Case Studies

Healthcare & Wellness Provider

Documenting Clinical Governance and Patient Data Controls After an Inspection

Overview

A private clinic and wellness provider in Al Ain, UAE (“the Clinic”) received inspection findings highlighting weaknesses in clinical governance documentation, complaints handling and patient data protection. The clinical care itself was sound, but processes and records did not meet the regulator’s expectations. The health regulator in Al Ain is the Department of Health, Abu Dhabi (DoH).

Marensa Advisory was engaged to help the Clinic respond to the findings, build practical governance and data-protection processes, and give the owners confidence that future inspections could be handled calmly.

Client profile

Multi-disciplinary clinic with medical, wellness and aesthetic services
Mix of local and international patients
Clinical team led by a senior medical director; lean admin function
Multiple third-party systems for bookings, EMR and marketing

Key challenges

Tacit clinical governance
Informal practices existed for case reviews, incident discussions and escalation, but there were no charters, agendas or records to show a structured approach.
Complaints and incidents not systematically logged
Staff dealt with complaints and near-misses, but logging was inconsistent and often limited to email chains.
Patient data scattered across systems
EMR, booking, billing and marketing platforms each held parts of the patient journey. No one had mapped how data moved or who could see what.
Regulator remediation deadline
The Clinic had a defined timeframe to address the inspection findings and report back on corrective measures.

Marensa’s approach

1. Understanding current practice

We started with on-site interviews and process walkthroughs:

How clinical decisions and escalations actually happened
How complaints were received, triaged and resolved
How staff used different systems and communicated with patients

We were careful not to impose hospital-level bureaucracy on a relatively small clinic.

2. Clinical governance structure

We helped the Clinic formalise what was already happening:

Defined a Clinical Governance Committee with clear membership and responsibilities
Set a realistic meeting schedule and core agenda items (incident review, complaints, audit results, training needs)
Created minute templates that captured decisions, actions and learning points without consuming too much time

We also suggested pragmatic internal audits (e.g. random file reviews, consent form checks) to feed into the committee.

3. Complaints and incident management

We designed simple but robust processes:

Standard forms and logs for complaints and incidents, with severity levels
Timeframes for acknowledging and responding to patients
Clear ownership for investigating, documenting outcomes and closing cases
Linkage between complaints/incidents and staff training or process changes

We ensured that the process still allowed clinicians and staff to resolve minor issues quickly while capturing patterns over time.

4. Patient data mapping & privacy controls

Working with the Clinic’s IT provider, we:

Mapped patient data through EMR, booking, billing and communication tools
Identified who had access to what and where the highest risks were (e.g. export functions, shared email inboxes)
Drafted privacy notices in clear language for patients, covering how their data was used and their rights
Suggested access controls, password and screen-lock practices proportionate to the Clinic’s size

We also designed a simple incident and breach response checklist in case of mis-sent emails, lost devices or unauthorised access.

5. Response to the regulator

Finally, we helped the Clinic prepare a remediation report:

Summarised each finding and the root cause
Described corrective actions taken, with supporting evidence
Set out any further steps planned, with target dates and owners

The tone of the response was factual and collaborative, demonstrating that the Clinic had taken the inspection seriously and used it to strengthen its governance.

Outcomes

Within a few months:

The Clinic had a living clinical governance structure with regular meetings and documented decisions.
Complaints and incidents were logged and analysed, with learning fed back into practice and training.
Patient data flows were better understood, with clearer controls and more transparent communication to patients.
The regulator’s follow-up review acknowledged significant improvement and closed the original findings.

Why it matters

Healthcare providers are often judged not only on outcomes but on how they manage risk and learn from issues. What we achieved above shows that disciplined but practical governance and privacy controls can be built on top of existing good clinical practice, improving both regulatory relationships and patient trust.