Punjab Healthcare Commission needs to be supported and strengthened

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To ensure patient safety and minimum healthcare standards

Punjab Healthcare Commission needs
to be supported and strengthened

In a country where medical profession does not practice
self monitoring, PM&DC remains paralyzed, PHC seems to
have the right credentials to undertake this responsibility 

By Shaukat Ali Jawaid

LAHORE: How many healthcare professionals are properly trained and competent to undertake various interventional procedures in Pakistan? How many healthcare establishments in Pakistan have adequate facilities? How many un-necessary angiographies, angioplasties and stenting, laparoscopic surgeries, assisted reproductive techniques, endoscopies, colonoscopies, FESS, are being performed in Pakistan without any indication? How many infertility clinics are functioning in Pakistan and what is their success rate? Do we have any system of registration, monitoring and ensuring accountability of healthcare professionals and healthcare establishments? When answer to all these questions are simply NO, members of the medical profession have failed to come up with any feasible, practical self monitoring mechanism, professional specialty organizations and associations of private hospitals and clinics have failed to monitor and hold its members accountable, where Pakistan Medical & Dental Council which is supposed to ensure that healthcare professionals and healthcare facilities uphold professional ethics but in fact remains paralyzed, ineffective, someone has to fill up this gap. In these circumstances Punjab Healthcare Commission in the province of Punjab atleast seems to have the right credentials to undertake this responsibility. Hence it needs to be supported and strengthened and similar institutions needs to be established in all the other provinces and federating units.

Mr. Justice(R) Amer Raza Khan
Chairman
Punjab Healthcare Commission

A few incidents of professional negligence leading to death of patients which was highlighted by the media and resulted in extreme resentment in public some years ago forced the Government of Punjab to wake up and take some appropriate measures. The result was the establishment of the Punjab Healthcare Commission. Punjab Healthcare Commission Act 2010 was passed by the Punjab Assembly on July 22nd 2010; assented to by the Governor of Punjab on July 30th 2010 and Gazette notification issued on August 2nd 2010.


This is not something unique; such institutions are working in most of the civilized developing and developed countries of the world. Quality Care Commission in UK ensures clinical governance with the help of a system of standards setting and facilitates compliance. The Indian Public Health Standards were introduced in 2005 and since then Quality Council of India has expanded its scope with the launching of Standards for the Health and Wellness Industry in 2008. The Australian Council on Healthcare Standards was initiated in 1974 that has facilitated the development of the New Zealand and Singapore Council, La Haute Autorite de Sante is the French equivalent. Accreditation Canada formally known as Canadian Council on Health Service Accreditation became independent from the Joint Commission for Accreditation of Hospitals (JCAH) in 1953. The Quality Holistic Accreditation Trent Accreditation Scheme is based in UK and Europe and has serviced Hospitals in Asia as well. High mortality rates in paediatric cardiovascular surgery in one of the centers in UK forced the British Government to form a Commission to investigate the facilities at all the healthcare facilities performing paediatric cardiac surgery and come up with minimum acceptable standards. In Pakistan, we have no such system in place. A large number of Infertility Clinics and IVF centers are functioning in the country without any monitoring, registration and control and fleecing the patients. Bariatric surgery is a new upcoming specialty. One may ask whether all the surgeons doing bariatric surgery in Pakistan which is also publicized in the media to attract patients are well trained, competent and experienced enough to undertake these surgical procedures? Health Authority of Dubai has introduced standards to protect people seeking bariatric surgery for weight reduction and other weight related problems. It includes details about patients who are eligible for this surgery and the qualification, experience of the surgeons. Now unified guidelines are being developed for the whole of United Arab Emirates. When amateur surgeons start doing bariatric surgery, we see lot of problems and complications. So far we have no system in place whereby Registration and Accreditation of all those undertaking various interventional procedures are registered, monitored and held accountable besides having central registries. No one has seriously bothered to look at the healthcare facilities both in public and private sector whether they have the minimum healthcare standards, facilities and qualified, well trained staff to ensure patient safety.

