhabi Health Services Company PJSC ( SEHA ), Standards of Conduct Abu Dhabi Health Services Company PJSC ( SEHA ), Standards of Conduct 6

PATIENT CARE 

AND MEDICAL TREATMENT 

PATIENT CARE AND MEDICAL TREATMENT 

SEHA is committed to providing quality and predictable outcomes of care to 

each of its patients in a compassionate, respectful and culturally sensitive 

manner. 

Joint Commission International and Accreditation Standards 

SEHA has committed to have its facilities accredited by Joint Commission 

International, an international healthcare accrediting organisation. Each 

employee of an accredited facility must act in accordance with current Joint 

Commission International accreditation standards. 

In carrying out its commitment to its patients, each SEHA healthcare facility 

has a quality department whose job it is to ensure consistency of treatment 

and care among its patients. Each medical department and service also has 

standard operating procedures and policies which are designed to incorporate 

the appropriate procedures into the actions and activities of the individuals in 

the department. These include policies implementing the International Patient 

Safety Goals developed by Joint Commission International, which help the 

facility to: 

• Identify patients correctly 

• Improve effective communication 

• Improve the safety of high-alert medications 

• Eliminate wrong-site, wrong-patient, wrong-procedure surgery 

• Reduce the risk of health-acquired infections 

• Reduce the risk of patient harm from falls 

Standard Procedures and Guidelines 

Each department will utilise and follow standard operating procedures and are 

expected to share best practices standard operating procedures among other 

hospitals and physicians within the SEHA healthcare system through the SEHA 

corporate office or directly with others. It is also the responsibility of the SEHA 

corporate office (through its clinical affairs and operations divisions) to facilitate 

and ensure that such best practices are being practiced and shared. 

SEHA has adopted the use of clinical guidelines and protocols which are 

intended to ensure consistency of treatment and predictability of clinical 

outcomes. Clinical guidelines are implemented after a prescribed process 

set forth in the SEHA clinical guidelines policy to ensure they reflect current 

best evidence-based practices. According to the policy, any deviation from 

the guidelines must be based on documented reasons and included in the 

patient’s medical record. 

7 


Adverse Medical Events 

Medical treatment is not a risk free endeavour and in the unfortunate event 

that an unanticipated adverse event occurs in treatment, our medical staff will 

remain open, honest and keep the patients’ and their families interest as the 

Abu Dhabi Health Services Company PJSC ( SEHA ), Standards of Conduct 8

primary concern and focus. Our hospitals have policies for communicating 

with patients in such circumstances and these policies must be followed by 

all employees. 

All SEHA healthcare facilities must comply with a sentinel events policy which 

requires them to report to SEHA corporate office and to the health regulator 

in accordance with applicable health regulation unexpected occurrences 

involving death or serious physical or psychological injury (including loss of 

limb or organ function) or the risk thereof (i.e. where injury did not occur but 

nonetheless a recurrence of the processes would carry a significant chance of 

a serious adverse outcome the next time). 

Each hospital must fully and fairly conduct a root cause analysis intended 

to identify causes and contributing factors to the sentinel event and every 

employee participating in the root cause analysis must provide all assistance 

as necessary in an open, honest and forthright manner to ensure learning from 

the event and to prevent a similar occurrence in the future. A SEHA corporate 

office Sentinel Events Committee comprising a multifunctional team reviews 

all sentinel events and root cause analyses to ensure consistency in approach 

and quality and to act as a central knowledge base to facilitate sharing of best 

clinical practices. 

Systems Reviews 

SEHA corporate office (through its Clinical Affairs Division) implements clinical 

system reviews which are scheduled according to an annual plan based 

on clinical priorities or conducted on an immediate basis when there is an 

indication of need for improvement in a particular clinical program or service. 

In addition to assisting in identifying areas for improvement, clinical system 

reviews also indicate areas of excellent practice which can be shared across 

SEHA healthcare facilities. Medical staff and management of SEHA healthcare 

facilities must cooperate fully with those conducting system reviews to ensure 

that the benefits of such reviews are realised. 

Any SEHA colleague who believes that the patient and quality standards set 

forth above are not being met has a duty to notify the appropriate persons 

(including their manager, quality supervisor) and follow up with regard to their 

concern until it has been satisfactorily addressed. 

SEHA has implemented University HealthSystem Consortium Patient Safety 

Net (UHC PSN®) for recording, assessing and remediating clinical and other 

adverse patient incidents (including medication errors). SEHA colleagues must 

report and follow-up on all patient incidents in accordance with the incident 

reporting and management policy. 

Clinical Data 

All SEHA medical facilities have implemented clinical dashboards. This display 

tool provides clinicians and decision makers within SEHA with relevant and 

timely information to inform daily decisions that improve the quality of patient 

care. 

SEHA has implemented or is in the process of implementing quality improvement 

initiaitves in order to collect and assess clinical outcomes, including American 

College of Surgeons National Surgical Quality Improvement Program (ACS 

NSQIP®), American College of Cardiology National Cardiovascular Data 

Registry Program (NCDR®) and The Society of Thoracic Surgeons (STS) National 

Database Medical and other staff are obligated to ensure that all information 

which is included in the dashboard (much of which is automatically captured 

electronically from the Health Information Management System) is reliable 

and accurate. 

9 



OUTSOURCED MANAGEMENT 

OF HOSPITALS AND SERVICES 

OUTSOURCED MANAGEMENT OF HOSPITALS AND SERVICES 

Certain SEHA hospitals and medical and administrative services are 

managed on behalf of SEHA by international healthcare and business 

management services companies through management services agreements 

with SEHA. 

Under these management arrangements the senior management of such 

hospitals and services, referred to as key personnel (such as the Chief Executive 

Officer, Chief Operating Officer, Chief Medical Officer, Chief Nursing Officer and 

Chief Information Technology Officer), are employees of the management 

services company. 

Needs of Patients and Hospitals 

These individual managers of such hospitals or services and the management 

services companies must at all times put the needs of the hospital or service 

and SEHA patients first. This means that they must always: 

• Be forthcoming with information when requested by authorised SEHA 

personnel 

• Utilize the resources of SEHA, the hospital or other business entity with care 

and efficiency 

• Manage the employees of the hospital or other business entity on an equal 

basis whether or not management company employees 

• Avoid conflicts of interest between their obligations as managers of the 

hospital or service and their employment with or actions on behalf of the 

management services company and in cases where conflict cannot be 

avoided, prefer the interests of patients and the hospital or other business 

entity. 

