Patient Safety at the Heart of PHC’s Standards

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Patient Safety at the Heart
of PHC’s Standards
Dr. Mushtaq Ahmed Salariya*

While there is no empirical research on the healthcare burden associated with medical errors in Pakistan, global statistics quoted by the World Health Organization are alarming. Every year, 134 million adverse events occur due to unsafe care in hospitals in low and middle income countries, contributing to 2.6 million deaths. Given the state of affairs, ‘patient safety’ has been declared a global health priority.

As a regulatory body working towards high-quality and safe healthcare services, the Punjab Healthcare Commission (PHC) is focused on institutionalizing mechanisms at healthcare establishments (HCEs) that reduce the risk of preventable harm to patients. Finding patterns of care to be highly divergent, and strongly associated with clinical outcomes, the Commission has set about standardizing healthcare service delivery at the various types of HCEs offering services in Punjab. To reduce variations that may be detrimental to patient safety, it was imperative to first define acceptable standards of service delivery and specify indicators to assess their compliance.


Dr. Mushtaq Ahmed Salariya

Not just limited to hospitals, the PHC’s regulatory ambit covers facilities, both public and private, being wholly or partially used for rendering allopathic healthcare services or those delivered under the Unani, Ayurvedic and Homeopathic Practitioners Act 1965. Thus far, it has successfully defined Minimum Service Delivery Standards (MSDS) for 12 types of HCEs, including four different categories of hospitals, basic health units, homeopathic clinics, dental clinics, rural health centers, Matabs, clinics of general practitioners, clinical laboratories, and radiological diagnostic facilities.

Based on a comprehensive, internationally accepted framework, the MSDS encompass all aspects of service delivery. While standards can be broadly categorized as pertaining to ‘clinical care’ or ‘operational management’, it is pertinent to note that the procedures and practices prescribed within are interdependent. When implemented together, they deliver a system of care that prevents avoidable errors and institutionalizes protective and preventive measures to protect patients from harm. A review of the standards reveals that patient safety is, in fact, a core theme of the MSDS.

Standards addressing clinical care prescribe cross-functional, overarching policies to avoid errors while conducting investigations or dispensing treatment. These include appropriate protocols for patient identification prior to any investigation or procedure, and systems to ensure that only qualified and trained personnel perform or supervise services such as laboratory or imaging tests, administration of anesthesia or medication, performance of surgeries, provision of obstetrical care, etc.

At the same time, specific policies have been prescribed for certain aspects of healthcare service delivery, laxity in which may pose a direct and significant risk to patients. For example, where the use of blood or blood products is involved, the MSDS direct proper screening of donors, safe administration of blood to recipients, etc. Similarly, it is compulsory for competent healthcare service providers to document and monitor anesthesia patients for complications. With regards to surgical procedures, HCEs must have a system in place to prevent adverse events such as wrong site, wrong patient or wrong surgery. In fact, the MSDS make it mandatory for HCE staff to monitor adverse events and reactions and analyze these for corrective and preventive action. During inspections, PHC surveyors specifically look for the documentation of such incidents, including real and suspected blood transfusion reactions, anesthesia related complications, surgical site infections, etc., and evidence of consequent quality improvement initiatives to prevent recurrence.

Standards also address the timeliness of care. For patients accessing emergency services, a triage process has been prescribed, which prioritizes patients on the severity of their condition. Similarly, indicators mandating the immediate reporting of critical laboratory or imaging results bar procedural delays from putting lives at risk.

With regards to the management of medication, an area having direct implications on patient safety, standards prescribe safe practices for administration, ensure adequate guidance to patients self-administering medication, permit only authorized individuals to write orders and advise caution in dealing with high-risk medications and verbal orders. Collectively, these practices create a system that reduces the chance of errors and misuse; ensuring that the right patient is given the right dose of the right drug, at the right time, and through the right route.

To protect patients from nosocomial infections, MSDS require HCEs to develop and implement integrated infection control programs, which incorporate sterilization and surveillance activities, hygiene procedures, the use of protective equipment and the proper collection, handling and disposal of sharps and biological waste.

On the other hand, while managerial and administrative matters may not seem directly linked to patient safety, the operations of a HCE impact clinical outcomes and shape patient experiences. Aiming to facilitate patients and attendants, MSDS require that HCEs be easily identifiable and accessible, with adequate facilities and civic amenities. The latter includes ramps for wheelchairs, adequate seating arrangements, drinking water, etc. Furthermore, the management is to ensure that all equipment at the facility is in prime working condition and is used and maintained by qualified professionals only, and in accordance with relevant standards.

To reduce actual and potential risks to patients, HCEs must implement a continuous monitoring and quality improvement program. Among other things, this must include the investigation and analysis of sentinel events at the HCE, including unexpected deaths, serious adverse events, violence against staff and patients, etc. During inspections, PHC surveyors look for evidence of corrective actions and ensuing policy changes.

In assuring patient safety, the MSDS go a step further, taking into account the fact that patients accessing a HCE may be exposed to risks beyond those posed by the course of treatment or provision of care. In line with this, HCEs are required to be suitably equipped to deal with emergencies and natural disasters. This includes infrastructural arrangements, such as marked emergency exits, and managerial enterprise, including evacuation plans, simulation exercises, etc.

Certain standards prescribed by the Commission also have the added advantage of facilitating healthcare service providers in delivering safe and high-quality care. These include compulsory employee trainings to remain updated on policies, thus minimizing the chance of violations, and the maintenance of correct and chronologically updated medical records to avoid errors caused by confusion.

While the aforementioned standards directly or indirectly reduce the margin of error in the delivery of care and improve patient experience, an entire section of the MSDS directly addresses the rights of patients. Affording due consideration to aspects of consent and privacy, standards prescribe that patients be made aware of their rights, including the right to complain, and be educated on the risks, benefits and alternatives of a procedure or treatment so that they may make informed decisions. In order to adequately respond to concerns, HCEs must have a system in place to register and investigate complaints.

Acting as a set of rules for HCEs, the MSDS collectively place patient safety at the heart of the Commission’s reform agenda. In evaluating impact, it is important to understand that the PHC’s regulatory initiatives are geared towards shifting the psyche of healthcare service providers. Aiming to bring about a cultural change, where patient safety assumes priority, the PHC has strayed away from coercion as the closure of non-compliant HCEs would only compromise the health of patients seeking treatment with limited alternatives. Consequently, it has maintained a balance by running a capacity building program to facilitate healthcare service providers in achieving regulatory compliance, while executing interventions that enforce the implementation of certain critical standards in a more stringent manner. The latter include the surveillance of operation theaters, adequate arrangements for hospital infection control, the provision of safe emergency and blood transfusion services, arrangements to deal with fire and non-fire emergencies, the segregation and management of hospital waste, and functional complaint management systems.

Given the scale of the Commission’s reform, as a regulator, it is still in its infancy. Open to collaborating with the government and development agencies working within the healthcare sector in Punjab, the PHC is hopeful of gaining support and assistance in the enforcement of its MSDS. Not only do its standards adopt a holistic, multifaceted approach towards ensuring patient safety in complex healthcare systems, they also constitute a legal requirement for HCEs delivering services in Punjab.

*The author is the CEO of the Punjab Healthcare Commission.

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