Dr. Mathew Samuel an eminent interventional cardiologist from Apollo Group of Hospitals in India has trained most of our interventional cardiologists. He visited Pakistan many times and conducted workshops, trained Pakistani cardiologists in these interventional procedures at Punjab Institute of Cardiology, National Institute of Cardiovascular Diseases Karachi, and Armed Forces Institute of Cardiology at Rawalpindi. He is also a former President of Asia Pacific Society of Interventional Cardiology. In an exclusive interview Dr. Mathew Samuel told me in 1997 that a person must have performed atleast five hundred angiographies before he or she starts learning angioplasty. Then he must assist in fifty cases. Then do fifty cases as first operator with senior person. Only then he can be allowed to work independently. In United States anyone who does less than twenty five angioplasties in a year is struck of the Register and he is supposed to go for further training. All the interventional cardiologists doing angioplasties, stenting in India are registered and we have a central Registry which is continuously updated. An eminent gynaecologist from Singapore addressing the Society of Obstetricians’ and Gynecologists meeting at CPSP in early 90s gave details how the Infertility Clinics, IVF Centers in Singapore are monitored, registered with a central registry and their success rates are constantly monitored to ensure ethical practice and standards. Why we have not set up any such system of monitoring and central registry in the country is a big question mark. These are some of the reasons that we do not have authentic reliable data in Pakistan. Professional specialty organizations which are an important resource and could have taken the initiative to monitor its members lack the moral courage to do this. Hence, patients cannot be left at the sweet will of the healthcare establishments to do whatever they like. Patient safety has become an important issue these days hence, institutions like Punjab Healthcare Commission which seems to have the right credentials to undertake this responsibility of ensuring patient safety and minimum healthcare standards must be further strengthened and supported.

Dr. Mohammad Ajmal Khan
Chief Operating Officer,
Punjab Healthcare Commission

A visit to the Punjab Healthcare Commission at Lahore on April 25th 2014 on an invitation from its Chairman Mr. Justice (Retd) Amer Raza Khan and brief meeting with PHC’s Chief Operating Officer Dr. Mohammad Ajmal Khan revealed that the commission has done lot of homework over the last three years. It has produced Minimum Service Delivery Standards (MSDS) and indicators which include the fundamental elements that should be present in all healthcare establishments in order to deliver safe health services. They are consistent with the Pakistani national indicators currently being developed. These thirty Minimum Service Delivery Standards are dynamic reflecting the constant development of healthcare treatments, practices and protocols. They are driven by evidence based research and are designed to promote a safe environment with managed risks. It is for the benefit of both the patients as well as healthcare establishments and contributes to the social objectives of the people of the province. These professionally developed thirty MSDS are the “Foundation Standards” with 162 associated indicators for Secondary and Tertiary Hospitals functioning in the province of Punjab.

The PHC Act 2010 provides for a Board of Commissioners as a governing body to set a strategic direction for the Commission whiles the Technical Advisory Committee to render advice on its regulatory initiatives. According to Justice Amer Raza Khan Chairman of the Commission, “implementation of standards is erroneously perceived as a resource intensive process by service providers unaccustomed to regulation. Keeping this in mind, the Commission has undertaken to ensure that number of handling hospital staff is trained before the inspection visits. After the enactment of PHC Act, the Commission has sole jurisdiction over cases pertaining to alleged medical negligence, malpractice or administrative failure and healthcare service providers have immunity against proceedings conducted against them at any other forum.” The spirit of PHC Act requires all the healthcare establishments to ensure delivery of quality healthcare. It recognizes the vital role of hospital management, health practitioners including nurses and paramedics, Hakeem’s and Homeopaths and all other support staff in providing quality healthcare services responsive to the needs of the people. The Commission has developed the MSDS through a consultative process to ensure their successful implementation at all Primary, Secondary and Tertiary Healthcare Establishments in both the public and Private sectors in the province.


PHC has taken a pioneering initiative in setting up a credible, transparent, technology driven Complaints Management System based on principles of natural justice and impartiality. It aims to improve the quality of healthcare besides fostering a culture of Clinical Governance. PHC Core Values include Integrity, Innovation, Teamwork, Transparency and Quality. The Commission has mandate to:
• Enhance patient safety
• Enable improved access to quality healthcare at all levels
• Build a culture of patient-centered care and enhance patient satisfaction through redressal of complaints.
• Ensure accountability at all levels of healthcare.
• Increase awareness amongst patients and healthcare establishments about their rights and responsibilities.
• Address medical quackery in all its forms and manifestations.