We recognize the detailed terms of the contractual relationship and believe 

this obligation and the foregoing principles to be consistent with such terms. 

Required Standards of Key Personnel 

Each such key personnel must read, understand and comply with the terms 

of the management services agreement, including the standards of care 

set forth therein. These standards are set forth in detail in the contracts, and 

require that their actions conform to the law, SEHA policy, Joint Commission 

International or other applicable accreditation standards (if accredited 

thereunder), applicable hospital contractual requirements and good healthcare 

(or other managed services) practice defined with reference to standards of 

world-class healthcare and those of the manager’s other owned or managed 

facilities (in certain cases) or otherwise a highly skilled efficient and leading 

provider of such services. 

11 Abu Dhabi Health Services Company PJSC ( SEHA ), Standards of Conduct 


OUTSOURCED MANAGEMENT OF HOSPITALS AND SERVICES 

Transparency 

The key personnel must in the performance of their duties to SEHA act at all 

times with transparency. This means that all decisions and actions taken by 

such personnel and the reasons for taking such decisions and actions must be 

open, made on a reasonable basis and be able to be disclosed upon request, 

including keeping or making proper records to support the foregoing. 

Steering Committee 

Each hospital or service managed by a management services company has a 

steering committee made up of representatives of SEHA and the management 

services company with the rights and responsibilities set forth in the agreement. 

The steering committee is the highest governing body representing the hospital 

or other business entity and is considered to be the steward of the hospital 

or business entity. As such, each representative of the steering committee is 

required to act in the best interests of the hospital or other business entity and 

acknowledges their fiduciary duties to the hospital or business entity in this 

regard. 



MEDICAL STAFF RIGHTS 

AND OBLIGATIONS 

MEDICAL STAFF RIGHTS AND OBLIGATIONS 

Our medical staff are one of our most valuable resources. The importance of 

SEHA’s medical staff in achieving its vision of providing world-class healthcare 

requires that we place significant obligations upon and also provide important 

rights and protections to our medical staff. 

Medical Staff By-Laws 

All medical staff are subject to the provisions of medical staff by-laws 

implemented at their medical facility. These by-laws are standardized to a 

material extent across the SEHA health system. The medical staff by-laws 

provide procedures for the employment, credentialing and privileging of 

medical staff. These procedures must be carefully followed by hospital 

management to ensure that only the most qualified physicians are employed 

by SEHA. 

The medical staff by-laws also provide procedures for suspension, discipline 

and termination relating to medical care provided by medical staff. These 

include standard due process rights of peer review, hearings and appeals in a 

case where the physician’s right to practice may be affected. 

Legal Representation 

SEHA understands that from time to time patients will feel the need to seek 

legal recourse in relation to the outcome of their medical treatment (whether 

the treating physician was negligent in such treatment or not). SEHA has 

implemented detailed procedures for the legal protection and representation 

of medical staff who become involved in such legal proceedings. This 

includes the commitment of SEHA’s legal professionals to accompany medical 

professionals to investigations conducted by governmental authorities (such 

as the health regulator) and court proceedings. This policy requires SEHA to 

pay for legal costs and judicially awarded damages for medical malpractice 

on behalf of the medical professional except in cases of gross negligence or 

intentional act amounting to criminal misconduct. 

Treatment of Medical Staff 

SEHA does not tolerate physical or verbal harassment of our medical staff 

by patients or their families, other staff or visitors to the hospital. We require 

that all such persons treat our medical staff with respect and courtesy at all 

times, even in cases of stressful events and occurrences. Healthcare facilities 

are required to have a written policy and procedures for reporting of such 

incidents to their heads of security, legal advisor and/or other appropriate 

persons (for serious incidents on a twenty-four hour, seven days a week 

basis) and employees are required to report all cases of physical and verbal 



MEDICAL STAFF RIGHTS AND OBLIGATIONS 

harassment to their supervisor immediately upon occurrence in accordance 

with such policy and procedures. SEHA commits to pursuing all legal remedies 

available against any person who commits criminal activities (such as assault) 

against our medical staff while performing their duties to SEHA. 

Medical Licenses and Privileges 

Medical staff who are required to maintain professional licenses, certifications 

or other credentials pursuant to health regulation or applicable law in order to 

practice are responsible for maintaining them in effect and must comply with 

all laws and regulations applicable to their professional practice at all times. 

Healthcare facilities must maintain effective processes and procedures for 

ensuring required licenses are in effect and appropriate privileges are granted 

and complied with. 

Providing Services in Non-SEHA Facilities 

All medical staff of SEHA (other than occasional visiting physicians and certain 

house staff such as interns and residents) are full-time employees of SEHA 

and are expected to devote their full-time medical practices to SEHA and its 

patients. Exceptions may be made on a case-by-case basis for physicians 

who are UAE nationals and approved by SEHA corporate office in accordance 

with human resources policy (see the Conflicts of Interest section below). 

Any member of the medical staff who receives any notification that his or her 

license or other credentials has been suspended or that he or she is under 

investigation shall immediately notify the medical director/ chief medical 

officer or other member of facility management. 

Reporting to Police 

As a result of the nature of their duties, SEHA medical staff are occasionally 

required to treat individuals who have been involved in or who are victims of 

conduct which may be subject to criminal laws. All medical staff are required 

pursuant to SEHA policy on reporting to the Abu Dhabi police to report crimes 

or suspected crimes immediately upon becoming aware of them (or aware 

of facts which may indicate the occurrence of the foregoing) regardless of the 

identity of the patient. These include (but are not limited to) the following: 

• Pregnancy of any woman who is not married or is a minor 

• Abortion or attempted abortion contrary to law (eg. procedure outside of a 

medical facility without a physician) 

• Drug abuse or addiction to an illegal narcotic 

• Assault, sexual assault with intent to commit rape or murder, manslaughter 

or battery, intentional act causing death 

• Motor vehicle accident 

• Injury caused by employment or otherwise related to work 

• Injury sustained in a physical assault or altercation or through the use of 

any weapon 

If an employee is unsure whether the facts of which they are aware constitute 

a crime, the facts should be reported accurately to hospital security and the 

facility legal department who can make a determination as to whether a crime 

has occurred or likely occurred and must be reported to police. 



