At the model Rawalpindi Institute of Cardiology, buck stops at the top!

Islamabad

Imagine a public sector hospital where your medical condition comes first; where treatment begins without the fear of catastrophic out-of-pocket spending; where all medicines are adequately stocked and dispensed for free; where the entire range of diagnostic equipment remains in perfect working order; where equity matters so that there is no disparity between the quality of care provided to the rich and the poor; where cleanliness is a norm rather than a cosmetic measure associated with VIP visits; where consultants are predictably available in their clinics to examine patients; where negligence is punished and responsiveness rewarded; and most importantly, where patient satisfaction supersedes all other priorities.

While not a single government hospital in Islamabad can even remotely come close to the above description, one was pleasantly surprised to see the 272-bedded Rawalpindi Institute of Cardiology (RIC) faring remarkably well vis-à-vis all the basic parameters that gauge a hospital’s performance.

This scribe had the opportunity to visit RIC twice in the last week; the first was a planned visit undertaken with the intent of interviewing RIC’s Executive Director Major General (r) Dr. Azhar Mahmood Kayani, while the second was made for a critical reassessment of the standard of healthcare provision available to patients at the said facility.

“What kind of expenses have you incurred on your father’s treatment,” a male attendant in the waiting area was asked. “This is a free hospital in the true sense. My father needed a pacemaker, which costs between Rs50,000-100,000 in any other hospital. Here, we haven’t paid a single rupee from our own pocket, nor have we been asked to purchase any medicines from the market,” he replied.

Standing against the wall of the 48-bedded emergency, which is the largest emergency in any public sector hospital of Rawalpindi and Islamabad, was a middle-aged woman who appeared visibly shaken. “Is everything okay,” she was asked. “My mother just passed away. She had been hospitalized for two days,” she responded. “Was it negligence,” she was asked. “No. She received best possible care. Her time in this world had come to an end,” she remarked. “Emergency treatment costs no less than Rs20,000-30,0000 per day but we were neither asked for admission slips, nor any kind money,” she added in response to a query.

The standard of hygiene at RIC was enviable, to say the least. The same was true for the cooling system; the air-conditioned environment was a blessing for the poor, especially in the present hot and humid weather conditions.

Despite the large influx of patients at RIC, which was a painful reminder of the rising incidence of heart diseases in Pakistan, there were no long queues of patients, neither in the OPDs and nor in the waiting areas or the laboratories. And there was a reason behind this. Unlike the Pakistan Institute of Medical Sciences (PIMS), all specialists at RIC make themselves available in their clinics for the entire duration of the working hours. At PIMS, specialists are rare commodity. Doctor absenteeism is high and remains ignored; in fact, there are a few who attend their clinics only twice a week for a couple of hours only, and yet draw full salaries! Long queues of patients are hence a repercussion of such permissible laxity on part of consultants and specialists.

“A hospital administrator in Pakistan has to lead by example. I arrive at 7.30 a.m. so my consultants also observe strict adherence to clinic timings. You do not see long queues in our OPDs because we do not, as a policy, subject our patients to unwarranted delays. Our doctors do not skip clinics so the queues remain small, if at all. Since we conduct a weekly assessment of all diagnostic equipment to prevent malfunction, there are also no long queues outside our laboratories. Our patients never return home disappointed because of malfunctioning equipment,” remarked Dr. Kayani, who took charge of RIC in September 2012 after retiring as Commandant of the Armed Forces Institute of Cardiology.

The ED starts his day with a morning round of the hospital. “I take account of the previous day’s in-hospital mortalities and ascertain whether any of the deaths was preventable or caused by negligence. We also do a postmortem of admissions. Shortage of medicines, though rare, is sorted out by 7.30 a.m. All inquiries start during the morning round. I feel accountable to patients. There can be no justification for my presence here if patients are to leave dissatisfied. I am responsible for any patient who feels not being looked after and for any patient who is charged for any service or medicine,” the ED stated.

Dr. Kayani believes that his physical presence in the hospital is what makes a difference. “I keep a close eye on who is working and who is not. Diligent performers are rewarded and work shirkers instantly sacked. This hospital is not for people who want to relax in their armchairs,” he said.