Technical Advisory Committee

The Technical Advisory Committee of Punjab Healthcare Commission is a fairly well represented body having representation from all the different stake holders including medical institutions like Medical and Dental Council, College of Physicians & Surgeons Pakistan, Nursing Council, Federal Mental Health Authority, University of Health Sciences, King Edward Medical University, PMA, provincial assembly, District Governments, Councils of Tibb and Homeopathy, Punjab Medical Faculty, Young Doctors, national and international healthcare experts which ensures that justice is done and ensured in performing its functions, duties and responsibilities all directed at ensuring patient safety. The Commission has laid down criteria for Registration and Licensing of healthcare providers, provided details regarding different types of licenses. It has also taken upon itself the responsibility of preparing and publishing standards in relation to the provision of healthcare services and keeps standards under constant review and intend to publish amended standards whenever deemed appropriate.

Annual Report 2012-2013

The PHC’s annual report for the Year 2012-2013 gives lot of useful information and the Commission’s accomplishments so far. According to Chairman of the Commission Justice Amer Raza Khan the ”PHC’s senior management includes professionals who have been affiliated with the health sector and are fully conversant with the limitations that impede the available standardized service for a major segment of the population. There is recognition of the fact within the commission that an arbitrary imposition of laws and regulations is not possible in the prevailing scenario. The Commission has, wherever possible, taken to itself the role of a facilitator, ensuring that capacities are built prior to insistence on standards. It is vital that medical professionals cooperate with the Commission, as it is important for the Commission to be their voice, if need be. We have an effective, responsive Complaints Management System to ensure that patient’s grievances are addressed in a satisfactory and timely manner. This system also ensures that medical professionals are not unduly harassed or impeded in the discharge of their duties by fear of reprisals, while affording full protection to the rights of patients.”

According to Dr. Mohammad Jamal Khan Chief Operating Officer of the Punjab Healthcare Commission it “ continues to face challenges in fulfilling its obligations under the law and most of these pertain to the ambiguity that persists in the minds of medical practitioners, local administration and other stakeholders with respect to the scope of the Commission’s authority. That is why we have embarked upon an advocacy and sensitization campaign to address this information gap and to apprise all stakeholders about the work of the Commission, the scope of its authority, the rights and responsibilities of stakeholders and the accurate interpretation of the PHC Act 2010. The menace of quackery needs to be checked and addressed effectively. We are in the process of formulating an Anti Quackery Strategy and the groundwork for the same is underway.”
Pre assessment surveys undertaken by the Commission of various healthcare establishments have been beneficial in removing prejudices with respect to the inspection process as service providers realize that implementation of these standards is not a resource intensive process and merely involves compliance of standards by improving procedures and maintenance of documents and requisite records. The Commission believes that internal strengthening of the organization to remove human resource deficiencies will enable the organization to meet its existing targets and gradually enhance its capacity.

The Commission has had to overcome quite a few obstacles due to its unprecedented nature of its mandate and the resistance, skepticism on the part of service providers against a regulatory mechanism says Mr. Justice Amer Raza Khan. Despite these impediments the Commission has made significant headway in meeting its regulatory obligations. So far the Commission has issued nine regular licenses, registered 702 HCEs, issued provisional licenses to 316 HCEs and conducted 57 inspections. Three hundred five complaints were received of which forty one have been decided by the Board. One hundred fifty complaints are under investigation while 114 were disposed off. Most of the complaints were against surgeons and that too mostly related to obstetrics and gynecology involving communication problems. It was related to complications about which the patients were not provided enough information beforehand.


PHC has prepared Clinical Governance and Delivery Standards for tertiary care, teaching hospitals, prepared MSDS for Homeopathic Clinics, Mattabs, and Clinical Laboratories while preliminary work as regards MSDS for GP Clinics has been completed. For capacity building PHC has conducted 17 workshops, 159 hospitals have been trained, 416 hospital staff have been trained besides training 37 Expert Surveyors. Sensitization meetings have been conducted at Rawalpindi, Sargodha, Sahiwal, Multan and Bahawalpur. Similarly sensitization meetings with Academic Councils of medical institutions have been organized at Lahore, Multan, Bahawalpur, Gujranwala, Sahiwal and Faisalabad.

So far the PHC seems to have adopted a very sensible approach of sensitizing, creating awareness about its functioning and gone for gradual implementation of its mandate which is indeed commendable. However, there is always room for improvement and the fact that PHC management is receptive to suggestions is creditable. Involvement of professional specialty organizations in its awareness campaign, educating the healthcare providers and healthcare establishments to realize their duties and responsibilities to ensure standardized care will make its job easier. One of its failures seems to be effective use of media to convey its message to all the stake holders and dispel the impression that it was another policing force to control the healthcare providers and healthcare facilities.

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