PATIENT RIGHTS 


Non-Discrimination 

SEHA does not differentiate in the admissions or treatment of patients based 

upon gender, race, religion, national origin, disability or type or amount 

of insurance held by a patient. In particular, once a patient is admitted or 

registered clinical staff and other staff at a SEHA medical facility may not make 

any determination regarding the care or treatment of a patient based upon 

whether they are a self-pay patient, covered by basic insurance or any other 

type of insurance. 

Patient Basic Rights 

Each patient is provided with a statement of the patient’s rights upon admission 

to a SEHA healthcare facility. The expression of statement of rights differs 

among facilities however they provide for the following basic rights: 

• To be attended to on a timely and courteous basis upon entering the 

facility 

• To know the risks, benefits and alternatives to proposed treatments 

• To receive information in easy to understand terms that will allow for an 

informed consent or refusal of the proposed procedure or treatment, 

including medications 

• To be provided information about physicians or other clinicians who will be 

providing care to the patient 

• The right to a second opinion or to have their care transferred to another 

physician or healthcare facility if they are not satisfied with the care or 

medical opinion provided 

• To receive reasonable responses to reasonable requests for services 

• To leave the hospital against the advice of the attending physician 

• To examine and receive an explanation of the bill for services or consumables 

received 

• To receive a copy of their medical records 

• To have any complaint they may make acknowledged, fully investigated 

and be provided with a timely response 

• To be provided care at the end of their life which is respectful and 

compassionate 

Patients’ rights (other than in respect of care) also apply to persons who may 

have legal guardianship or responsibility for healthcare decisions on behalf of 

such patient. 

Patient Satisfaction and Complaints 

SEHA cares about its patients’ satisfaction with our services and we take their 

views and concerns seriously through monitoring patient satisfaction and 

responding to customer complaints. 



Each year SEHA conducts a satisfaction survey of individuals who have 

attended a SEHA medical facility as an inpatient or outpatient, receiving their 

input and ratings on a number of important criteria. The survey approach and 

questions are consistent from year to year in order to allow SEHA to compare 

results over a long-term time frame and accurately monitor and respond to 

trends which may occur in our services. 

SEHA (through the facilities or otherwise) maintains a customer complaints 

department assigned to receive and respond to customer complaints. A 

customer complaints policy sets out the required procedures and actions 

employees and those assigned to respond to complaints must take. The policy 

requires that SEHA staff respond fully and accurately to all patient complaints 

and to elevate complaints which are not addressed to the satisfaction of the 

patient. 

In accordance with our approach to patient complaints, employees are 

expected to treat all patient complaints with the utmost care and attention 

in a constructive manner in order to alleviate concerns of patients which can 

be addressed immediately and to ensure that future occurrences of service 

failures can be minimised or avoided or to improve upon services to meet 

patient expectations. 

Emergency Treatment 

SEHA maintains policies regarding the provision, in accordance with health 

regulation and applicable law, of emergency medical treatment to those who 

enter a SEHA facility. SEHA medical staff must, regardless of whether such 

patient is covered by health insurance or the ability of such patient to pay 

for medical treatment, provide all such care and treatment as necessary to 

stabilize the patient and ensure that no loss of life or permanent damage 

occurs and to obtain the best possible medical outcome for the condition. 

In emergency cases, medical screening may not be delayed to inquire about 

the patient’s ability to pay including obtaining or verifying insurance information 

or advising the patient of his or her financial responsibility for payment of 

services rendered if he or she receives emergency treatment. SEHA contracts 

with health insurers are consistent with the requirement to provide emergency 

treatment to beneficiaries without requiring prior guarantee of payment from 

the insurer. 


Under the bylaws of the Federal Law on Organ Transplant approved by the 

UAE Health Council of the Ministry of Health, physicians may follow a patient’s 

written directives in his or her will to donate organs following death. In certain 

circumstances such organs will be permitted to be donated upon the irreversible 

cessation of brain functioning due to injury or illness (considered death of a 

patient) which can only be determined by a committee of specialized physicians 

in accordance with the bylaws. The law and the SEHA policy implementing the 

law in this regard must be strictly adhered to by all medical staff. 

Obligation to Provide Public Medical Services 

As the public healthcare provider SEHA medical facilities must provide certain 

services regardless of whether they are able to make a profit or cover costs 

of such services. Examples of these services may include trauma, burn unit, 

emergency and VIP services. While it is anticipated that these services will 

be paid for by the Government of Abu Dhabi through a funded mandate all 

medical facilities and healthcare professionals must continue to provide such 

services to the same standards as other areas of care. 

Documentation of Medical Care and Treatment 

All care provided to patients must be properly documented and entered 

into the patient’s medical record as required by SEHA patient information 

confidentiality, management and security policy and professional standards 

(such as those of Joint Commission International). 

Registration and Discharge 

Optimal patient care as well as efficient utilization of hospital resources are 

required of each SEHA hospital. Achieving these requirements begins with 

proper patient admission and discharge procedures. Each SEHA facility has 

established policies for the admission, discharge and referral of all patients 

who present themselves for care. Admission staff must ensure that proper 

documentation in accordance with applicable law and facility policy is obtained 

and maintained regarding the medical condition, history and needs of each 

patient. 

End of Life and Organ Donation 

Currently under applicable law (consistent with Sharia law) medical staff are 

prohibited from ending a patient’s life for any reason, even if requested by the 

patient or his or her guardian or custodian on compassionate grounds. As 

such, advanced directives of a patient requesting non-resuscitation or other 

non-interventions will not be permitted to be acted upon by medical staff of a 

SEHA healthcare facility. 



CONFLICTS OF INTEREST 


External Personal and Financial Interests 

Employees have an obligation in performing their work to put the interests of 

SEHA ahead of their own personal and financial interests. As such, employees 

must not have or maintain any personal interest or financial interest which is 

incompatible or may appear to be incompatible with the interests of SEHA. 

Although it is not possible to list the possible ways in which a conflict of interest 

may arise, it may derive from knowing someone personally, having access 

to certain information, serving in more than one capacity or being personally 

involved in something. Some simple examples may include: 

• Being a board member or executive of a company which supplies products 

or services to SEHA 

• Having an interest in a personal or family business which competes with 

SEHA 

Employees may also be considered to have a conflict of interest if their offwork 

activities or obligations hinder or distract the employee from carrying out 

his or her work obligations. Examples of this may include: 

• Owning or being a partner in a business which requires devotion of a 

material commitment 

• Providing teaching services which take a significant amount of time 

If an employee believes that he or she may have a conflict of interest in respect 

of any material decisions to be made on behalf of the company, he or she 

must in accordance with SEHA’s conflict of interest policy report the conflict of 

interest to their legal or compliance officer and remove themselves from the 

decision making capacity. 