Dr. Kayani has a reputation for zero tolerance to inefficiency, negligence, and political influence. RIC is one of the few government hospitals where institution-based private practice is thriving. “Negligence on part of consultants may range from forfeiture of a day’s salary to suspension of their private practice for a month. In more serious cases, three explanation letters are served, followed by a termination letter. And many have been shown the door. I do not give in to political interference, be it from the office of the PM, the CM, or a minister. When a strong message to this effect is disseminated, even slow coaches start working,” he remarked.

Responding to a question about the Prime Minister’s hospital-based health reforms in Islamabad, Dr. Kayani rejected the need for infrastructural expansion and construction of new towers in PIMS till such time that its existing infrastructure is put to best use. Indeed, all PIMS needs is efficient and capable human resource, and an honest and robust administration. PIMS should not be a hospital where only the administration block (housing the executive director’s office) is regularly and religiously swept. It should not be a facility that reminds visitors of Florence Nightingale’s words: ‘Overcrowded and poorly ventilated hospitals are gateways to death.’

“How important is timely intervention in a heart attack,” the ED was asked. “There have been instances when patients as young as 30 to 40 years old have ended up with irreversible damage to their hearts due to delayed medical intervention. A majority of the patients rush either to the Benazir Bhutto Hospital or Holy Family Hospital, resulting in wastage of precious time. Most of the Medical Officers in these hospitals are not even trained to read ECG,” Dr. Kayani pointed out. Indeed, it is crucial to remember the significance of early hours in a cardiac arrest.

“We encourage people to rush to RIC without the fear of having to pay. We use top-of-the-line stents for rich as well as for the poorest of the poor. “We buy all medicines directly from manufacturers at a 20% discount from the market rate and give them to patients for free,” Dr. Kayani maintained. A maximum of five cardiac surgeries are currently being performed at RIC; its fourth OT will be functional from next month, which shall resultantly allow more surgeries.

Widows are also entitled to free treatment at RIC; this includes widows who come from affluent families but are dependent on their children. “Since such women are often seen by their children as a burden, we protect their dignity by offering free treatment to them,” Dr. Kayani said.

The culture of doctors, nurses or paramedics going on strikes does not exist in RIC. “It is my personal responsibility to ensure the welfare of all. Even a sweeper at RIC gets a share of the revenue generated from institution-based private practice because he too is a member of the team that looked after patients in one way or the other. Why would anyone go on strike when they know that they will get their rightful share? Institutions are run by promoting a sense of ownership,” the ED stated.

RIC’s future plans include induction of neonatal surgeons this year, and initiation of heart transplants. At present, complicated paediatric cases are being handled by visiting teams of paediatric cardiologists from the UK. “Only recently, Columbia University, Korean University, and Leicester University have agreed to undertake capacity building of our doctors. Starting next month, they will be sending their teams (consisting of a paediatric surgeon, a cardiologist, OT and ITC nurses, a perfusionist, and a physiotherapist) to RIC,” he added. RIC will be the first hospital in South East Asia to host a ‘Workshop on paediatric electrophysiological studies of the heart’ in November 2016.

Dr. Kayani shared that patients from AJK are treated from Pakistan Baitul Mal (PBM) funds. “If they come to us with just the first tranche of money from PBM, we do not suspend the treatment for want of remaining funds; instead, RIC foots the expenses for sake of continuity of treatment. PBM needs to work hard to ensure that its funds reach its just and needy target—the poor and the deserving only,” he stated.

The encounter with Dr. Kayani made it abundantly clear that there is no rocket science involved in effective hospital management and administration. There is no reason why the RIC model cannot be replicated at PIMS or its likes anywhere else in the capital or other cities of Pakistan.

RIC’s management practices and patient satisfaction levels should serve as a wake-up call for the top bosses of Islamabad’s hospitals, which are notorious for mismanagement, collusion, and lack of vision. At a time when there is an acute trust deficit vis-à-vis healthcare systems, it is organizations of the ilk of RIC that restore peoples’ hopes. If the intention is to serve, there can be no excuses. Befittingly, the plaque sitting on Dr. Kayani’s table reads: “Please be Brief and to the Point: Patients, People and Problems might be Waiting.”