An employee wishing to undertake any activity which may or which may be 

considered to be a conflict of interest must get the prior approval of SEHA 

(through their legal or compliance officer who is required to keep a log of 

such requests and approvals). Approval of such activities will not excuse the 

expected level of performance of a staff in regard to their duties to SEHA. 

Employees who work in departments or functions which are at the greatest risk 

of conflicts of interest (such as procurement or others who interact regularly with 

vendors or make purchasing decisions) must complete an annual declaration 

disclosing any conflicts of interest in accordance with the company’s conflict 

of interest policy. 

Relationship with Contractors 

When conducting business with vendors or suppliers to SEHA, it is expected 

that employees will make decisions that are in the best interests of SEHA. 

Employees must maintain impartial relationships with SEHA’s vendors and 

other contracting parties and be motivated solely to acquire goods, purchase 

services and make other transactions on terms most favourable to SEHA. 



Care must be taken to avoid even the appearance of favoritism on behalf of a 

vendor or supplier due to personal or professional relationships. 

Accepting Gifts and Other Items 

Employees are prohibited from soliciting tips, personal gratuities or gifts from 

patients and vendors. Occasionally medical and other staff will be offered 

gifts by patients or contractors (including potential contractors). In certain 

cases (particularly in VIP patient services) these gifts may be significant. SEHA 

encourages the excellent service which may lead a patient or other party 

to express his or her gratitude by offering gifts. However, we must keep in 

mind the importance of not appearing to perform our medical services in the 

expectation of receiving any such gifts (other than the normal patient charges) 

or allowing any external rewards to affect the impartiality of our judgment. 

In this spirit, non-monetary gifts such as baskets of edible items, flowers, 

or promotional materials with low monetary value may be accepted if they 

appear to be genuinely and voluntarily offered, are shared among all relevant 

staff in the department (to the extent capable of being shared) and would 

not influence, or reasonably appear to others to be capable of influencing, 

the employee’s business judgment in conducting affairs with the patient or 

vendor. 

If the value of the gift is substantial or there is any question regarding whether 

the gift meets the standards referred to above, the employee must seek prior 

approval from his or her supervisor and/or the legal or compliance officer or 

refuse the gift and promptly return the gift to the contracting party or patient. 

Offering Gifts 

The rules for offering gifts by employees to others are the same as acceptance 

of gifts. As such, employees may not give to any person or firm who is 

conducting business with or who seeks to conduct business with SEHA any 

item of value except for those items noted above. 

Meals and Entertainment 

Building and maintaining good business relationships based on appropriate 

factors is recognized by SEHA as a valuable aspect of doing business. In the 

course of such relationships employees may be offered or wish to offer to 

others entertainment and meals. These offers may be made or accepted 

provided that they are reasonable in monetary amount (for example, AED 

300 per person) and frequency (for example, every two months or less) and 

there is a reasonable expectation among the employee and other party 

of reciprocation. Any question as to the reasonableness of an expenditure 

or offered expenditure should be discussed before acceptance with the 

employee’s supervisor in consultation with their legal or compliance officer. 

Medical Staff Commissions 

No medical staff or other employee may receive anything of value in return 


for utilizing a product, equipment, medication or consumable in his or her 

practice or at the facility. 

Vendor Sponsorship 

Attendance at conferences in which travel costs, hotel costs or other perquisites 

from such companies are paid by any company is permissible in accordance 

with the requrements of SEHA conflicts of interest policy regarding relevance 

of event to a business need and reasonableness of expenses (including 

entertainment and number of nights lodging) following the approval of a staff 

member’s supervisor and management. All requests and approvals must be 

reported to the legal or compliance officer who is required to keep a log of 

such requests and approvals. 

Patient Referrals 

SEHA requires that its physicians, medical staff and management provide the 

best care to patients without financial or other inappropriate considerations 

affecting any patient care decisions. SEHA maintains strict policies regarding 

the referral of patients to or from SEHA facilities. SEHA and its employees may 

not: 

• Pay any other person a fee or offer anything of value for referring patients 

to it 

• Receive a fee or accept anything of value for referring any patient to another 

healthcare provider or facility 

• Refer a patient to any healthcare facility or service in which the referring 

physician or medical staff or any member of his or her immediate family has 

a financial or ownership relationship, including for any healthcare services, 

such as laboratory, radiology, physical therapy or inpatient or outpatient 

medical services 

Outside Employment 

Department heads and managers above such level may not be employed 

by any other healthcare entity, contractor or supplier of SEHA while employed 

by SEHA. During personal (non-working) time other employees may work for 

other companies, including healthcare entities, contractors or suppliers to SEHA 

provided it does not interfere with or adversely affect their job responsibilities 

and performance with SEHA and is permitted by applicable law (including 

immigration laws). Currently, immigration law does not permit any person 

employed pursuant to a work visa to work outside of such person’s sponsorship 

including during time off or whether it is paid or unpaid (voluntary). 

Physicians employed by SEHA and who are UAE Nationals may in accordance 

with human resources policy practice in other medical facilities following their 

official SEHA working hours subject to approval by their SEHA medical facility 

and the Corporate Office (Clinical Affairs) and to the on-going conditions set 

out in the policy. 



PATIENT INFORMATION 

PATIENT INFORMATION 

Confidentiality 

In attending and being treated at a SEHA medical facility either as an 

outpatient or inpatient, information about the patient’s medical condition, 

history, medication, family background, treatment and personal and insurance 

information is requested from or recorded about the patient. A necessary 

condition for proper treatment is effective and open communication with 

patients, which is only possible if patients are confident that such information 

will remain confidential and will be properly used. 

SEHA maintains a detailed patient information confidentiality, management 

and security policy which reflects applicable laws and health regulations and 

best international practices and provides requirements and procedures as to 

how to maintain the confidentiality of patient information, who is permitted 

to have access to such information and how and under what circumstances 

such information may be disclosed. The policy defines confidential information 

as not only the written (or electronic) medical record but also observations and 

verbal communications regarding the patient and which identifies the patient 

or which allows a person receiving the information to determine the patient’s 

identity. 

In accordance with the policy, employees may only use, obtain and disclose to 

others confidential patient information: 

• Which is strictly necessary for them to perform their work function and for the 

purposes of treatment, payment or healthcare operations 

• Necessary for business purposes, such as implementing information 

technology systems or outsourced services arrangements, pursuant to a 

written confidentiality and use agreement 

• Required by a regulatory authority or judicial authority such as the court or 

police in an investigation pursuant to an official written request 

• Which has been consented to in writing by the patient 

Granting access to SEHA data systems (including those accessible to SEHA 

through the internet) by any means is prohibited except in accordance with 

the patient information confidentiality, management and security policy. 

Each facility has appointed a health information manager who is responsible 

for maintaining the procedures, documentation and systems relating to 

confidentiality and disclosure of patient information and ensuring the 

confidentiality of such information. 

Document Retention 

Patient records must be retained for periods set forth in the policy, depending 

upon the particular circumstances. This may be for a period of years or 

indefinitely (for example, in the case of United Arab Emirates Nationals). 

Employees should consult the patient information confidentiality, management 

and security policy before destroying any medical records. 



WORK-PLACE CONDUCT 


Discrimination and Harassment 

All employees have the right to work in a safe and respectful environment 

free of discrimination and harassment based on gender, nationality, religion, 

race or ethnic origin or other characteristics. All colleagues must treat each 

other with courtesy, fairness and respect. Inappropriate jokes, comments and 

other behavior based on such characteristics are also not permitted. SEHA 

will take all required action to fairly and objectively address complaints of 

discrimination, harassment or other forms of inappropriate behaviors. 

In addition, physicians, nurses or other hospital employees who observe or 

are otherwise made aware of disruptive behavior by a physician are required 

to document the behavior and report it to the facility human resources 

department, legal or compliance officer or a member of facility management, 

who must act on such report. Disruptive behavior is considered to be any 

conduct which disrupts the smooth operation of the hospital, poses a threat 

to patient care or exposes the hospital, SEHA or employees to liability or the 

potential for adverse effect on their reputation. 

Criminal and Dangerous Activities 

Criminal or dangerous activities are not permitted on SEHA or hospital property. 

All cases of such activity (including theft, assault and other violent behavior) and 

attempts at such activity must immediately be reported to the head of hospital 

security, facility human resources department, a legal or compliance officer or 

member of hospital management. No person is permitted to bring onto SEHA 

or hospital property any dangerous, harmful or potentially harmful weapons, 

devices or materials and employees are required to report any violation of 

this policy immediately upon becoming aware of such to the aforementioned 

persons. 

Substance Use and Mental Acuity 

In addition to adhering to the religious requirements of the United Arab 

Emirates, to protect the interests of our employees and patients SEHA is 

committed to an alcohol and illegal drug free environment. Non-permitted 

substances include alcohol, illegal drugs or prescription medication intended 

for another person or for a purpose not medically necessary at the time of 

taking such medication. 

All employees while on the job or SEHA premises must be free of any such nonpermitted 

substance or any substance which may impair the job performance 

or endanger the safety of any other person. 

It is recognized that employees may take prescription or over-the-counter 

medications from time to time to alleviate temporary medical conditions 

or symptoms. Such medications could, taken in the prescribed dose or 



excess dosage, affect or impair performance or skills required to do the job. 

Employees must act responsibly when taking such medications and if they 

become aware that such medication may be affecting their performance or 

tasks, immediately notify their supervisor and cease such activities. 


Health and Safety 

The health and safety of employees relating to their working environment and 

practices are of prime concern to SEHA. As such, SEHA maintains policies and 

procedures which are compliant with applicable laws and regulations intended 

to minimise workplace accidents and ensure a safe working environment. All 

employees must: 

• Become familiar with and understand how these policies apply to their 

specific job responsibilities 

• Comply with these policies and applicable laws and regulation 

• Abide by safe operating procedures and workplace practices and be 

responsible for guarding their own and their co-workers’ workplace safety 

• Report to their supervisor or safety officer any workplace injury or condition 

or practice they perceive to be unsafe, unhealthy or hazardous to employees 

or patients 

The corporate office and all business entities are required to maintain a safety 

management program. 



ACCURATE BILLING 


We make every effort to submit accurate and truthful bills for our services and 

we bill only for services that were actually provided and properly documented 

and coded. 

Accurate Coding and Billing 

We have implemented policies, procedures and systems to facilitate accurate 

coding and billing to insurance providers, government payers and individual 

patients. These policies are in accordance with healthcare regulation and the 

insurance law. 

All SEHA colleagues who are responsible for coding and billing for medical 

services provided by SEHA must adhere to these policies and procedures. We 

prohibit any employee from knowingly presenting or causing to be presented 

false or misleading claims for payment or approval or engaging or participating 

in intentional misrepresentation or deception intended to influence any 

entitlement or payment under any health insurance reimbursement agreement 

or scheme. Claims must reflect only the actual services ordered, documented 

and performed. Coding of diagnoses and procedures must be in accordance 

with applicable coding guidelines and procedures of health regulation. 

Management of healthcare facilities and revenue cycle management services 

are responsible for taking all necessary action to prevent coding and billing 

mistakes and duplication of claims. 

Discovery of Errors 

If an employee notices or becomes aware of an error on a bill, he or she is 

required to immediately notify a supervisor in their department or the billing 

department. An investigation is then performed and the bill is corrected. If 

the bill has already been submitted to the insurance provider, the insurance 

provider is notified and a refund is provided. If SEHA is notified by an insurer 

or other third party of an error in a bill, it will promptly investigate and correct 

such error. 

If the results of an investigation determine that an employee has negligently or 

dishonestly caused or contributed to a billing or reimbursement claims error, 

the employee will be subject to appropriate sanctions, including dismissal. 

On-going monitoring and auditing of billing procedures is required to be 

performed by the responsible managers at each facility and revenue cycle 

management services business entity (as applicable) and by internal audit 

in accordance with SEHA’s coding compliance program and accurate billing 

policies. 

Medical Records 

In support of our accurate billing, medical records must provide reliable 



documentation of the services we render. It is important that all individuals who 

contribute to medical records provide and record accurate information and do 

not destroy any information considered part of the official medical record. This 

includes physicians who must accurately, clearly and completely document 

their treatment and services in a timely manner. Each SEHA facility is required 

to provide sufficient training to physicians and other medical staff regarding 

proper medical entries and recording of medical treatment information. 


Funded Mandates 

SEHA expects to receive reimbursement from the Government of Abu Dhabi 

through The National Insurance Company – Daman, Department of Finance or 

other governmental authorities for certain programs and activities which may 

not be profitable but are required to be provided by SEHA as part of its public 

healthcare obligations. These “funded mandates” are based on cost estimates 

and projections prepared by SEHA facilities with the oversight and assistance 

of the corporate office. SEHA requires that all employees and individuals 

involved in preparing such funded mandates report all costs accurately and 

based on good faith estimates and complete and reliable data. 

All requests for reimbursement must not duplicate other costs which are 

reimbursed by the Government under another funded mandate or program, 

by a health insurer or billed directly to a patient. 

SEHA healthcare facilities and the corporate office will continue to review 

profitability of services in relation to these funded mandates and a healthcare 

facility may not terminate or reduce any services which are subject to such 

mandates without the approval of the corporate office. 



MEDICAL RESEARCH 


Ethical and Legal Standards 

SEHA hospitals and physicians sponsor and participate in medical research, 

investigation and clinical trials. The benefits of SEHA’s research program extend 

to patients and the field of medical research in Abu Dhabi, the United Arab 

Emirates and the Middle East. While we believe that it is important to obtain 

the benefits of such research, we also believe that it is equally important to 

conduct research in an ethical manner in accordance with all applicable 

health regulations and international ethical standards. 

Ethics and Research Committee 

SEHA maintains research policies which reflect the principles and requirements 

of ethical research and which protect the rights of patients and research 

subjects. Before any research is conducted which involves patients or other 

individuals as subjects, the sponsor of such research (the physician in charge 

of the research) must obtain approval of the hospital ethics and research 

committee or other committee designated to review and approve such 

research (sometimes also called the Institutional Review Board or IRB). 

Research Subject Rights 

The sponsor conducting the research must fully inform all individuals 

participating in research of their rights and important information regarding the 

research. These include the benefits, side effects, risks and discomforts which 

may result from the research, the alternatives to such treatment which may be 

available (in cases such as experimental drugs or treatments which may be 

the last resorted to option for certain patients), the right of the patient to receive 

timely information and updates regarding their current condition and the right 

to withdraw from research at any time. The individuals must be fully informed 

of the procedures to be followed during the research, particularly in cases 

of experimental research. Failure to participate or withdrawal from research 

may not prejudice or affect the right of the patient to continue to be treated by 

SEHA and its medical staff. Prior to conducting research, the individual must 

provide his or her written informed consent which must be retained pursuant 

to applicable SEHA policy and laws. 



Conflicts of Interest 

Researchers must not be subject to any conflicts of interest in conducting 

research. This means that they may not have any personal or financial 

interest in the outcome of the research and must not accept any gifts, financial 

rewards or incentives or other items of value from medical companies who 

may sponsor such research. 


Financial support for research studies from private industry (such as 

pharmaceutical companies and medical device manufacturers) while 

permissible under certain circumstances is subject to strict rules and 

requirements under SEHA’s research policies. 

Information and Intellectual Property Rights 

The publication and dissemination of the results of the research are subject 

to strict SEHA policies. Such results must be accurate, not misleading and be 

based on the results of the research study. 

All ownership and intellectual property rights arising from the research will be 

the property of SEHA, unless otherwise agreed with the researcher or sponsor 

of the research and all researchers will be required to enter into an agreement 

with SEHA providing for such intellectual property rights. 



FRAUD AND MISCONDUCT 


Harmful Effects of Fraud and Misconduct 

SEHA and its employees recognise the importance of detecting and preventing 

inappropriate or improper financial losses, including loss of financial 

opportunity, through intentional, negligent, careless or unintentional acts or 

omissions. 

We understand that such losses and the actions which cause them can 

individually or over time have serious negative and damaging effects on our 

business, employees and stakeholders through financial losses, damage to 

the reputation of SEHA and employees and loss of trust of SEHA’s stakeholders 

and the community. 

Fraud and Misconduct Policy 

SEHA has therefore through its policies and expectations set a zero-tolerance 

policy for all conduct which might lead to improper financial or other economic 

loss to SEHA and is either intentional or negligent. In order to effectively carry 

out its expectations, SEHA has fraud and misconduct policies which define the 

type of conduct which is prohibited and encourages employees and others 

who interact with SEHA to report suspected violations of the policies. The intent 

of the policies is to detect, prevent and respond to instances of fraud and 

misconduct. 

The actions which are prohibited under the policy are: 

• Fraud and Theft - misrepresentation or deception with the intention 

of inducing a person to act to his or her financial detriment and acts of 

common theft, including taking or appropriating property which belongs to 

the company or to which the company is entitled 

• Corruption - giving an advantage to a third party in a way inconsistent with 

one’s official duties or the interests of SEHA in exchange for some personal 

benefit 

• Bribery – accepting or giving (or offering to accept or give) a private benefit 

in exchange for official, public action 

• Misconduct - a violation of law, regulation, SEHA policy or unethical business 

conduct which causes or may cause economic harm or loss, including 

waste, abuse and failing to act with accountability, independence and 

honesty and integrity 

• Waste - thoughtless or careless expenditure, consumption, mismanagement, 

use, or squandering of SEHA owned or operated resources to the detriment 

of SEHA, either by action or inaction (such as lost opportunity) 

• Abuse - excessive or improper use of SEHA assets, using SEHA assets for 

one’s own gain or use or abuse of one’s position or authority for personal 

gain 



• Accountability – failing to make decisions or taking actions (a) in a transparent 

manner including with respect to the reasons for such decisions and actions, 

(b) on a basis which is supportable and reasonable and not arbitrary or for 

a purpose which is contrary to the best interests of SEHA and (c) on the basis 

of all information internally and externally reasonably required or available 

• Independence – failing to act in a manner which is independent (and with 

the appearance of independence) of SEHA contracting parties 

• Honesty and integrity – failing to act honestly, with integrity and otherwise 

in accordance with the Standards of Conduct in his or her work-related 

activities 

Reporting 

Employees and everyone working for or on behalf of SEHA are required to 

report any actual, suspected or potential occurrences of unethical actions, 

fraud and misconduct of which they become aware though any source of 

information. 

Employees and everyone working for or on behalf of SEHA 

are also encouraged to report anything of which they become aware which 

may indicate weaknesses or potential problems in policies, procedures or 

systems relating to fraud controls or which could indicate fraud risks. 


policies and fraud contorl policies will be carried out. If the investigation 

determines that fraud or misconduct has occurred, SEHA will take appropriate 

disciplinary actions against those who have committed or contributed to such 

acts. 

Use of Organisational Assets 

The assets of SEHA are to be used only for the benefit of the organisation. 

Each employee must ensure that organisational assets are used for proper 

purposes and not for the personal benefit of an employee. Assets include 

tangible assets such as physical plant, equipment, corporate funds, medicines, 

medical supplies, office supplies and intangible assets such as time, business 

information and strategies and financial data. 

Improper use or removal of any company assets, including transfer of any 

assets to another person for personal financial gain or otherwise than in the 

ordinary course of business, is considered to be a non-compliance with the 

Standards of Conduct. 

Use of telephones, printers, photocopies and internet during working hours for 

personal use must be kept to a reasonable minimum. 

Reports may be made by an employee to his or her direct supervisor or 

manager in his or her function or to the Corporate Compliance and Ethics 

Manager. Reports made to a supervisor or manager must promptly thereafter 

be reported to the Corporate Compliance and Ethics Manager. 

Reports by contractors and other third parties working for or on behalf of SEHA 

must be made to the SEHA Corporate Compliance and Ethics Manager. 

Reporting may be made anonymously by employees or 

contractors such that the name and identity of the reporting person may not be 

known. All employees to whom occurrences are reported are required to take 

all reasonable measures to and must (unless required otherwise by senior 

management or pursuant to applicable law) maintain the confidentiality of 

the reporting person and must provide or assist in providing assurances to 

the employee that he or she will not be retaliated against for reporting their 

suspicion of wrongdoing. 

Investigation and Discipline 

Before any determination that an employee has committed any act of fraud or 

misconduct, an investigation in accordance with the rules of human resources 



ORGANISATIONAL INFORMATION 

AND PROPERTY 

ORGANISATIONAL INFORMATION AND PROPERTY 

While we are performing our employment duties at SEHA (whether in an 

administrative office, a clinical setting or elsewhere) we are given or gain 

access to information belonging to other employees or the company. There 

is an expectation that such information will not be disclosed outside of the 

capacity in which we have been provided access or used for any purpose 

detrimental to our colleagues or the company. 

Business Information 

Like any business or person, SEHA and its employees (and their predecessors) 

have worked hard to create and grow a company of value. Part of this value 

comes from the unique proprietary rights which SEHA, as an organisation, 

is able to use in its business. In order to protect these proprietary rights it 

is necessary that SEHA employees follow the policies which SEHA maintains 

in relation to business information and intellectual property, the principles of 

which are based on the law of the United Arab Emirates. 

SEHA business information, such as strategic plans and objectives, financial 

and operating data, performance of SEHA and its healthcare facilities, 

healthcare statistics, partnership information (such as our relationship with 

vendors, suppliers and hospital managers) and contract information are 

owned by SEHA and, until publicly disclosed in press announcements or 

annual reports to the general public, is non-public information. As such, the 

following is prohibited: 

• Use of SEHA information for personal gain 

• Disclosure of SEHA confidential information outside of the organisation 

• Sharing such information with colleagues except on a professional basis or 

whose jobs require such information 

We must not remove such business information (including on a personal 

computer or media storage device) from SEHA premises unless authorized to 

do so as part of our job duties and when doing so must take precautions to 

keep such information and devices on which information might be contained 

safe and secure. In addition, SEHA employees may not engage in any illegal 

or unethical acts in order to gain such information from SEHA’s competitors or 

hire any employee of a competitor with the purpose of obtaining confidential 

or proprietary business information. Competitors’ personnel, customers or 

suppliers should not be urged or coerced to disclose confidential information 

nor shall such information be sought from former employees of competitors 

hired by SEHA. 



Employee Information 

Employees have disclosed to the organisation personal information as part of 

the hiring and (in the case of medical employees) credentialing and privileging 

process, including nationality, birth date, marital status, details about 

dependents, educational qualifications and work experience and previous 

employers. In addition, during the course of working at SEHA additional 

employment information is created about employees such as salary and 

other compensation, performance reviews, disciplinary actions and warnings, 

leaves and sick leaves. 

ORGANISATIONAL INFORMATION AND PROPERTY 

All employee information is confidential and must not be used outside the 

human resources department (in accordance with its business requirements) 

without the express consent of the person about whom the information relates. 

We must therefore be very careful in discussions with our colleagues or others 

outside the office so that we do not intentionally or inadvertently disclose or 

refer to such information about others (including in conversations sometimes 

referred to as “gossip”) or in storing such information where it can be accessed 

by unauthorized persons. If we become aware of any information that we are 

not authorised to have or are unsure of how to handle a situation which may 

involve a privacy or confidentiality issue, we must talk to our human resources 

department or our manager in accordance with human resources policy. 

Use of Recording Devices 

As a healthcare provider, our environment is often sensitive and personal for 

our patients and colleagues who have an expectation of privacy within our 

premises. Recording devices such as phone cameras, webcams, and video 

cameras therefore may not be used in our work environment, unless prior 

authorisation has been given by the department manager and is for a proper 

purpose such as marketing, business or training. 

If an image has been captured unintentionally by any recording device, the 

image may not be distributed from the recording device. 

A SEHA employee who becomes aware of a breach of this policy must report 

it within twenty-four hours to his or her manager. 

Copying and Printing Documents 

When printing or copying documents containing confidential or sensitive 

information, SEHA colleagues must not leave such documents unattended 

and they should immediately be removed from the copying or printing area or 

discarded in a confidential manner. 



ACCREDITATION 

AND REGULATORY COMPLIANCE 

ACCREDITATION AND REGULATORY COMPLIANCE 

Accreditation 

The majority of SEHA healthcare facilities, including its medical clinics, are or 

are planned to become accredited by Joint Commission International. Other 

accreditations of SEHA healthcare services such as Laboratory Accreditation 

Program by the College of American Pathologists, AABB Blood Bank 

Accreditation, Society of Chest Pain Centers Accreditation and Accreditation 

Council for Graduate Medical Education (ACGME) are also achieved, planned 

or under review. Following the applicable accreditation periods the facility or 

service must become re-accredited in accordance with the accrediting body’s 

procedures in order to maintain accreditation status. 

During the accreditation and re-accreditation process, all employees 

are required to cooperate fully and forthrightly with all such accrediting 

organizations’ staff and all information requested must be accurate and not 

misleading (including providing all other information required to make the 

information provided understood and accurate). No action may be taken, either 

directly or indirectly, to mislead any surveyor or other staff of the accrediting 

body. 

Employees are required to comply with the accreditations standards of all 

applicable accrediting bodies necessary to maintain accreditation. 

Regulatory Compliance and Risk Management 

The provision of healthcare in the United Arab Emirates, like in all developed 

nations, is a highly regulated industry. Governmental bodies regulating 

healthcare in Abu Dhabi include the federal government of the United Arab 

Emirates, the government of the Emirate of Abu Dhabi, the Ministry of Health 

and the Health Authority – Abu Dhabi. In addition to healthcare regulation, there 

are laws, regulations and mandatory guidelines applicable to other business 

areas of SEHA including company laws, laws regulating environment and 

occupational health and safety, criminal and civil laws, building development 

and construction laws, billing and healthcare insurance laws and many 

others. 

SEHA corporate office, healthcare facilities and all employees must comply 

with all such applicable laws, regulations, guidelines and other mandatory 

rules of government authorities. Any employee who witnesses or suspects any 

non-compliance with any laws, regulations or other mandatory rules should 

report the non-compliance or suspected non-compliance to his or her direct 

supervisor or manager or the legal officer of the corporate office or healthcare 

facility in accordance with SEHA‘s reporting policy and systems. 



Surveys and Investigations 

As part of the healthcare licensing process of healthcare facilities and health 

professionals, Health Authority – Abu Dhabi may conduct surveys, inspections 

and investigations of the healthcare facility or medical staff. Employees: 

• Must cooperate with inspectors conducting such inspections and provide 

information requested in accordance with SEHA policy relating to disclosure 

of information to regulatory authorities 

• May not destroy, conceal or alter any documents 

• May not make misleading or untrue statements to an inspector 

• Must not obstruct others from providing accurate information or mislead or 

delay the provision of records or information to the inspector 

ACCREDITATION AND REGULATORY COMPLIANCE 

If there is any question regarding any procedure which should be followed or 

a response to any request of an inspector by an employee, the employee may 

call their facility legal advisor or corporate office legal advisor, whose contact 

details are posted on the intranet. 



FINANCIAL ACCOUNTS 

AND REPORTING 

FINANCIAL ACCOUNTS AND REPORTING 

Employees responsible for recording or preparing accounting and financial 

transactions and accounts are required to do so with integrity, accuracy and 

care. The Chief Financial Officer and senior management are required to 

certify that SEHA financial statements represent fairly the financial position and 

results of SEHA in respect of the applicable accounting period and are free 

from material misstatements. 

Any employee certifying financial information or statements or providing 

information for the purposes of allowing such employees to provide such 

certification must ensure that the certification or information is true to the best 

of his or her knowledge (based on all necessary due diligence and information 

required to honestly and in good faith make such statement or allow such 

person to make such statement). 



MARKETING AND ADVERTISING 

MARKETING 

SEHA operates in a competitive environment, providing our services to 

consumers and communities. We may use marketing and advertising 

activities to educate the public, provide information to the community, increase 

awareness of our services or the performance of our hospitals and clinical 

departments, to recruit colleagues and to communicate our image and 

positive reputation. 

We strive to present only truthful, fully informative and non-deceptive 

information in these materials and announcements. All marketing practices 

must be conducted in truth with accuracy and fairness. Any marketing 

information regarding available services, capabilities and treatment outcomes 

must be substantiated and straightforward. We never make result-oriented 

guarantees or other promises regarding treatments. 

In accordance with Ministry of Health guidelines and policy we must obtain 

pre-approval from the Ministry of Health for all advertisements relating to 

medical services and products. 



REGULATORY RISK MANAGEMENT 

AND COMPLIANCE PROGRAM 

COMPLIANCE PROGRAM 

SEHA has initiated a regulatory risk management and compliance program 

which includes SEHA corporate office and all business entities and healthcare 

facilities. Its goal is to ensure compliance with all external laws, regulations, 

guidelines and policies (called regulatory sources) as well as internal 

policies which are applicable to SEHA and its employees (along with the 

regulatory sources called compliance sources). Compliance can only be 

attained through a culture of practice. Our regulatory risk management 

and compliance program will be implemented and maintained with the 

cooperation of many different institutions both within and outside of our 

organization. 

The elements of this program are: 

• Availability of all applicable compliance sources to employees on an online 

platform and on a continually monitored and updated basis 

• Useful summaries, guides and training material for the priority compliance 

sources available to employees 

• Assessment of the regulatory and compliance risks applicable to SEHA 

which forms the basis of the allocation of compliance resources and the 

strategic and operational direction of the program 

• Development and updating of policies and procedures which reflect 

applicable compliance sources 

• Training and education designed to help employees understand and 

carry out their activities in a manner which is consistent with applicable 

compliance sources 

• Monitoring and enforcement of compliance sources and policies, including 

the Standards of Conduct (including disciplinary and remedial actions in 

respect of non-compliances) 

• Reporting and responding to non-compliances in accordance with the 

reporting policies and systems 

Reporting 

Employees and any third parties we deal with are required to report any 

actual, suspected or potential non-regulatory issues, breaches or violations to 

the Corporate Compliance and Ethics Manager. Issues and non-compliances 

related to regulatory sources are required to be reported to a legal officer of 

the corporate office or healthcare facility. 

Non-Compliance with the Standards of Conduct 

All inviduals who do not adhere to the Standards of Conduct will be subject 

to discplinary and remedial action appropriate in the circumstances. The 

discipline imposed will be determined in accordance with human resources 

and compliance policy and will consist of one or more of the following: 

• Oral or written warning 

• Written reprimand 

• Suspension 

• Termination 


Abu Dhabi Health Services Company PJSC ( SEHA ), Standards of Conduct 58 

• Restitution

Acknowledgement 

Employees and third parties working for, or on behalf of SEHA and its healthcare 

facilities will be required to acknowledge (either electronically or manually) 

that they have read and understand the SEHA Standards of Conduct which 

summarizes mandatory policies of Abu Dhabi Health Services Company PJSC, 

and that they agree to abide by the Standards and all mandatory policies of 

the organization. 

59 

Abu Dhabi Health Services Company PJSC ( SEHA ), Standards of Conduct

Rev: May 2012

Our MISSION AND VISION - SEHA

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